Master Clinician Research Articles

Forecasting the Future of Aural Rehabilitation: Jerry Alpiner

Forecasting the Future of Aural Rehabilitation: Jerry Alpiner

The Dawning of a New Decade

The Dawning of a New Decade

The Florida Diabetes Master Clinician Program: Facilitating Increased Quality and Significant Cost Savings for Diabetic Patients

Up to 10% of Americans > 20 years of age have type 2 diabetes, and > 20% have the metabolic syndrome.1,2 The prevalence of both has increased by 33% during the past decade as a result of an increasingly sedentary lifestyle, the epidemic of obesity, the growth of ethnic groups at risk for the disease, and the aging of the population. The prevalence of the metabolic syndrome increases dramatically with age, and 45% of people > 60 years of age have the syndrome. Type 2 diabetes will develop in many of these individuals.1,2 In the United States, diabetes is the sixth leading cause of death; the leading cause of renal failure (end-stage renal disease), nontraumatic limb amputations, and blindness; and the leading contributor to cardiovascular disease (CVD). CVD accounts for ∼ 70% of deaths in adults with diabetes. The complications associated with diabetes lead to excessive suffering, increased use of health care resources, and excessive costs.3-6 Despite our increased knowledge and understanding of the pathophysiology and management of diabetes, patient outcomes have not shown a parallel improvement. A large gap exists between our knowledge and our performance.7,8 Based on excellent evidence, the American Diabetes Association (ADA) has set the following goals: hemoglobin A1c (A1C) ≤ 7%, LDL cholesterol ≤ 100 mg/dl, and blood pressure ≤ 130/80 mmHg. Nationally, only 48% of patients are able to reach the A1C goal, and only 33% are at the LDL and blood pressure goals. Only 7% are able to reach the goal for all three at the same time.9 The 58 Florida practices that participate in the Diabetes Master Clinician Program (DMCP) of the Florida Academy of Family Physicians Foundation (FAFPF) have been able to help patients attain better control …

Drawing From a Master Clinician's Well

Drawing From a Master Clinician's Well

An Advocate for Self-Assessment: Barbara Weinstein

An Advocate for Self-Assessment: Barbara Weinstein

Pulmonary hypertension: clinical manifestations, classification and diagnosis

Dyspnoea on exertion is the most common presenting symptom of pulmonary hypertension (PH), often a progressive and ultimately fatal condition. However, the presenting manifestations are protean, and more subtle features such hoarseness (caused by compression of the left recurrent laryngeal nerve) challenge master clinicians. Clinician scientists have refined the clinical classification in a manner that aids in accurate diagnosis and facilitates communication among healthcare providers and research investigators. Diagnostic algorithms emphasize confirmation and characterization of PH by catheterisation as well as differentiating between the current classes based upon essential and contingent diagnostic tests.

Reflections About Evidence-Based Pathology

expert. In anatomical pathology, as at the bedside, the trajectory of diagnostic inference is guided by clinical instinct, constantly reinforced by experience. The more times we have solved the problem, the better we become at solving the next one. But if we are to incorporate evidence-based practice into diagnostic anatomical pathology, the choice among alternative diagnostic methods and workup algorithms must be an informed choice, informed not by anecdote (not even repeated anecdote) but by objective evidence distilled from well-designed studies. The link between evidence and diagnostic reasoning must be transparent (so as to be easily apprehended by those in training) and continuously refined, and the evidence used to support the conclusions should be periodically updated. In the clinic, much of the objective evidence used in EBM is derived from meta-analysis of carefully designed and conducted trials. Anatomical pathologists are in a unique position because deciphering the gross and histopathological appearance of lesions can be challenging and far from objective, although the image is considered objective relative to the clinical narrative. With some frequency, placing a lesion in a defined category involves weighing the morphological elements that compose the lesion differentially and integrating these data in the context of the information provided by other approaches (anamnesis, imaging, laboratory values, and outcomes). Choosing what morphological elements of a lesion to use in reaching a diagnosis and selecting which features will guide therapy comprise an act that can be based on experience or on EBP. Mixing the two in the right proportion is an exercise that every practicing anatomical pathologist does with a frequency dependent on the complexity of the practice environment. A vast body of scholarly work in pathology provides data on the diagnostic significance of an entire universe of morphological features for many diseases and serves as the basis for EBP. When only personal experience is used in making a diagnosis, with little reference to Asignificant part of a recent meeting of directors of anatomical pathology was devoted to discussing evidence-based pathology (EBP), a subject that was comprehensively treated in an issue of Seminars in Diagnostic Pathology. This may in part reflect a sense that anatomical pathology needs to catch up with other medical disciplines in terms of evidence-based medicine (EBM) (ie, “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.”) Evidence-based medicine has emerged as a favorite teaching tool to instruct medical students and housestaff in the use of objective and rational data as the basis for deciding between alternative diagnostic, prognostic, or therapeutic choices. In EBM, clinical instinct and intuition are not so much replaced as aided by the critical use of evidence (mostly derived from randomized trials), an evaluation of its strength, and patient-based inference that is carefully reasoned along the principles of logic. The act of clinical diagnosis has traditionally rested on the capacity of the master clinician to identify, among the noise, the few cardinal elements that constitute a pattern (the disease entity) and to prove that he or she is correct judging by the efficacy of the therapy or the accuracy of the prognosis. The more noise, the more difficult it is to formulate the correct diagnostic hypothesis, and in complicated cases a final conclusion is only reached after considering several hypotheses and choosing the one most likely to be corroborated by objective data. The correct final diagnosis usually explains all the noise, and the cloud of data that may have confused the neophyte disappears under the light shed by the

Audiologic/Aural Rehabilitation is Valued and Necessary

You have accessThe ASHA LeaderFeature1 Jun 2007Audiologic/Aural Rehabilitation is Valued and Necessary Joseph MontanoEdD, CCC-A Joseph Montano Google Scholar More articles by this author , EdD, CCC-A https://doi.org/10.1044/leader.FTR2.12082007.5 SectionsAbout ToolsAdd to favorites ShareFacebookTwitterLinked In John O’Neill is the subject of the second article contributed by Special Interest Division 7, Aural Rehabilitation and Its Instrumentation, highlighting the work of master clinicians in audiologic/aural rehabilitation (AR). While in his doctoral program at Ohio State University, O’Neill worked in an AR program under the direction of staff that included three individuals from the Army and another from the Navy AR programs. The intensive residential program included hearing aid evaluation and dispensing, individual and group speechreading, and auditory training along with psychological counseling. He served on the Ohio State faculty and then joined the faculty at the University of Illinois, where currently he is professor emeritus. O’Neill became one of the founders of the Academy of Rehabilitative Audiology (ARA), and has served as its president. He was ASHA president in 1969. You have published and presented extensively on the complementary nature of vision and audition. What do you think is the historical impact of speechreading on the professions of audiology and speech-language pathology? Speechreading along with auditory training was one of the approaches to working individually with people who have hearing impairments that enabled audiology to separate from education of the deaf. Once audiology began to work with people who are hard of hearing, it utilized a therapeutic model that gave some emphasis to the need for speech training. Thus audiology and speech-language pathology needed to interact with each other. Some of our colleagues believe that traditional adult AR therapeutic intervention approaches such as auditory training and speechreading are no longer crucial components of the treatment of hearing loss. What is your opinion? I believe that a traditional-based AR therapeutic approach is still needed. Some individuals who receive hearing aids feel they do not help as much as desired. Other individuals who are hearing impaired cannot or choose not to utilize amplification because of slight or mild hearing loss or perhaps moderate or severe hearing loss with poor speech recognition. Both groups need help in developing emphasis on visual and auditory cues as well as developing coping mechanisms. As the population ages, these approaches along with the determination of previous communication skills will become necessary. How do you feel about the recent technological advances that have made services like speechreading and auditory training available for use as home-based interactive self-study? Home-based interactive services for speechreading and auditory training have a place for those individuals who have transportation and mobility problems. Such programs will need initial interaction with a clinician before the start of the programs. Further, there will be a need for a monitoring source. A continuing problem with any type of treatment program is the lack of an objective measure of significant improvement. What are your views on the current state of AR and what changes do you foresee in the future? I feel AR is quite neglected today with the clinical and research emphasis on the characteristics of the hearing aid and the function of the inner ear. In my experience, some recent AuD graduates tend to think in terms of fitting an ear rather than fitting an individual with a hearing loss. Until AR proves to be economically feasible, it will not be recommended often. Ongoing research is encouraging on the effects of individual speech elements on success in speechreading and aural reception in quiet and noise. Such approaches will give some objectivity to AR. The increase in the number of cochlear implants reveals the need for audiologic/aural rehabilitation or habilitation as a necessary part of success with some procedures. Increased attention should be paid to the individual needs and long-term performance of individuals who have received a hearing aid. Training of AuD candidates should include more of an emphasis on the value of and need for AR. Author Notes Joseph Montano, AdD, CCC-A, is director of audiology and speech-language pathology at New York Presbyterian Hospital-Weill Cornell Medical Center. Montano’s clinical expertise is audiologic rehabilitation with a particular interest in adjustment to adult-onset hearing loss, hearing assistive technology systems, and hearing aids. Contact him at [email protected]. Advertising Disclaimer | Advertise With Us Advertising Disclaimer | Advertise With Us Additional Resources FiguresSourcesRelatedDetails Volume 12Issue 8June 2007 Get Permissions Add to your Mendeley library History Published in print: Jun 1, 2007 Metrics Current downloads: 171 Topicsasha-topicsleader_do_tagasha-article-typesleader-topicsCopyright & Permissions© 2007 American Speech-Language-Hearing AssociationLoading ...

Teaching fever aphorisms: Osler revisited

Sir William Osler was a master clinician, renowned for his clinical method, attention to detail, and his diagnostic acumen. In Osler’s era, infectious diseases were rampant and Osler had the opportunity to observe and write about many infectious diseases that he encountered at the time. In his famous Textbook of Medicine, published in 1892, pride of place goes to infectious diseases, and the infectious disease section begins with 39 pages devoted to typhoid fever. Because diagnostic tests available at the time were limited, Osler based his diagnoses on a careful analysis of the patient’s febrile response and correlated that with the clinical findings to arrive at a diagnosis. Osler was able to correctly diagnose infectious diseases with similar presenting symptoms based on his careful analysis of the patients’ fever curves. He was also careful to note the relationship of each patient’s pulse to fever [1, 2]. In the 1850s, the most important differential diagnostic problem in infectious disease was the differentiation of typhoid fever from malaria. Most clinicians at the time were so confused by the similarity of symptoms of these disorders that the diagnosis of “typhomalaria” was used. “Typhomalaria” was a testimony to the lack of attention being paid to the details of fever curves associated with typhoid fever compared to those of malaria [3–5]. Osler not only appreciated that relative bradycardia was a cardinal sign of typhoid fever, he also understood the temporal relationships between relative bradycardia and the natural history of the infection. In the medical literature today, many authors report that relative bradycardia is not often present in typhoid fever and therefore is a less reliable diagnostic finding than previously described [1, 6]. Osler was careful to note that relative bradycardia occurred late rather than early in the natural history of typhoid fever. Today, we rarely have the opportunity to observe the untreated natural course of an infectious disease for more than a few days because of economic constraints on length of stay for hospitalized patients. However, this does not detract from the validity of his observations and it accounts for the discrepancy between his and contemporary descriptions of the incidence and diagnostic importance of relative bradycardia in typhoid fever [7, 8]. Osler solved the “typhomalarial” diagnostic dilemma by carefully comparing the fever curves and pulse relationships of these two different infectious diseases, thereby debunking “typhomalaria” forever. He also noted that coinfection is rare; patients have either typhoid fever or malaria and rarely, if ever, both simultaneously [1, 8]. Clinicians today often lament the excesses and undue reliance on diagnostic testing at the expense of careful diagnostic methods at the bedside. The lack of careful observation and diagnostic reasoning skills all too often lacking in some house officers is regrettable but, in part, it is the fault of many training programs. More time is spent ordering CT scans than in analyzing the patient’s fever curves and correlating them with clinical findings. How many hours of house staff core lectures or conferences throughout the academic year are devoted to the diagnostic significance of fever? If included in core lectures, fever of unknown origin, or the pathophysiology of fever are the topics covered most often. House officers are faced with diagnosing acute fevers in their hospitalized patients every Eur J Clin Microbiol Infect Dis (2007) 26:371–373 DOI 10.1007/s10096-007-0286-4

A Look at AR in the Last Decade

A Look at AR in the Last Decade

The role of the clinician educator in rheumatology

In the last 20 years, the clinician educator has become an integral, indispensable part of the academic team. Competition for clinical revenue and increased rigor of mandating physician competency and evidenced-based treatments have created a niche in academia in which the clinician educator can thrive. Academic clinician educators are needed in adult and pediatric rheumatology. A two-tiered system for promotion exists: research and publication are still rewarded faster and acknowledged more than teaching and excellence in clinical care. Clinician educators must be better prepared for teaching, stimulated to create new curricula and methods of evaluation, and provided opportunities to publish their work. Faculty development programs and advanced degrees in education are essential, and promotion criteria must be modified. Clinician educators have a place in academia, but they must continue to thrive as master clinicians, innovators in competency-based teaching methods and evaluation, and contributors to the literature.

Is there an association between occlusion and periodontal destruction?: Only in limited circumstances does occlusal force contribute to periodontal disease progression.

Examining the long-standing controversy about the role of occlusion in periodontal disease is a delightful look back at more than 100 years of periodontal theory and practice. The list of authors who have written on this topic in the past century reads like a “Who's Who” of some of the brightest minds in dentistry, and the debate has endured through several defined eras in the history of the specialty of periodontics. From the days when periodontics was dominated by those initially trained as pathologists, through the period when the specialty was led by master clinicians headquartered at certain universities, through an era characterized by meticulously controlled human and animal studies conducted both in the United States and abroad, up to the current period of evidence-based therapy, the debate has persisted. It is a reminder that even in this modern era, dentistry still is very much an art as well as a science.

The Power of Passionate Mentoring

You have accessThe ASHA LeaderAcademic Edge1 Sep 2006The Power of Passionate MentoringMentoring: Person-to-Person Professional Development Ray D. Kent Ray D. Kent Google Scholar More articles by this author https://doi.org/10.1044/leader.AE.11122006.26 SectionsAbout ToolsAdd to favorites ShareFacebookTwitterLinked In Advisor, tutor, master, sponsor, model, coach—these are six roles performed by a mentor. These roles enable the mentor to guide, equip, and encourage someone who is preparing for a professional career or other responsibility. The accomplished mentor emphasizes different roles as the needs of the protégé change, so that mentoring is dynamic and adaptive. Of course, mentors do not necessarily rationalize their work by thinking, “Today I will be more of a sponsor and model as opposed to an advisor or tutor.” Rather, the idea is that reflecting on these roles with respect to the protégé’s needs helps to remind mentors of the various ways they can help their protégés develop the skills and attitudes needed for career success. Mentoring takes different forms that are often determined by characteristics of the mentor, the protégé, and the circumstances of their association. Mentoring can be formal, such as when a department or supervisor assigns a mentor to someone who was recently recruited. More informal varieties of mentoring can arise through common interests or a connection of some kind. Mentors may be master clinicians, senior scientists, experienced teachers, or leaders in a profession who share their expertise with younger or less experienced individuals. Distal mentoring is increasingly important, as mentors and protégés connect by means of the Internet or by telephone. These opportunities enable mentoring across long distances. The tradition of mentoring is rooted in Greek mythology, when Odysseus (Ulysses) entrusted the care of his son, Telemachus, to Mentor. Mentor’s name survives to this day to refer to the activity in which an experienced person takes an interest in one who is less experienced, to guide him or her to proficiency. Over time and across circumstances, mentoring has served different purposes, such as grooming younger individuals in business, aiding nurses in the transition from classroom to ward-based training, developing research skills in graduate students, and teaching reflective and self-evaluative thinking to professionals of many kinds. In academic and professional circles, mentoring is the means to implicit knowledge about the “hidden curriculum,” that is, professionalism, ethics, values, career development, financial issues, and the art of practice. This implicit knowledge complements the explicit knowledge that is found in curriculum content. Mentoring offers mutual benefits to the protégé and the mentor. The protégé naturally benefits from the mentor’s experiences and may be supported financially, emotionally, and professionally. The mentor, in turn, generally experiences career growth and satisfaction, increased productivity, new ideas, networking, and self-evaluation. Selected References Berk R. A., Berg J., Mortimer R., Walton-Moss B., & Yeo T. P. (2005). Measuring the effectiveness of faculty mentoring relationships.Academic Medicine, 80, 66–71. CrossrefGoogle Scholar Johnson W. B. (2002). The intentional mentor: Strategies and guidelines for the practice of mentoring.Professional Psychology—Research & Practice, 33, 88–96. CrossrefGoogle Scholar Mahayosnand P. P., & Stigler M. H. (1999). The need for mentoring in public health.American Journal of Public Health, 89, 1262–1283. CrossrefGoogle Scholar Minghetti N. J. et al. (Eds.) (1993). Research Mentorship and Training in Communication Sciences and Disorders. Rockville, MD: American Speech-Language-Hearing Foundation. Google Scholar National Academy of Sciences, National Academy of Engineering, Institute of Medicine (1997). Advisor, teacher, role model, friend. Washington D.C.: National Academy Press. Google Scholar Rose G. L., Rukstalis M. R., & Schuckit M. A. (2005). Informal mentoring between faculty and medical students.Academic Medicine, 80, 344–348. CrossrefGoogle Scholar Author Notes Ray D. Kent, is professor emeritus at the University of Wisconsin-Madison and currently serves as ASHA vice president for research and technology. Contact him by e-mail at [email protected]. Advertising Disclaimer | Advertise With Us Advertising Disclaimer | Advertise With Us Additional Resources FiguresSourcesRelatedDetailsCited ByPerspectives of the ASHA Special Interest Groups6:3 (601-609)25 Jun 2021Undergraduate Student Success Initiatives in Communication Sciences and DisordersJairus-Joaquin Matthews, Twyla Perryman and Dena Kneiss Volume 11Issue 12September 2006 Get Permissions Add to your Mendeley library History Published in print: Sep 1, 2006 Metrics Downloaded 718 times Topicsasha-topicsleader_do_tagleader-topicsasha-article-typesCopyright & Permissions© 2006 American Speech-Language-Hearing AssociationLoading ...

Fatal Flaws

Back to table of contents Previous article Next article Book ForumFull AccessFatal FlawsJohn OLdham M.D., M.S.,John OLdham M.D., M.S.Search for more papers by this author,Published Online:1 Jun 2006https://doi.org/10.1176/ajp.2006.163.6.1115AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail From the pen of a master educator and clinician, Fatal Flaws, by Stuart Yudofsky, M.D., is a remarkable gift to mental health practitioners everywhere. Drawing on years of clinical experience, Dr. Yudofsky allows us into his consulting room and shares his views and strategies about how best to help patients who suffer from severe, complex, and disabling personality disorders. Most importantly, after careful “de-identification” of each patient, he presents (from enviably detailed and preserved clinical records) selected dialogues between himself and his patients as well as between his patients and their friends, family members, employers, and others with whom they have interacted regularly. Fatal Flaws is not designed to comprehensively cover all ten DSM-IV-TR personality disorders, but those presented include the personality disorders that are most disabling and prevalent in clinical practice (antisocial, borderline, histrionic, narcissistic, obsessive-compulsive, paranoid, and schizotypal). In addition, one “unofficial” personality disorder that Dr. Yudofsky labels addictive personality disorder is included. Each chapter focuses on a particular personality disorder and begins with a brief narrative capturing the essence of that disorder. A beautifully written case presentation follows, drawing the reader into the life story of the patient. A summary of the main features of the personality disorder in question is then provided, including its epidemiology, genetics, neurobiology, and typical psychosocial dynamics. Sidebar tables identify key principles in diagnosis and treatment, and the chapter then returns to the patient to delineate the course of treatment and long-term outcome.Dr. Yudofsky does not mince words when he states his beliefs, yet his experience, his conviction in the benefit of treatment, and his compassionate presentation of his recommendations to patients or families always preserve the clear principle that treatment is a partnership and that patients must make their own decisions about whether to follow his advice. An example of his wisdom and refreshing candor is as follows: “Many uninformed critics of psychology and psychiatry believe that…advice for extended, intensive treatment is self-serving by professionals, whom they accuse of trying to increase their fees. Rather, similar to dosage and duration requirements for all antidepressants to be effective, the psychotherapy of people with…personality disorder[s] necessitates an adequate frequency…and period of time…. I believe that undertreatment of people with personality disorders is mistreatment” (p. 64). Dr. Yudofsky never demonizes families as presumed causative agents of the personality disorders of their children; he does not, however, shirk from identifying the important role of dysfunctional families when they are central to the problem. On the other hand, he takes pains to point out plausible alternatives; for example, a child biologically predisposed to develop severe narcissism could have loving, caring parents but be unable to perceive their caring, a problem he describes as a brain-based condition in the child (p. 120).Fatal Flaws is a stimulating and compelling book that, after reading, one feels gratefully mentored, in this case by the author himself—similar to the generous appreciation Dr. Yudofsky expresses in the opening pages of the volume to his own teachers and mentors. Charleston, S.C. FiguresReferencesCited byDetailsCited ByNone Volume 163Issue 6 June, 2006Pages 1115-1115THE AMERICAN JOURNAL OF PSYCHIATRY June 2006 Volume 163 Number 6 Metrics PDF download History Published online 1 June 2006 Published in print 1 June 2006

Review of Interpersonal Reconstructive Therapy: Promoting Change in Nonresponders.

Reviews the book, Interpersonal Reconstructive Therapy: Promoting Change in Nonresponders by Lorna Smith Benjamin (see record 2003-02042-000). Lorna Smith Benjamin offers a refreshing and unique treatment approach with this book, for a group of patients who are defined less by a specific diagnosis than by their failure to respond to one or more treatment trials. A master clinician, Benjamin has spent most of her career researching and treating the interpersonal processes of patients with personality disorders and other interpersonal problems. Benjamin is especially impressive when describing the causality of the proposed model and the treatment. Reviews of empirical research are interwoven throughout the middle chapters and are linked smartly to critical treatment issues (e.g., attachment theory, insight, empathy, the therapeutic alliance). Benjamin's own research tool, the Structural Analysis of Social Behavior (SASB), is referred to throughout, but mostly discussed in a single chapter. Those knowledgeable in SASB will immediately recognize it in most of the treatment concepts. Yet those who are not familiar with SASB will have no problem mastering this book, even if they entirely skip the SASB chapter and references. It's hard to imagine many clinicians not advancing their own thinking and practices about working with their most difficult patients by reading this book. Benjamin has advanced the understanding of working with difficult patients to a new level. Regardless of whether this book proves to be superior in clinical trials, Benjamin's unique contribution to thinking about therapy is already a classic. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

Commentary on Vittorio Gonella's “Contribution of Harold F. Searles to An Emerging Therapeutic Relationship with a Chronic Schizophrenic Man”

Vittorio Gonella has given us an article that deserves wide reading. While written by a novice, it sets a standard of excellence few of us planning our retirements could equal. Not only does Gonella convey the essence of humanism, but he places this effort in the scholarly context of drawing inspiration from a master clinician. He thereby pays homage to Harold Searles and makes clear that a tradition of intensive interpersonal work with severely ill patients will continue for decades. Gonella will become a powerful teacher in his own right; he wants to bring the Other along with him toward a shared experience and understanding. Another Italian, Giovanni Stanghellini, a faculty member of the Department of Psychiatry, University of Florence, reminds us of the centrality of phenomenology in work with psychosis, a fact that was very clear to psychiatrists even at the beginning of the 20th century. If we look at articles by authors who published in journals such as the American Journal of Insanity a century ago, we find wonderfully colorful case histories and clear and intimate accounts of treatment sessions (Silver, 2002). The authors speculated on psychodynamics, using tools they were discovering from studying Freud’s early papers; they approached their work with zest. To keep our own perspective vibrant, we need to revisit the youthful days of our profession and to support the youthful adventures of early career mental health professionals. Stanghellini’s 2004 thesis, grounded in the works of Heidegger, Husserl, Mead, and many others, is that phenomenology is the science of experience. “The fundamental issue addressed by phenomenology is how to approach consciousness (including self–consciousness) . . . The goal of this close description of the phenomena of consciousness is to find the essential laws of consciousness . . . phenomenology is methodologically essential for psychopathology, whose endeavour is primarily illuminating the quality of subjective experiences, their personal meaning,

Osler, Flexner, apprenticeship and 'the new medical education'

These are bewildering times for doctors who teach medical students. The UK General Medical Council (GMC) has reminded them they have a duty to teach,1 yet stirred up such radical change that their task is unrecognizably different from what they themselves experienced as students.2,3 This essay draws on biographies of two people who changed the face of medical education in the 20th century to trace the origins of this bewilderment and suggest a direction for the 21st century.4,5 Most of today's doctors just associate the name of William Osler with nodes they were taught about but never see. In Michael Bliss's biography, he comes to life as a master clinician, apprentice-master, and humanist role model. I first became aware of Abraham Flexner as the author of a century-old report that got medical education into the mess it is in today. Wrong. He was a visionary educationalist who raised standards of medicine round the world by wedding it with biomedical science. After vignettes of these two men, I describe what the GMC has recommended and read between the lines of its recommendations. To finish, I suggest the wheel has come full circle. Apprenticeship, central to Osler and Flexner's educational visions, needs to be revitalized.

New Doors: A Community Program Development Model

SUMMARYThe need to provide occupational therapy services across a continuum of care has stimulated interest in moving into community-based arenas of practice. Limited job opportunities and lack of awareness of the benefits of occupational therapy are common barriers to this movement. This case study illustrates the “New Doors Model” and describes how a partnership between the university, master clinicians, students, and community agencies can result in (1) expanding occupational therapy services to facilities that have not historically interacted with occupational therapy, (2) training occupational therapists and occupational therapy students, and (3) promoting employment of occupational therapists by community organizations, and (4) a scholarship of practice that studies and supports the development of occupation based practice in community settings. The New Doors Model begins with exposing new sites to occupational therapy through level I fieldwork, progressing to level II fieldwork, and ending with creation of permanent occupational therapy positions

Women and Academic Psychiatry

This special issue of Academic Psychiatry provides an excellent and varied series of articles that celebrate the richness of women in psychiatry and highlight many of the challenges facing female psychiatrists in academia. The articles include surveys of female psychiatrists’ activities (1–3), reviews of the issues facing women in medicine and psychiatry during training and throughout their careers (4–7), and descriptions of the personal journeys of three academic psychiatrists with different backgrounds (8– 10). Since women now constitute approximately 46% of U.S. medical students and more than 50% of psychiatry residents, a better understanding of the issues and career paths of women in medicine and psychiatry is vital for those responsible for training physicians and structuring academic and medical care systems if we are to realize the full potential of women in our field. Psychiatry, pediatrics, and, more recently, obstetrics/gynecology have been the specialties most frequently chosen by female physicians due to the patient populations these specialties serve and the skill sets they require. In addition, many women choose psychiatry because it can be better time-defined than most other specialties and less intrusive to the rest of the practitioner’s life, therefore making its practice more compatible with parenting and other family roles. Although not overly-abundant, psychiatry has visible female leaders and role models, with several women having served as presidents of major psychiatric organizations and female psychiatrists holding prominent practice roles in the community. Today, female psychiatrists are more likely to enter academic careers than they were in the past but less likely than men to remain in academia or rise to the highest ranks. As a result, female psychiatrist role models at the highest academic ranks are sparse, and most Chairs and departmental leaders are still men. Many senior female psychiatrist role models are master clinicians and therapists, often serving as parttime or clinical faculty rather than full-time academics. Some suggest that this is a cohort effect that will change as more women enter our field and that women will eventually rise to academic and organizational leadership roles proportionate with their numbers. However, I believe that this prediction is unlikely, as women have a harder path than men in medicine and psychiatry because of both societal and professional cultural expectations. Our society continues to expect women to be primarily responsible for child and family care giving and the maintenance of the home, an issue, noted in one of the articles (9), that is even more significant in certain subcultures and for some international medical graduates. With the increasing number of dual career families, one member, usually the man, is expected to work full-time and earn the majority of the family income, while the other, usually the woman, is expected to decelerate her career and if necessary work only part-time in order to allow for time to take care of the children and the home. The training and junior faculty years coincide biologically with the usual time for child bearing and child rearing, resulting in female physicians with children being unable, and often unwilling, to devote full-time to a career that conflicts with their concurrent family responsibilities. This puts them out of step with the usual academic expectation that junior faculty are to devote full-time attention to their careers and establish a track record of productivity if they wish to be successful. In addition, postresidency research training, in either a formal fellowship or as a member of an ongoing research group, is often required for a physi

Iranian Cinema, 1968–1978: Female Characters and Social Dilemmas on the Eve of the Revolution

This article assumes that cinema is one of society's media for self-reflection, reaffirmation of values and charting alternative courses of action. Specifically, I focus on female characters in Ira...