All three involve both education and health care delivery.A 2014 external review of medical schools in Israel identified several issues of importance to the nation’s health. This paper focuses on three inter-related policy-relevant topics: planning the physician and healthcare workforce to meet the needs of Israel’s population in the 21The physician workforce is aging and will need to be replenished. Several physician specialties have been in short supply, and some are being addressed through incentive programs. Israel’s needs for primary care clinicians are increasing due to growth and aging of the population and to the increasing prevalence of chronic conditions at all ages. Attention to the structure and content of both undergraduate and graduate medical education and to aligning incentives will be required to address current and projected workforce shortage areas. Effective workforce planning depends upon data that can inform the development of appropriate policies and on recognition of the time lag between developing such policies and seeing the results of their implementation.stáge), and graduate medical education (residency) are conducted as separate “silos” and not well coordinated. The content of basic science education should be relevant to clinical medicine and research. It should stimulate inquiry, scholarship, and lifelong learning. Clinical exposures should begin early and be as hands-on as possible. Medical students and residents should acquire specific competencies. With an increasing shift of medical care from hospitals to ambulatory settings, development of ambulatory teachers and learning environments is increasingly important. Objectives such as these will require development of new policies.The preclinical and clinical phases of Israeli undergraduate medical education , the mandatory rotating internship  in Israel is financed primarily through universities, and they receive funds through VATAT, an education-related entity. The integration of basic science and clinical education, development of earlier, more hands-on clinical experiences, and increased ambulatory and community-based medical education will demand new funding and operating partnerships between the universities and the health care delivery system. Additional financing policies will be needed to ensure the appropriate infrastructure and support for both educators and learners.If Israel develops collaborations between various government agencies such as the Ministries of Education, Health, and Finance, the universities, hospitals, and the sick funds (HMOs), it should be able to address successfully the challenges of the 21st century for the health professions and meet its population’s needs. The principal objective of medical education throughout the world is preparation of a competent workforce of highly skilled physicians who are prepared to handle the challenges they will encounter daily and are capable of responding to the changes in medical practice that inevitably will arise during their working careers.The capacity of any nation to meet the health care needs of its population depends upon the specific policies and infrastructure that govern the education, postgraduate training, and support of its health care workforce, including physicians and other health care professionals. Since it takes at least 10 – 14 years to educate and train physicians, depending upon their specialty, development of a suitable national physician workforce requires a lot of forward thinking and coordination of resources. Unfortunately, most national governments manage education, health care, and other social services necessary to promote health through a variety of different agencies or ministries without any overarching coordinated workforce strategy or plan. Israel is no exception.ad hoc external committee appointed by the Israeli Council for Higher Education  to perform a review in 2014 of Israel’s four accredited medical schools. The committee’s General Report to the CHE has many recommendations related to a wide spectrum of school-specific, education-specific, and broad national policy issues.1The authors of this paper were members of an The committee, in writing this paper, recognizes that the Israeli health care system and medical education system have developed against a background of warfare and generations of high immigration. This has resulted in Israel’s having a very large number of physicians coming from varied medical educational backgrounds, a large increase in the population to be served by the health system, and great diversity of the population. The committee members were struck by the fact that Israeli medicine had so rapidly reached an advanced stage, and that there were many similarities between the critical issues faced in Israel and those in the United Kingdom (U.K.) and the United States (U.S.), countries with much longer histories of development of their health care and education systems.In the U.K., U.S., and Israel, there are issues involving the development and financing of the physician workforce. Three key issues are: workforce planning; enhancing the coordination and efficiency of medical education across the continuum of education and training; and the continual need to examine the financing of all the stages of medical education and training so that they best support development and deployment of the needed workforce. In Israel, these issues extend well beyond the purview of the CHE, the agency that commissioned our review of medical schools and formal reports. The collaborative solutions necessary to achieve more efficient and effective production of the Israeli physician workforce will need to involve a varied group of stakeholders including several government, public, and private entities. Given the small size of the country, the intimacy of the academic and practice environment, and the degree to which both the educational and health care systems are supported by government funding, the committee sees great opportunity to attain even better results in planning and developing Israel’s national physician workforce.In 2014, a committee of eight senior physicians, who have all had wide experience in medical education and collectively have had extensive experience in areas such as clinical care, research, and management, was assembled by the CHE to perform a periodic review of the four older, accredited medical schools in Israel: Ben-Gurion University, Hebrew University Hadassah, Tel Aviv University, and the Technion. Reviews of these schools had occurred in 2000 and 2007. This, however, was the first review committee whose chair was not Israeli and whose membership consisted primarily of non-Israeli physicians. The eight person committee included four from the U.S., two from the U.K., and two from Israel. Although not part of the original charge to the committee, four members also made a brief advisory visit to the new Bar-Ilan medical school in the Galilee. All school visits took place between mid-February and early June, 2014.In preparation for the committee’s reviews, each of the medical schools produced an extensive self-evaluation report. The CHE specifies the format the schools are to use for the self-evaluation reports  and for ad hoc committee. Accepted reports with their recommendations then serve as the basis for follow-up with the schools.The LCME’s standards for accreditation and reaccreditation of medical schools in the U.S. are explicit . There iThe members of the committee read the self-evaluation reports in advance of their meetings and then spent approximately one work week on each school’s review, including a day of preparation, a three-day site visit, and a day developing an initial report including observations and recommendations. The site visits consisted of meetings with administration, faculty, and students with each school being allowed by the CHE to decide who the committee should meet within each category and what it should see. Additional writing and editing of the reports for each school was done remotely. The reports were submitted to the CHE which, in turn, distributed them to each school for reaction and response before they were presented to the Council.The committee, informed by the reviews of each school and by the extensive prior experience of each committee member, also identified a large number of general, or national, issues that comprised the basis for the committee’s General Report to the CHE. The general issues included: the organization and conduct of the medical study programs across the country; institutional policies and practices among the medical schools’ parent universities; the health system in Israel and its interaction with the process of medical education; and a variety of other considerations of national importance.This paper, written for a policy-making audience, has a section devoted to each of the three key issues mentioned above: workforce planning; enhancing the coordination and efficiency of medical education across the continuum of education and training; and financing medical education. Each section opens by referring to a table listing pertinent knowledge and observations of the committee.National planning and management of the physician workforce is “an important subset of overall health workforce planning and management, which contributes to a country’s having an effective and efficient health care system.” Nonetheless, it is “a multifaceted, difficult, and even controversial activity” . Table 1Planning a national workforce for the future requires having good information on the current composition of the physician workforce and its dynamics, e.g., age distribution, regional distribution, entrants to the profession each year, emigration of physicians from the country, retirements, etc. It requires knowing how adequately the existing physician workforce meets current population needs; and it requires projection of future population needs. The process also requires an understanding of how the workforce might be supplied and whether there are alternatives to physician services.In the U.K. the GMC maintains a register that records specialty, including primary care. Recently the GMC has introduced a re-registration process termed “revalidation”.Depending upon the way it crafts its policies, a country can vary the degree to which it educates its own physicians or imports them after they have studied medicine in other countries. In the U.S., U.K., and Israel, a significant percentage of practicing physicians have gone to medical school abroad. In the U.S. and U.K., approximately 25 % of practicing physicians have received their medical degree from schools in other countries. All physicians in the U.S., irrespective of where they went to medical school must pass the U.S. Medical Licensing Examination (USMLE) in order to apply for medical licenses. In addition, in order to apply for a medical license in the U.S., all international medical graduates must complete graduate medical education (residency) within the U.S., even if they already have undertaken graduate medical education in another country. In the U.S. approximately 20 % of international medical graduates, or five % of all U.S. practicing physicians, are Americans who studied abroad.In Israel, data on newly licensed physicians show that in the years since 1995, over 50 % each year have studied medicine abroad . But, whIn the U.K., where most physicians and other health care workers either are employed by the NHS , or receive most of their revenue from it, there have been attempts at central planning of the physician workforce. In 2012, the Higher Education Funding Council for England (HEFCE) and the U.K. Department of Health published a review of medical and dental school intakes that included a review of what had happened following the third report of the Medical Workforce Standing Advisory Committee in 1997, and on this basis made recommendations for the next several years , 9. In cAt the present time, both Israel and the U.S. are attempting to increase the number of physicians who receive a medical degree from schools within the country. In the U.S., although there were no new medical schools between 1986 and 2001, as a result of a projected physician shortage, and without a government mandate, 17 new schools granting the MD degree have opened since 2002. Combined with increases in class size in some older medical schools, overall enrollment is projected to increase by 30 % from 2002 to 2017 . The U.SIn the U.K., several new medical schools and programs have opened in recent years including some that offer post-baccalaureate four-year programs. There are now 33 medical schools in the U.K. including nine that have opened since 2000.In Israel, the government requested substantial increases in the size of the undergraduate student body in the medical schools and has fostered the development of the new Bar-Ilan medical school . As noteAcross all three countries, despite increased numbers of medical students in existing and new schools, there are short supplies of various medical and surgical specialists, e.g., psychiatry and neurology in the U.S., emergency medicine in the U.K., and fields such as anesthesia, neonatology, and intensive care in Israel. In all three countries, there are growing shortages of primary care physicians, and we shall focus on that issue here.The U.S. is known to have a higher ratio of specialists to primary care physicians than other developed countries and is widely believed to have a shortage of primary care physicians. Yet, data from the U.S. demonstrate that a locally higher primary care supply and a locally lower ratio of specialists to primary care physicians are associated with lower age-adjusted mortality and mortality from specific causes such as heart disease and cancer . This haThe 2012 OECD report on health care quality in Israel  creditedThe OECD report also noted a paradox - that one of the major factors helping to ensure the adequacy of the Israeli primary care workforce in recent decades is now a factor placing the future physician supply in jeopardy, particularly in the periphery. Many physicians in Israel, including many of the family physicians, entered in the wave of immigration from the former Soviet Union in the early 1990s and many are now beginning to retire. The entire physician workforce in Israel has been aging , and thiThe external committee saw very little emphasis on undergraduate ambulatory and community-based medical education among the schools it visited, with the exception of Ben-Gurion University. Even there, as at the other medical schools, exposure to family medicine consists of a several week block in the sixth year, which is late for influencing specialty choices. In a survey of sixth-year students in Israeli schools at Hebrew University Hadassah School of Medicine and Ben-Gurion University, only 25 % felt that family medicine was an “interesting and challenging specialty”; and this was lower than for specialties currently considered to be in short supply in Israel, e.g., anesthesiology (43 %) and general surgery (62 %) .stáge) was not part of the official charge to the committee, our understanding is that it allows the option of electing, but does not mandate, a family medicine rotation. In 2011, Afek et al. recommended significant changes in graduate medical education [Although review of the mandatory rotating internship  includes several provisions that are expected to increase the supply of primary care physicians. These include increased reimbursement for primary care services, new slots for primary care residents, and expanded low-interest student loan programs for persons choosing a primary care field . In the stáge) year. Financial incentives play a role, but there is also a need to invest in supportive infrastructure. In parallel, there should be an assessment of national primary care needs and the degree to which they are being met by physicians or can be met by other health professionals.Thus, the current and growing primary care workforce supply shortage in Israel is not unique; but it does raise several national policy issues that directly or indirectly affect medical study programs. Though no one thing is in itself sufficient to solve the problem, there are several possibilities for making primary care more attractive and for enhancing the supply of primary care services. Undergraduate medical students need to encounter the subject early in their education; and they need exposure to enthusiastic role models, particularly ones who have been developed to be excellent teachers. In general, there needs to be increased emphasis on ambulatory and community-based medical education including during the internship  that may facilitate its moving to a competence-based curriculum in which the time for UME varies with the learner’s ability to acquire necessary competencies. Also, with a competence-based curriculum it becomes possible to guarantee to the population that each physician who emerges from a training program meets high standards of competence. And, even if the duration of the study program remains fixed, a competence-based curriculum should permit learners who reach acceptable levels of a competence before the allotted time is up either to acquire mastery in that area or to work on acquiring additional areas of competence.Yet another issue is whether Israel can move from time-based to competence-based curricula. Currently, students entering medicine spend three preclinical years, three clinical years, one internship year, and at least four years of residency depending upon the specialty. This is a time-based curriculum. In contrast, a competence-based curriculum would specify levels of competence, or milestones, for each of several competencies that a physician was expected to gain but allow the time in which the learner acquired the competencies to vary , 36. A cThe external committee was asked to look only at UME. In the U.K., the importance of the continuum of development of a physician from entry as an undergraduate through internship and residency into the career-long phase of continuing professional development has been recognized very recently in a decision that the GMC, a regulatory body, should be responsible for evaluating and monitoring all the phases . The extFinancing of medical education generally involves a number of policy considerations and decisions. These relate in part to whether medical education is considered a public good; in part to the fact that the various stages in the education and training of a physician that need coordination might have different financing mechanisms; and in part to the fact that the education and professional preparation of physicians and other health professionals occurs in clinical settings as well as in traditional educational institutions. This contrasts with the education of most other professionals, scientists, and scholars. Not surprisingly, different countries take different approaches to these issues.In the U.S., UME occurs in several types of medical schools including private medical schools with high tuitions, state medical schools with somewhat lower tuitions, and one military medical school, the Uniformed Services University of the Health Sciences, where tuition is waived in consideration for several years’ military service. Students in all civilian medical schools are eligible for a variety of loans and some need-based scholarships. A large percentage of graduating medical students have acquired a significant amount of debt due to loans during both their college and medical school years . During Higher education funding in both the U.K. and Israel derives primarily from two sources: a central funding organization that gets its money from the government; and student tuitions. In the U.K., HEFCE funds undergraduate medical and dental training jointly with the NHS. HEFCE support consists of a grant that is part of the annual funding allocations to each university. It is calculated on the basis of the number of medical and dental students in each medical and dental school; and those numbers are determined by a target for each school.9In addition, students may be eligible initially for student loans and later for scholarships to help support tuition fees. In the first four years of the standard five-year UME curriculum, students can apply to a government organization, Student Finance England.The committee’s findings and observations with respect to financing of medical education in Israel are shown in Table Israeli universities do charge tuition, and the tuition has been rising. Annual tuition fees in Israeli medical schools  are higher than in Europe (approximately 500 Euros = 560 dollars). In the U.K., annual tuition is higher than elsewhere in Europe ; but tuition in both Israel and the U.K. is much lower than in U.S. medical schools which average over 31,000 dollars at public universities and over 53,000 dollars at private universities. Students in the U.S. have school responsibilities that do not permit significant paid work; and they do accumulate very large levels of debt by the time they graduate medical school. In 2014, 84 % of graduating U.S. medical students had debts reflecting their college and medical school expenses; and the average indebtedness for those students with debt was 180,000 dollars . Israel,In Israel a university faculty appointment carries monetary benefits such as sabbaticals and travel funds. In consequence, a faculty appointment represents a financial commitment for the universities. The basic science faculty members are all employed by the universities and accordingly receive university appointments. Young faculty members are expected to do research and teaching. Assuming the university has chosen persons whose research is productive, those faculty members will be promoted within the university as their careers develop. In effect, all that has been built into the VATAT funding formula for the university. In contrast, the clinical teachers are employed by the health system, not generally by the university. Physicians, unlike PhDs, generally do not get salary support for doing research; but in order to be eligible for university appointments and promotions they still are expected by the universities to have done and published research. Thus, they have to do research during uncompensated time, often nights and weekends. And, were the universities to have a more inclusive definition of scholarship that allowed many more clinical teachers to be eligible for appointments and promotions (see above), then the universities would have to make a financial commitment to a group of people they currently do not support. The funds would need to come either from universities themselves or from funds allocated to the delivery system. In either case, there currently are no funds from either source; and the majority of clinical teachers in Israel do not have a university appointment. This is a disincentive to clinicians engaging in medical school teaching during the pre-clinical years or increasing their teaching commitments in the clinical years.There are financial implications to providing more ambulatory-based clinical education. Teaching undergraduates and even residents in the early years of GME in ambulatory settings is known to reduce the clinical productivity of the faculty during the time when they are teaching. Only in the later years of GME do residents usually have the capability of contributing to overall clinical productivity. Thus, if clinicians working in the ambulatory sector who are being paid almost exclusively to be clinically productive are to become more involved in clinical teaching, there will need to be a source of financial support for that teaching. An increase in ambulatory and community-based teaching also involves the need for capital funds. It will require upgrading facilities so that there is space for learners and for related teaching activities. Both this capital expense and the benefits it could provide should be considered against the costs and benefits of expanding hospital facilities and hospital-based clinical teaching.In light of VATAT’s current practice of only providing funding to each individual university, developing and sustaining central resources that can be shared by all the medical schools requires all of the educational institutions to agree jointly to equitable funding for each resource. An alternative would be to supplement the current arrangement with a central source of funding for shared resources and developing a process for planning and allocating funds to the highest priorities.MD-PhD programs are important for developing physician researchers. Though there is some variation, in the majority of Israeli medical schools a student enrolled in an MD-PhD program can receive funding for doing research for only a relatively short period. It has been as short as two years, although three is more common, and sometimes it is possible to extend to four years. In the U.S., support for the research of MD-PhD students is generally four years and can be longer, particularly if the trainee and his/her mentor obtain grant support from one of several sources including pre-doctoral fellowships from the National Institutes of Health.Three medical schools  have four-year English language medical study programs. These programs provide the universities with substantial tuition revenue that complements VATAT funding. With the government’s desire that the Hebrew-language medical school class sizes increase to accommodate national needs, the nation’s hospital resources for teaching are overburdened. Were the English language programs either to be reduced or eliminated to free up some of the hospital teaching resources, there would be a need for alternate funding sources to replace present tuition revenues. Hebrew University, though it does not have an English language program, appears to face a similar clinical resource strain. It has 60 students per year in the military medicine (Tzameret) program, funded by the military, and the smallest number of affiliated hospital beds per medical student .An important first step for Israel would to understand that medical education raises the many financing issues above. A next step would be to establish a collaborative process to address them. It is likely that the process would involve several relevant government ministries and agencies, with input from educational institutions, the sick funds (HMOs), and health care delivery organizations. The distribution of funds for teaching between the universities and the clinical facilities with which they are affiliated seems to have been a contentious issue in the past , and wilWe believe that Israel needs to reform its medical education system to meet the needs of its population for the 21st century. It will be essential to determine workforce needs and examine the capacity of Israel’s medical schools and health care delivery system to develop the number of physicians the country needs. They must be developed effectively and efficiently across the entire trajectory of education and training. Israel’s primary care workforce needs to be augmented in order to sustain the successes recently praised by the OECD ; and at Likely reforms within UME include: adopting interactive learning methods and competence-based education; providing earlier exposure to clinical medicine and more hands-on experiences; increasing significantly the use of ambulatory and community-based clinical facilities for teaching; and ensuring that all physicians will have excellent life-long learning skills to cope with the pace of change that is occurring in medicine and is expected to continue.We definitely believe that Israel can develop an excellent and efficient mechanism for educating the physicians it needs. Israel has the advantage of having a small number of medical schools and a limited number of clinical facilities that will require coordination. It also has the potential advantage of government being the major source of funds both for education and clinical care. Yet, Israel will need to bring into balance the traditional values of higher education institutions and health care delivery organizations. Universities are legitimately concerned about academic freedom and the importance of scholarship. Clinical facilities are legitimately concerned about providing excellent care to their patients. Each type of institution also has legitimate concerns about financial solvency, a pre-requisite for achieving its major mission. Since both the universities and health care delivery system are currently feeling substantial financial pressures, ensuring that the sources of funds to ensure development of the workforce that Israel needs are adequate will require a collaborative effort involving the institutions and their current and potential funders.th century. If Israel does develop collaborations between various government agencies such as the Ministries of Education, Health, and Finance, the universities, hospitals, and the sick funds (HMOs), it should be able to address successfully the challenges of the 21st century for the health professions and meet its population’s needs.We know that Israel was able to prepare an excellent cadre of physicians for the needs of the 20


Based on their characteristics, biological toxins are at the interface of classical biological and chemical agents: for example, ricin and saxitoxin are prohibited substances under both the Chemical Weapons Convention and the Biological Weapons Convention. The latter also prohibits bacterial toxins such as botulinum neurotoxins (BoNT) and staphylococcal enterotoxins (SE). Generally, biological toxins are substances produced by living organisms , but they are not living, hence unable to reproduce, propagate or spread from person to person. Therefore, they share many of the characteristics of classical chemical agents . However, since high molecular weight proteins like ricin or BoNT exert an enzymatic function within the body amplifying their potency, they are clearly different from the low molecular-weight chemical warfare agents and, additionally, they display orders of magnitude of higher specific toxicity to humans.Generally, biological toxins are relevant in the health and food sector as well as in the security sector. On the one hand, biological toxins are linked with natural intoxications worldwide and some of them cause severe and recurrent diseases . On the other hand, the relative ease in preparing some of the mentioned toxins and the world-wide availability of the biological sources constitute them as potential agents of bioterrorism. The ricin-containing letters sent to U.S. President Obama and several other decision makers in the USA in 2003 and 2013 showed that biological toxins can be produced by laypersons and that they can be intentionally released in a criminal act to harm individuals or groups of people. In recognizing that biological toxins are a source of natural intoxications as well as potential agents of bioterrorism, it is important to know how well prepared our vulnerable, open societies are with respect to detection of biological toxins of potential bioterrorism risk. www.equatox.eu) from January 2012 to December 2014. One major goal of the project was to set up a network of nationally appointed laboratories for the detection of biological toxins of potential bioterrorism risk. The EQuATox project focused in-depth on biological toxins and their intricacies with respect to detection, identification, structure and function—topics that might become relevant for an efficient management of natural or man-made incidents involving biological toxins. The main task of EQuATox was to define the status quo of detection technology for biological toxins in EU-28 and associated countries. In this context, the European Union funded a project abbreviated EQuATox  and BoNT. The results are highlighted in a series of 13 articles in the current Special Issue “Detection and Identification of Biological Toxins in International Proficiency Tests” in Ricinus communis in the isoforms ricin D and ricin E, accompanied by the 90% identical agglutinin. BoNT is released by the bacterium Clostridium botulinum and other Clostridia in seven different serotypes and can be grouped into more than 40 subtypes, which can significantly differ in their amino acid sequence. A similar variety occurs in SE with more than 26 isoforms.From a diagnostic point of view, biological toxins are a challenging group of agents as they may act in the absence of the producing organism and its genetic information. Therefore, the focus of detection cannot be—as in the case of viruses and bacteria—on nucleic acid-based methods. Rather, the toxin itself has to be detected either by spectrometric, immunological, chromatographic and functional assays or combinations thereof. The precise detection and identification of biological toxins is difficult, since they naturally occur in different isoforms or variants: ricin, for example, occurs in the plant Generally, different technologies for toxin detection and analysis are in use in expert laboratories. However, there are hardly any universally agreed “gold standard” methods, nor qualified or certified reference materials available for most of the toxins in focus . Expert laboratories currently use various purified in-house materials, which makes any comparison of accuracy and sensitivity of different methods nearly impossible. Furthermore, no interlaboratory exercises for the mentioned toxins had been performed, especially exercises which take into account detection from complex environmental matrices, clinical matrices or food. One major aim of EQuATox in facing these technical challenges was to identify good analytical strategies and to highlight any critical gaps in detection technology. Based on the solid information obtained in four large international proficiency tests—one on each of the above mentioned toxins—it is important to state that there is room for improvement in the standardisation level for the detection of biological toxins. The situation is clearly different to the field of bacterial and viral pathogens, where steps towards standardisation have been successfully taken on an international level. Toxins Special Issue is to highlight the current status of toxin detection focusing on ricin, saxitoxin, SEB and BoNT. For each of the four toxins, a series of manuscripts describes the reference materials produced in the project, as well as the results of dedicated international proficiency tests taking into account the balance between information sharing and confidential issues . Additionally, for each toxin different articles provide information on good analytical practices identified in the exercises. In this context, the data presented provides a solid basis and a starting point for future advancement in quality assurance efforts.The aim of this Toxins for their expert input throughout the project. Special thanks go to all proficiency test participants—it was their scientific input and experimental effort that allowed us to critically evaluate the status quo of toxin detection and to draw meaningful conclusions for future actions.We would like to thank all authors contributing to this Special Issue in


Introduction: Interprofessional learning is a critical pre-requisite for future interprofessional work. Structural adaptations in education offer possibilities to introduce new concepts. Rheumatic and musculoskeletal diseases (RMD) are both prevented and treated by physicians and physiotherapists but the development of interprofessional roles is seldom part of curricula.Project description: A complex, longitudinal interprofessional educational approach for future doctors and physiotherapists was designed and implanted at various stages . Most segments of the RMD curriculum are now based on interprofessional classes. Student satisfaction with learning is continually and comparatively evaluated. Learning success is assessed with practical and written exams.Results: Interprofessional teaching was first introduced in 2013 for 420 first-year and 360 fourth-year medical students, along with 40 first- and third-year physiotherapy majors. The satisfaction with teaching and learning is high and distinctly above average for all teaching areas . The percentage of those who pass the final exam is 94%. 100% of the students surveyed support the continuation of this interprofessional unit.Conclusion: Interprofessional teaching of RMD can be successfully implemented for future physicians and physiotherapists at different learning levels. Bundesärztekammer) [http://www.aerzteblatt.de/nachrichten/62214/Interprofessionelles-Lernen-soll-zu-einer-besseren-Versorgung-fuehren]. Detected barriers are organizational, such as separate and autonomous responsibility for education in each of the different health professions, the educational approach with the more practice-oriented colleges of applied sciences on one and the academic study of medicine based on several years of pre-requisite theoretical learning on the other side.Health professionals collaborate interprofessionally on a daily basis when providing health care to patients. This workplace reality is at present unaccounted by the educational programs in the different health care disciplines taught at German educational institutions and universities, where there is a conspicuous lack of interprofessional education. Based on international experiences , calls tekammer) , . Wi. Wi4]. WRheumatic and musculoskeletal diseases (RMD) pose a great challenge for routine health care. They are not only the most common reason for prescribing medications, formally excusing patients from work, and even for early retirement, but also clearly limit quality of life and ability to participate , 6]. RM. RM6]. RThe musculoskeletal system offers students a good place to start formal learning due to the relative ease of clinically examination, the wide experience of many with injuries, and the often simple, mechanical explanations. Physiotherapists and physicians play both important roles in the treatment of RMD, even though different approaches and therapies are generally available to them. Physiotherapy is often viewed during medical education as a less important and not evidence based form of therapy. Physiotherapists often view the physician primarily as the source of medical orders, and communication is usually limited to a few words or medical indication codes. Whoever has been fortunate enough to experience an interprofessional medical round or case consultation knows that joint assessment and cooperative therapy planning are distinctly more effective.People who have RMD or who wish to prevent it are not just to be viewed as passive recipients of a therapy, but rather to be recognized as active participants who can prevent and treat through their behavior. Even patients must be trained and can be integrated into educational curricula.RMD has many different causes: the basic ones are congenital disorders, age, injury and inflammation. Along with bones and joints, tendons and ligaments, muscles, fascia, nerves, vessels, skin, metabolism and the immune system are all necessary to maintain mobility. Even self-perception and the personal motivation to move and exercise appropriately are central factors in maintaining vitality.Competency-based education regarding RMD is valuable and meaningful when done in an interdisciplinary, interprofessional manner in close cooperation with patients. In cooperation with the School of Physiotherapy and the patient self-help groups at the University Hospital, the Medical School at the Heinrich Heine University has created an opportunity for precisely this by developing and implementing a joint concept for teaching and learning.The changes to the medical program were radical. The pre-clinical and clinical phases have been replaced by qualification phases; competencies and overarching learning objectives were formulated. The curriculum is now no longer sequenced according to subjects, but rather organized under interdisciplinary topic headings.In the following we present how RMD has been included in the curriculum in terms of form and content with a focus on interprofessional education.The teaching of RMD was developed by Rheumatology together with Trauma Surgery and Orthopedics at the different qualification levels; the RMD unit is now jointly taught by these three departments. The design of the educational approach took place over four years with equal participation of all involved subject areas independent of profession. Suggestions were reviewed by the university’s teaching commission and included in the curriculum. The instructors and student representatives meet regularly, at least three times during the academic year, to further optimize teaching, address uncertainties and strengthen interprofessionalism. A coordinator is available to help with short-term solutions.The School of Physiotherapy has restructured its curriculum so that a group of students from one cohort are able to participate in the interprofessional education unit, while the remaining students continue with their practical training.The interprofessional education unit began with the implementation of the competency-based curriculum in Düsseldorf during the 2013/14 winter semester. A total of 420 medical students in their first year of study, 360 fourth-year medical students and 80 future physiotherapists (40 in the first year of training and another 40 in the third) have now participated in this joint learning program. Continuation is intended: in the 2016/17 winter semester the students who began in 2013 will have reached the second qualification phase.Examining the healthy musculoskeletal system is taught in the first year of study. In a block focusing on the human body and movement, gross anatomy is covered theoretically and practically by the anatomical institutes (dissection course). As this is accomplished, basic physical terms are elucidated in an integrated manner and, in close cooperation with the School of Physiotherapy, physical therapy concepts are presented to students early on in the form of practical exercises. Shoulder, hand, knee, back, and foot are the focal topics that are each covered in an interdisciplinary and interprofessional manner over the period of a week  present, explain and practice examination techniques on humans with the first-year students. Physical therapy is presented and learned at work stations. Future physiotherapists have the chance to participate in gross anatomy.During the second semester, general practitioners teach how to record medical case histories. Patients in the local ankylosing spondylitis self-help group participate as example patients on whom students can practice. Future medical doctors can then apply this knowledge of recording case histories and examining the musculoskeletal system during the first general practice internship. A standardized method of documentation was developed for this purpose . Since this is only of partial relevance to the topic of RMD and of no relevance for future physiotherapists, PT students were not included.Starting in the fourth year of study, multiple four-week practical blocks are offered with instruction involving patients (outpatient care or operating room), of which there is one with RMD-specific subjects. These blocks have already been presented in this journal . Just liThe second qualification phase for RMD is structured by a four-week block dealing with the musculoskeletal system. Third-year PT students take equal part in the entire study block. They also take the same final multiple-choice exam. This 60-hour unit is divided into 24 hours of lecture  and 36 hours of seminar , and one week of individual study of cases (CASUS) and preparation for the exam.Major weekly topics cover the musculoskeletal system and aging, accidents and inflammation. Instruction is based on cases that are initially covered in small groups at the start of the week. Along with the core subjects, important aspects are taught in seminars on human genetics, neuropathology, microbiology, psychosomatics, epidemiology, etc., and at the end of each week a summary from the perspective of general practice is presented  and have the opportunity to jointly provide patient care in an inpatient setting. Both groups of students also serve as tutors for the subsequent semesters.Medical students meet up again with the future physiotherapists on hospital wards during their practical year .All of the instructors who took part in the survey reported positive experiences and supported the continuation of this approach .Future medical doctors approached this opportunity to experience interprofessional education with great curiosity, but had no particular expectations . Individual students expressed concern that, as a result of the course, there would be less time available to learn the material covered by the multiple-choice exams.The first-semester students were at first more uncertain about performing physical exams on each other than were the third-year students who had already received instruction in examination techniques. This was addressed right away by including an explanatory introduction. The willingness to participate in the physical examination was more visible among the future physiotherapists and the medical students took this as a “cue” to do the same. Student satisfaction with this curricular unit as measured in the central teaching evaluation , knowledge gain and satisfaction with course structure and sequence were with a mean rating of 2.4 distinctly better than the evaluation results for the other topic-specific study blocks, which received mean ratings of 3.3  are achieved by the great majority of the students. The passing rate for medical students was 94% with a minimum passing grade of 60%; a total of 14% earned the grade of very good, 58% that of good, 14% satisfactory, and 8% achieved sufficient results.A measurable effect of interprofessional education as it is described here on the passing rate for the centralized exams has not yet been ascertained.Access to the university’s electronic learning materials that accompanied the course was not possible at first for the PT students; however, it was possible to arrange for special access.The future physiotherapists experienced the shared learning environment with the medical students as a successful meeting of the two professional groups, who should be closely interlinked for the purpose of providing optimal patient care. Assuming the role of tutor early on, physiotherapy students were able to practice asserting confidence when giving patient care. The future physiotherapists experienced a high level of professional esteem as tutors and the open curiosity of the medical students. The written responses of the medical students regarding the expertise and motivated friendliness of the physiotherapists also obviously provided impetus for even closer collaboration on the wards during the internship. During the subsequent internships, almost all participants continued the productive interaction with those whom they met during the RMD study block. News of the existence of such constructive cooperation has spread and, in turn, led to further synergetic effects in providing therapy and negotiating therapy goals with patients in concrete situations. Physiotherapists realize that they are not only able to but even should contribute to giving physicians deeper insights into the possibilities of physiotherapy so that these therapies can be prescribed in a more targeted manner. Arriving at therapy goals in a team comprised of all those involved offers a basis for the best possible health care. Through joint learning in the module on the musculoskeletal system, a forum for collaboration on equal footing is implicitly experienced and becoming as self-evident as the goal of providing the best possible health care. On the standardized evaluations, all of the respondents  were satisfied with the interprofessional education.Of the future physiotherapists, 91.7% passed the final exam on which there was a minimum passing grade of 50%.While it is easier to implement interprofessional education at medical schools at which training for different professions is offered, as is common in other countries , many diWe are able to present a concept that has been implemented successfully focusing on interprofessional learning between patients, medical and physiotherapy students. Our approach fulfills not only the minimum requirements set by the position paper of the GMA committee on Interprofessional Education for the Health Professions , but is The practical implementation and subsequent evaluation are simpler for the program presented here than for small isolated solutions, for instance those affecting only one seminar. Interprofessional education has become a matter of course in our case.When planning and implementing the curricular changes here, we were able to count on the support of faculty members for program restructuring and a practical focus on competency, as well as on an enthusiastic team representing various professions as being a great help.Individual sequences, such as the physiotherapy “obstacle course,” had already been tried out in other settings (Rheumatology Summer School). As a result, the risk of failure could be reduced.However, the success of such an extensive project is certainly not foreseeable and can only be ensured by frequent re-evaluations. To accomplish this, standardized and required (anonymous) evaluations are helpful, as long as the response rate is assured. The voluntary evaluation was in this case thoroughly supportive and positive, but is not representative with a response rate among instructors of 10%. At the student level, evaluations are for the most part established and can be used as a helpful measure. Organized participation of PT students in the educational design and development has not yet been implemented. This is crucial for long-term success.Confirming the educational approach through passing rates on the central exams is the next step to be taken in this project.When designing an interprofessional approach to teaching and learning, attention should be paid to the steps described by Hall and Zierler ; sufficiThe authors declare that they have no competing interests.


Artificial light at night is profoundly altering natural light cycles, particularly as perceived by many organisms, over extensive areas of the globe. This alteration comprises the introduction of light at night at places and times at which it has not previously occurred, and with different spectral signatures. Given the long geological periods for which light cycles have previously been consistent, this constitutes a novel environmental pressure, and one for which there is evidence for biological effects that span from molecular to community level. Here we provide a synthesis of understanding of the form and extent of this alteration, some of the key consequences for terrestrial and aquatic ecosystems, interactions and synergies with other anthropogenic pressures on the environment, major uncertainties, and future prospects and management options. This constitutes a compelling example of the need for a thoroughly interdisciplinary approach to understanding and managing the impact of one particular anthropogenic pressure. The former requires insights that span molecular biology to ecosystem ecology, and the latter contributions of biologists, policy makers and engineers. Ecological systems are organized foremost by light, and particularly by daily and seasonal cycles of light and dark . First, rotation of the Earth partitions time into a regular cycle of day and night, such that the intensity of incident light at a site typically varies by ca. eight orders of magnitude Fig. . Second,2, precipitation, temperature) have historical analogues, having previously altered naturally over geological or evolutionary time in similar ways to those presently experienced, albeit often at different rates. The most fundamental human-caused change to light cycles has two key characteristics, changes in the spatial and temporal occurrence of light and changes in its spectrum.These daily, annual and lunar geophysical cycles have also remained rather invariant over long periods of time. For example, the Earth’s period of revolution around the Sun has been effectively constant. Its period of rotation around its axis, presently 24 h, has experienced deceleration, such that day length has increased through geological time, from ~21 h at the beginning of the Cambrian Wells . HoweverALAN has introduced light in places, times and at intensities at which it does not naturally occur Figs. , 2. The Light emissions detected from satellite imagery and aerial surveys can bear complex relations to those experienced at ground level. Key features of ALAN on the ground include a marked degree of spatial heterogeneity, with maximum values of intensity in areas of direct illumination, complex patterns of shading on the ground surface due to the number and location of light sources, and large areas affected by lower intensity illumination from reflected and scattered light in the atmosphere. It varies markedly in intensity, with areas such as sports fields and parking lots often lit to illuminance values of several hundred lux or above, ground-level illuminance in the vicinity of street lights around 10–40 lux and reduced to <1 lux several metres away.ALAN that is emitted or reflected upwards can be scattered by water, dust and gas molecules in the atmosphere, resulting in skyglow. Studies of sky irradiance have been made for individual sites, sets of sites, and cities . Urban areas are typically defined in terms of the level of coverage by buildings and associated infrastructure. Estimates of urban land cover are highly variable Gaston , but typTerrestrially, the headlights of road vehicles produce substantial quantities of ALAN. On all but the busiest roads these emissions are temporally highly variable, occur predominantly in the horizontal plane, and are thus underestimated from satellite and aerial imagery. The orientation of these emissions means they may propagate over long distances. They have also progressively increased with major developments in headlight technology  employs the use of artificial nighttime lights as attractants, sometimes on an industrial scale . Almost nothing is known about the form of dose–response curves for ALAN, and thus critically how responses are likely to change when ALAN attains different levels.What are the impacts of ALAN on ecosystem functions and processes? Broadly speaking, most is known about the impacts of ALAN on the physiology and behaviour of organisms, less about those on population dynamics, little about those on communities, and almost nothing about the impacts on ecosystem functions and processes. Given that ALAN can influence the abundances of species and trophic interactions there seems little doubt that such effects on ecosystem functions and processes do occur.Although the potential for ALAN to have significant biological impacts has long been recognized and a large body of studies has ensued  by switching off street lights in low-risk areas from late at night until the early hours of the morning (Gaston et al. Part-night lighting. Many areas are presently lit at times of day when this carries limited or negligible human benefit. Particularly following the global financial crisis, and pressure on public expenditure, numerous towns and cities have sought to reduce energy costs (and COTargeting spectra. There are doubtless substantial opportunities to reduce the ecological impacts of ALAN by employing spatially more nuanced approaches to the use of lighting with different spectral properties. Developing alternatives to presently installed systems, which have often evolved as different technologies have become available and affordable, will require balancing of multiple pressures. These include cost, practicality, human perceived and actual need, and environmental concerns. In general, there would seem to be a number of advantages to the use of reddened spectra in environmentally more sensitive areas because, relative to white or blue sources, these reduce skyglow (Kyba et al. Various management options have been highlighted by which the ecological impacts of ALAN can be limited and/or reduced (Falchi et al. Arguably, there is a trade-off between the economic costs and the perceived social costs associated with implementing these different strategies to managing ALAN. This constitutes the major challenge to limiting its ecological impacts.


N = 38,017), we estimate the impact of the GFC on 1 general and 11 domain specific measures of wellbeing at age 19 and 22. Significant differences in wellbeing in most life domains were found, suggesting that wellbeing is susceptible to economic shocks. Given that the GFC in Australia was relatively mild, the finding of clear negative effects across 2 ages is of international concern.Recent research has suggested significant negative effects of the Global Financial Crisis (GFC) on mental health and wellbeing. In this article, the authors suggest that the developmental period of late adolescence may be at particular risk of economic downturns. Harmonizing 4 longitudinal cohorts of Australian youth ( The influence of macrolevel events and conditions on psychological variables is of central interest within the social sciences . In partIn this article, we took a multidisciplinary approach, using literature and methodological approaches from psychology, sociology, and economics to estimate the impact of the Global Financial Crisis (GFC) on the multidomain wellbeing of Australian youth. To do this we used four cohorts of the Longitudinal Study of Australian Youth (LSAY) with wellbeing measured in 12 domains. Unlike previous research, we used longitudinal data from multiple birth-cohorts to estimate the effects of a unique and pervasive economic crisis. We also used wellbeing measured across most major life domains. This is in contrast to most research to date, which has focused on a single general domain. Furthermore, we leveraged the unique opportunities afforded by the LSAY to estimate these effects at two distinct ages (19 and 22 years of age). To do this we used statistical models, rarely used in previous research, to provide counterfactual estimates of the effect of the GFC .There has been growing interest in recent years of the effects of macrocontext  on individual factors in psychology . HoweverRecent research by In relation to the GFC, a review by Taken together, the literature to date suggests three important considerations. First, changes in macrocontexts, and economic conditions in particular, can have meaningful impacts on wellbeing. Second, these may have an impact upon everyone . Third, consideration of general wellbeing should be supplemented by consideration of domain specific measures within multiple life domains, given findings that social domains of life appear to be vulnerable to economic conditions.Although Socially, not only is the post-high-school period defined by identity formation and uncertainty in social and occupational roles  but it iEconomically, not only is unemployment particularly high during this developmental period, but in Australia, the United Kingdom, and the United States the jump in unemployment levels during the GFC for those aged 16 to 24 was notably larger than for the working population as a whole; youth unemployment in Australia jumped from 8.9% to 13.8%, whereas overall unemployment grew from 4% to almost 6%, in the period of 2008 to 2011 . As noted above, both unemployment and the risk of unemployment has a particularly detrimental effect on wellbeing . The risPsychologists, economists, and sociologists have all been interested in the influence of both micro- and macrolevel conditions on wellbeing. A common thread across much of this research is general or aggregated wellbeing . There is, in contrast, relatively little attention given to how such events might differentially affect multiple life domains. Part of the reason is that it is difficult to determine how many and which life domains to cover. As Derived from the work of Cummins and colleagues, however, youth surveys of the Australian population have covered between 12 to 14 life domains focusing on achievement, social life, community engagement, perspectives on the future, and living standards. These domains are derived from empirical research on what most participants consider to be important and have been used over long periods of time, across countries, and age groups. This provides strong evidence of validity and utility of multiple dimensional measures of wellbeing in these areas see .Thus, taking a multidimensional perspective, we consider the degree to which there are differential impacts of events like the GFC on wellbeing measured in different domains. As noted above, there is some evidence to suggest that social wellbeing and optimism for the future is particularly at risk during economic hard times , yet resHypothesis 1: The GFC will have a negative impact upon young people’s wellbeing across the major domains of importance to late adolescents.Hypothesis 2: We expect the influence of the GFC to differ by life domain, with particular impact on domains related to social life and long-term prospects.Hypothesis 3: As existing research base is not yet large enough on which to make a strong hypothesis, we do not anticipate that there will be differences in the size of the effect of the GFC at age 19 compared to 22.Empirical research suggests economic conditions can lead to significant changes in wellbeing. This literature, however, has tended to use cross-sectional studies without the ability to follow individuals over time. Here we make use of the unique opportunities afforded by the LSAY datasets, which follow young people from four birth cohorts for up to 10 years. The nature of the LSAY data, four birth cohorts measured roughly three years apart, allows us to compare the influence of the GFC at two distinct ages in the post high-school transition period . As can be seen in n = 9,738; ages covered 17–25) and 1984 . Two cohorts did experience the GFC during the study: birth cohorts 1987 at age 22  and 1990 at age 19 . The cohorts are named after the modal birth year. The structure of the data is represented in Four cohorts of the LSAY database were used. Two of those cohorts did not go through the GFC during the time period covered in the study: birth cohorts 1981  particular design effect including the disproportionate sampling of schools and (b) participant attrition . Thus thvery happy) to 4 (very unhappy). To aid interpretation, these answer points were reverse scored such that higher scores reflected greater happiness. An additional response point was included representing “can’t say/don’t know.” This choice was selected by less than 1% of the sample on average and never more than 4% for any question in any wave. This response was coded as missing for the purposes of the current study. Abbreviations will be used for the 12 wellbeing variables (exact item suffix in brackets) as follows: general (your life as a whole), living (your standard of living), home (your life at home), future (your future prospects), career (your career prospects), work , money (the money you get each week), leisure (what you do in your spare time), location (where you live), social , people , and independence .Wellbeing was assessed using a measure similar to the Personal Wellbeing Index (PWI) originally developed by Cummins and colleagues e.g., . VersionThe GFC is generally considered to have begun during 2008. However, the impact on Australia and the individuals in the study likely came later. A long running concern in developmental psychology has been how to disentangle the effects of age, period, and cohort see . Age effEven when such data are available, there are concerns about identifying such effects given they are confounded . To account for this we consider age as fixed . Second, we aim to minimize the influence of cohort by making statistical comparisons between cohorts who were born closest in time thus ensuring that they share much of the same historical context see . Thus, wIn addition to concerns relating to isolating period effects, we were also concerned with providing estimates of the effect of the GFC that were as close to causal as the data would allow. To do this, we aimed to find counterfactual conditions that serve as an indication of what would have occurred to a variable of interest had a given event not occurred . Put simMatching aims to find strategic subsamples of individuals in the exposed and nonexposed groups that either match participants across groups exactly on a small number of critical confounding variables, match approximately on a large number of confounding variables, or some combination of the two . In the The aim of PSM is to create samples of exposed and nonexposed individuals who are similar  on a wide range of potentially biasing covariates. Initial analysis consisted of modeling the relationship between the covariates and presence in either the exposed or nonexposed groups. We used logistic regression to estimate the propensity score and, based on these scores, we used nearest neighbor matching with matches allowed when participants were within .20 of the standard deviation of the logit of the propensity score. As noted above, exact matching was used for several demographic, educational, and occupational status variables. One-to-one matching was used, without replacement see  and regrPRE_Ybefore the GFC (age 18 for the 19 year-old comparison and 21 for the 22-year-old comparison), β is the parameter of interest—the difference in Y between the GFC exposed cohort (coded 1) and control cohort (coded 0). Subscript j was the school that individual i was in at wave 1. Importantly, PSM allowed us to match participants on both grade in school and age in days, thus ensuring participants were similar in both biological and social developmental stage at the comparison point.Here γ represented the effect of the wellbeing variable As a robustness check, and to provide population estimates, we also adapted the logic of DID to estimate the GFC influence across cohorts. A DID approach estimates trends in a variable of interest in an exposed and nonexposed group. It assumes that both trends are essentially parallel and would remain so had an event of interest  not occurred. A DID approach estimates the shift from parallel trends at the exposure point see . The assTypically this model is used to explore the potential effect of a treatment in two or more contemporaneous groups; one in which the treatment is present and one where it is not. For the GFC, however, young people either went through the historical period at a particular developmental stage or they did not. The multiple cohorts of LSAY, however, allow us to extend the logic of the DID approach to noncontemporaneous groups, given that the same measures were collected using the same survey collection procedure on participants of approximately the same age. As noted above, we thus make the assumption that cohort effects are negligible.Following, t refer to individual observations at a given time wave, i refers to individual participants under which observations were nested, and j relates to the primary sampling unit which, in our case, was the school the individuals were in at the first wave of data collection.Where β is the first order estimate of cohort on the wellbeing variable Y, γ is the first order estimate of the GFC and δ is the parameter of interest  provide clustered standard errors for individual observations nested within participants who were themselves nested within schools; (b) apply sample and attrition weights; and (c) multiply impute wave specific missing data. Imputation was achieved using a bootstrapped expectation maximization approach . Given thttps://pdparker.github.io/GFCweb/. Microdata is available by application from the Australian Data Archive (https://www.ada.edu.au/).The means and confidence intervals for each cohort were plotted in the following manner see . HoweverA visual inspection of all the graphs suggested that the 1987 and 1990 cohorts had similar (or slightly higher) levels of wellbeing across domains than the earlier cohorts before the GFC. However, a relatively large gap emerges between the earlier and later cohorts, starting at age 19 for the 1990 cohort and age 22 for the 1987 cohort. Thus, results were consistent with the hypothesis that the GFC had a negative impact on wellbeing. Interestingly, there was some evidence of recovery in 2011 (ages 21 for the 1987 cohort and 24 for the 1990 cohort), where in many cases the wellbeing levels returned to those of the other cohorts before again diverging and growing progressively larger. Finally, the first wave of the 1984 cohort was well below trend and may represent an outlier for consideration in later models.The close-up graphs provide strong evidence for the negative impact of the GFC with most of the relevant contrasts displaying overlapping confidence intervals in the years prior to the GFC before diverging. It was on this basis that we explored the hypotheses using PSM and DID models.Two sets of PSM models were estimated; one comparing the 1990 with the 1987 cohort at age 19 and one comparing the 1987 to the 1984 cohort at age 22. Matching was done exactly on gender, social class, state of residence, and Indigenous status; as well as labor market status, university status, and number of years of high-school completed. Propensity matching was done on age in days and all pre-GFC wellbeing variables. Negative effects indicate that the GFC exposed cohort was lower on wellbeing than the comparison cohort . Importantly, however, these results tended to be smaller than the comparison at age 19 but generally not significantly so. Indeed, As a robustness check to the PSM results we ran a series of DID models. In this case two sets of models were estimated. First, we compared the 1990 cohort (who went through the GFC at age 19) to the 1987 cohort. Second, we compared the 1987 cohort (who experienced the GFC at age 22) with the 1984 cohort. Negative DID estimates represent the disadvantage of the GFC exposed cohort over the comparison cohorts in terms of wellbeing.For the DID at age 19, we found significant results for 11 wellbeing variables when we assumed a common trend (satisfaction with money was not significant) and all 12 were significant when we controlled for cohort specific trends. Of these, nine had effect sizes larger that .10. In order of effect size these were satisfaction with leisure time, social life, future prospects, independence, work, career prospects, home life, general, and people in general. Interestingly, the GFC appeared to have a small positive effect on satisfaction with money.z tests, the GFC had significantly larger effects for 19-year-olds than 22-year-olds in terms of satisfaction with leisure time, where you live, social life, living standards, and future prospects (ordered in terms of size of difference).At age 22, results not controlling for trend were significant in all domains but only two domains when controlling for cohort specific trends  during the same period. Thus, although research in other countries is needed, it is likely that the results in countries such as the United States and the United Kingdom, let alone Greece, Italy, Ireland, and Spain, was considerable. Importantly, given our focus on the population as a whole, unmoderated by individual exposure, the effect sizes of above .10 standard deviation units, and often above .15, were concerning given effects of unemployment of .50 . This suAn interesting effect present in the trend plots for wellbeing was a drop in wellbeing in 2009, consistent with our hypothesis, before a recovering during 2010 and then a step decline again from 2011 to 2013. Although we did not provide a hypothesis for this pattern, exploration of the unemployment rates provides a potential explanation . AlthougRelatively little research has considered the differential effects of macro or micro contextual events on multiple domains of wellbeing. When such a comparison is made it is often done in relatively few domains. Our research was one of the few to comprehensively test the impact of events like the GFC across a wide spectrum of youth’s lives. Previous research has suggested that social domains are particularly at risk. There was some evidence that this was the case with effects on satisfaction with social life, at age 19, and getting along with people in general at age 22 being particularly affected.For both age groups, social domains, general life satisfaction, and satisfaction with career or future prospects appeared to be most strongly affected. Such results are consistent with the developmental challenges these two groups face. In particular, these transition periods are primarily focused on the developmental tasks of developing new friendship networks and renegotiating existing relationships . LikewisImportantly, the findings suggest that the GFC had a significant impact across most life domains indicating that this event touched most aspects of young people’s lives. Importantly, the finding of small, nonsignificant results of the GFC on satisfaction with money suggests that results across domains were not merely a poisoned well effect . As such these findings indicate that economic hard times have a pervasive negative effect on the wellbeing of young people.Although the type of domain effects across 19- and 22-year-olds were similar, a consistent finding was that effects were routinely smaller in the older age group. This difference, however, was only consistently significant in three cases; social life, independence, and living standards. These particular domains may be associated with the many upheavals that occur during the post high-school transition see . As can ceteris paribus comparisons as possible, readers should consider the potential biasing effect of birth cohort differences. Finally, it should be noted that we used single-item measures for wellbeing in each life domain. Multi-item measures would have allowed for latent variable modeling and thus a control for measurement error.There is some tension between the degree to which macroforces represent shared or qualitatively different experiences for different sectors of the community . Here weThe current article was concerned with whether the GFC had an effect on young people’s wellbeing across multiple life domains. We focused on an age group that was undergoing a large number of developmental tasks at a critical period of life that has implications across the life span . We foun


As the number of immigrants to Japan increases, the health problems of foreign nationals also have an increasing impact on Japanese medical institutions. The aim of this study was to clarify the Japan–specific health problems related to both the physical and psychological symptoms of foreign nationals from the viewpoint of psychosomatic medicine. The second aim was to clarify the measures that should be taken in Japan and similar countries where immigration may still be considered less than common.The study period was from June 2004 to May 2015. The data of non-Japanese patients who had visited the Department of Psychosomatic Medicine, Kinki University Hospital and its branches, Sakai Hospital and Nihonbashi Clinic, were collected. All patients were aged 16 years or over. Multiple factors, such as age, sex, nationality, length of stay, marital status, employment status, level of Japanese proficiency, clinical symptoms, physical and psychiatric diagnosis, psycho-social factors and therapy were retrospectively analyzed from the medical charts of 20 non-Japanese patients. Cases were divided into two groups; early onset and late onset cases. This study showed that multiple factors related to the health problems of non-Japanese patients were combined and had a mutual influence, however, they can be summarized into two important clinical observations. These are 1) cultural differences, and 2) language barriers related to both the physical and psychological symptoms of non-Japanese patients from the viewpoint of psychosomatic medicine.Future efforts should focus on sensitizing health care professionals in Japan to the psychosomatic problems of non-Japanese patients as well as on facilitating medical systems with services such as medical professional interpreters and liaison-consultation models. It is essential to take measures against language barriers and to promote the field of transcultural psychiatry and psychosomatic medicine in Japan. In addition, the Japanese government should introduce a more comprehensive social support system for non-Japanese people. Due to the increase in international migration all over the world, the health problems of migrants have also been rising. Several reports of physical and mental health characteristics have been published in the US, Canada, Australia, and Europe. These papers clarified the multiple factors related to the health problems of immigrants, such as the effects of social connections , socioeconomic status and immigration-related factors  .Unlike western countries with more liberal immigration policies, Japan has been quite adverse to accepting foreign nationals, including asylum seekers . The forThe aim of this study was to clarify the Japan–specific health problems of non-Japanese patients related to both physical and psychological symptoms from the viewpoint of psychosomatic medicine. The second aim was to clarify the measures that should be taken in Japan and similar countries where immigration may still be considered less than common.Foreign nationals who had visited the Department of Psychosomatic Medicine, Kinki University Hospital and its branches, Sakai Hospital and Nihonbashi Clinic from June 2004 to May 2015.Patients who had physical symptoms due to psychosocial distressThose aged 16 years or overThe inclusion criteria of the patients in this study were as follows:Patients with primary psychiatric diseases, for example having hallucination and/or delusionForeign nationals visiting Japan on tourist visasPatients who were unwilling to participate in this study and contacted us to refuse participationThe exclusion criteria were as follows:This was planned as a case series study.All patients who visited our department for the first time filled out a systemic medical questionnaire including their demographic background, subjective physical complaints, and psychological distress, after which semi-structured interviews were performed by doctors. The distress was classified into four factors; physical, psychological, social distress, and spiritual pain; as is done for the “total pain” of cancer patients.During the study period, all items assessed during routine clinical practice were extracted from the patients’ medical charts, including age, sex, nationality, length of stay, marital status, employment status, clinical symptoms, physical and psychiatric diagnosis, psycho-social factors and therapy. In order to make an objective assessment, multiple independent researchers, using the same standards, analyzed and discussed the psycho-social factors of each case.The level of Japanese proficiency was evaluated and separated into four levels: Level 1. Unable to communicate in Japanese at all; Level 2. Able to exchange greetings but not express thoughts sufficiently; Level 3. Able to understand and participate in daily conversation but still having limitations when communicating; and Level 4. Able to communicate sufficiently in Japanese.The Self-rating Depression Scale (SDS)  and the Physical diseases such as irritable bowel syndrome, headache, and asthma were diagnosed as psychosomatic disorders based on “A guideline for the diagnosis and treatment of psychosomatic disorders 2006” . Each paApproximately 2,900 new patients come to Kinki University Hospital and its branches, Sakai Hospital and Nihonbashi Clinic, and 20 to 25 new patients visit the Department of Psychosomatic Medicine every month. Although the exact number of non-Japanese patients is unclear, twenty cases were eligible for this study according to the inclusion criteria.Detailed demographic characteristics of the patients are listed in Table Clinical characteristics are listed in Table The physical (psychosomatic) disease and psychiatric diagnoses are shown in Table The psycho-social factors ranged widely, from culture shock, maladjustment to Japanese society, break-up or conflict with a partner and/or family member(s), and work-related social problems to serious physical diseases such as lung cancer and acute exacerbation of hepatitis type B. The basic underlying problems were cultural differences and communication difficulties between these non-Japanese patients and their Japanese partners, family members, co-workers, and medical staff due to the language barrier.Having studied Japanese and Karate prior to his arrival in Japan, the patient in case 1 had had various expectations of his life in Japan. However, the reality was different from what he had imagined. He suffered a cataplectic attack and was diagnosed with adjustment disorder and possibly panic disorder.The patient in case 2 was an assistant English language teacher at a junior high school. She had become frustrated and felt alienated due to a lack of conversation with her co-workers and because she was much younger than them. She felt the atmosphere in the teachers’ room was unfriendly. On her working days, she developed a sense of isolation and suffered from epigastralgia and nausea.The patient in case 3 had been in Japan for more than 20 years and had been working as a social worker and English teacher at a private conversation school. She was dismissed from the English school due to a lack of students. She was divorced from her Japanese husband and had three grown-up children who lived apart from her. She suffered insomnia and anxiety about her future. Despite having friends and being a member of the local church, she felt a sense of solitude living in Japan.The patient in case 4 complained of appetite loss, insomnia, and depressive mood since giving birth. She did not have any support from her Japanese husband’s family members or community support, and she was diagnosed with postnatal major depression.The patient in case 5 was a single 27 year-old English teacher. When she had job-related stress such as conflict with co-workers due to differences in work approach, she manifested urticaria and anxiety.The patient in case 6, a 41 year-old man ran an English conversation school with his wife. When he had job-related stress and conflicts with his wife, he felt a sense of isolation and had palpitations and sweating attacks. According to the criteria of DSM-IV-R, he was diagnosed with panic disorder, and an antidepressant, a Selective Serotonin Reuptake Inhibitor (SSRI), was effective.The patient in case 7 was shocked by her husband’s sudden death and fell into a depressive mood. Although she had been in Japan for 30 years and her Japanese proficiency level was 3 according to our scale, she had not yet established any close human relationships with Japanese members of the community. She was concerned about her future and complained of various types of physical pain, such as headache and back pain.After the patient in case 8 lost his job, his wife worked fulltime and he became a ‘house husband’, doing housework and taking care of their children, in what is usually regarded as a female role, particularly in Asian societies. He complained of fatigue and headache and gradually became depressive.The patient in case 9 complained of dyspnea and chest pain, and was diagnosed with asthma. His physical symptoms occurred just after breaking up with his girlfriend, so his state was considered to be acute stress disorder. Anxyolytics somewhat mitigated both his physical and psychological symptoms.The patient in case 10 was a 56 year old Chinese man. He had been in Japan for 14 years and was married to a Chinese national. After losing his job, it was difficult for him to find a new one and he remained unemployed for three years. He suffered from irritable bowel syndrome and gradually fell into depression. When his wife sometimes complained about his unemployment, his depressive state was exacerbated and he needed hospitalization.The patient in case 11 had been working for an automobile factory. He had artificial hip joint replacement surgery and had to resign from his job. Because his Japanese proficiency level is very low , he could not find a new job and had to live on welfare. He had been suffering from both depressive mood and anxiety, and complained of various types of physical symptoms, such as fatigue, dizziness, and unstable blood pressure.The patient in case 12 had had several operations for abdominal pain. In the first operation, he suffered from subileus and needed to have an operation to improve it. Months later, he again complained of abdominal pain and was referred to an emergency hospital. Because he could not explain his symptoms precisely in Japanese, the doctors had to refer to his past history of subileus, and the same operation was again performed on him. The same situation repeated itself several times and consequently the patient developed a strong anticipation anxiety toward abdominal pain.The patient in case 13 complained of epigastralgia and dizziness, but could not explain her past history of hepatitis type B sufficiently in Japanese and her doctor could not immediately make a differential diagnosis.The patient in case 14 also suffered from sweating and tremors when she felt anxiety about her medical condition and her future, but she could not explain her feelings appropriately at the hospital.The patient in case 15, a single Taiwanese woman, had been in Japan for 19 years and had a steady job as a Chinese teacher. She manifested epigastralgia and appetite loss and was diagnosed with functional dyspepsia just after breaking up with her partner.The patient in case 16 was a student at a vocational school and reported suicidal ideation because she could not make friends and felt isolated.The patient in case 17 was a 38 year old, married Korean employee. After he was promoted in a Japanese company, he had a human relationship issue with his Japanese subordinates and complained of headache and dizziness and was diagnosed with adjustment disorder with mixed types. The combination of medication with anxyolytics and antidepressants and autogenic training for relaxation was effective.The patient in case 18 was a Christian priest. He had had difficulties in the past with missionary work and psychological distress because Japan lacks a strong background in Christianity and, furthermore, he developed chronic pain syndrome and dizziness in the wake of a traffic accident.The patient in case 19 was a 40 year old, self-employed Indonesian. He was under pressure at his company because the management system in Japan is different from his home country. He suffered from adjustment disorder with anxiety and complained of chest pain and palpitation.The patient in case 20 complained of anxiety related to his lung cancer diagnosis. He was a devout Buddhist and always contemplating the meaning of life, which is commonly connected to the spiritual pain of cancer patients.This study showed that multiple factors related to the health problems of non-Japanese patients combined and had a mutual influence on the disease of these patients, however, they can be summarized into two important clinical observations. There are cultural differences and language barriers related to both the physical and psychological symptoms of non-Japanese patients that require intervention in the form of psychosomatic medicine.The length of stay in Japan of our cases was between one month and 30 years. This time frame may be related to the heterogeneity of the cases. Thus, early onset cases  and late onset cases (cases 3–20) should be discussed separately. In addition, careful attention must be given to the wide range of cultural differences the patients will exhibit.Early onset cases  were the result of maladaptation to a change of environment and culture shock . This tyGroups from Western societies tend to initially come to Japan alone for short-term experiences. Some of them find a partner in Japan, marry, and continue to live in Japan for a long time. Conflict or breaking up with a partner is one of the most stressful life events for people . An addiOn the contrary, groups from East Asia tend to immigrate to Japan with their family members for economic reasons. They often live in a community made up of people from the same country. Though it can be supportive to newcomers, it sometimes hinders them from integrating into Japanese society because they do not have enough chances to communicate with Japanese residents or co-workers outside of their community or family. The patient in case 16 suffered from maladaptation to school life due to a lack of support from her peers, illustrating another example of the importance of communication support.More comprehensive social support for non-Japanese people needs to be introduced by the Japanese government because the continuing increase in immigrants is inevitable due to necessary measures being taken to combat the declining birthrate and rapid aging of Japanese society.In the workforce, once non-Japanese people become unemployed, finding new employment can be difficult , as seenAlternatively, the patients in cases 5, 6, and 17–19 had job-related stress due to differences in attitude toward the work at hand. Traditional Japanese working culture, such as lifetime employment and a seniority wage system, continues to survive in some companies and may be alien to those unfamiliar with such systems. Similarly, the philosophy that work is a higher priority than personal commitments sometimes conflicts with Western values. Non-Japanese patients experienced trouble with their co-workers and partners stemming from such differences in values. In addition, non-Japanese patients could not communicate competently with people around them due to the language barrier. Thus, in many cases cultural differences and the language barrier can combine to further complicate the situation.Another manifestation of cultural differences concerns religious issues, which were revealed in cases 18 and 20. In general, despite the majority being Buddhist from birth, Japanese people lack a strong religious background and, due to this lack of understanding, we could not give sufficient psychological support to some non-Japanese patients.The second significant factor is the language barrier. All patients in our study had experienced language based communication problems, regardless of their length of stay in Japan, which ranged from 1 month to 30 years. Difficulties in communication with medical staff can lead to serious misdiagnosis and bring grave anxiety to patients, as seen in cases 12–14.There were some limitations in psychotherapy due to the language barrier and, as a result, we could not give sufficient medical care to these patients. Without an interpreter non-Japanese patients were unable to clearly express their psychological issues. Among health problems, psychological distress is especially difficult to express in a foreign language, anywhere in the world , 14. EvePsychosomatic medicine was established in Japan in 1996 as one of the specific medical fields in which “psychosomatic disorders” are dealt with, and it has been developing widely in both Japan and Germany. Psychosomatic disorders are defined as physical diseases whose onset and course are closely related to psychosocial factors and contain both organic and functional disorders . The depThe present study has several limitations. First, this study was based on consultation cases only in our hospital. Further studies are needed to investigate the present treatment strategies for non-Japanese patients all over Japan and to assess the significance of our practice. In addition, our hospital is located in Osaka, which is the third biggest city in Japan and is home to many foreign nationals of Asian origin. There were no patients in this study from the Philippines, Peru, or Brazil, who make up approximately 25% of the total immigrants to Japan Fig. . Second,Although our study has several limitations, some highly suggestive results were seen as helpful information for clinical psychosomatic practice for non-Japanese patients and for suggesting future studies. In order to elucidate the significance of a specific outpatient service for non-Japanese patients and to promote psychosomatic medicine, further research addressing the present study’s limitations is necessary.In conclusion, this study focused on the physical and psychological health problems of foreign nationals who visited the department of psychosomatic medicine. It provides preliminary findings of the characteristics of the psycho-social factors affecting non-Japanese patients. The basic underlying problems were cultural differences and communication difficulties due to a language barrier. Non-Japanese patients complained of various types of psychological and physical symptoms, therefore future efforts should focus on sensitizing health care professionals from all fields, not only psychiatrists, in Japan to the psychosomatic problems of expatriates. In addition, it is necessary to facilitate medical systems with services such as medical professional interpreters and liaison-consultation models. The Japanese government should introduce a more comprehensive social support system for non-Japanese people, as a continued increase in immigration is inevitable due to necessary measures implemented to combat the declining birthrate and rapidly aging Japanese society.Although the health problems of immigrants have been well studied in the US, Canada, Australia, and Europe, we believe that our study has important implications for countries, particularly in Asia, where the number of immigrants has been increasing due to the spread of globalization.http://www.kindai-psychosomatics.com/) so that those unwilling to participate could contact us to refuse participation.This study was approved by the ethics committee of our hospital (No. 27–004). We paid attention not to infringe on patient privacy as much as possible and publicly displayed information regarding this study on the homepage of our department (