This article evaluates the effect of the choice of survey recruitment mode on the value of water quality in lakes, rivers, and streams. Four different modes are compared: bringing respondents to one central location after phone recruitment, mall intercepts in two states, national phone-mail survey, and an Internet survey with a national, probability-based panel. The modes differ in terms of the representativeness of the samples, non-response rates, sample selection effects, and consistency of responses. The article also shows that the estimated value of water quality can differ substantially depending on the survey mode. The national Internet panel has the most desirable properties with respect to performance on the four important survey dimensions of interest. There are two principal dimensions of influence that we analyze in this article. First, the mode influences who chooses to respond to the survey, thus affecting the extent to which the responses reflect the valuations of the population of interest. Second, for the particular sample of respondents, the survey recruitment mode affects whether the survey elicits their preferences accurately. Thus, the mode alters how they respond to the survey questions and the valuations that are elicited. This article explores the valuation of a single environmental commodity using different survey recruitment modes.et al. has shown that questions presented visually can lead to different answers compared to questions presented aurally, particularly for questions using scales [There is a substantial literature regarding the effects of survey mode on responses, particularly due to the increasing difficulty over time of reaching potential survey respondents by phone, mail, and e-mail. Lindhjem and Navrud have an excellent discussion of research on survey mode effects . This dig scales .et al. found that respondents interviewed face-to-face about the amount they would pay to visit a national park had values over 20% higher than those who self-administered the survey on paper [et al. in comparing face-to-face interviews with Internet responses to a survey about environmental preservation in Portugal [et al. reached similar results with face-to-face and Internet surveys on rail safety [The nature of our computer-based interactive survey and cost considerations led us to explore a series of survey modes other than door-to-door in person interviews. Several previous studies have considered that survey mode and the evidence regarding face-to-face interviews is mixed. Surveys administered in the presence of an interviewer may not be the gold standard as this survey mode has been shown to influence responses due to a social desirability effect, or a conscious or subconscious tendency on the part of a respondent to give answers that might please the interviewer. Maguire found that respondents to a face-to-face interview were more likely to agree to participate in a survey about hypothetical charitable contribution than telephone respondents, and the amount of the contributions by those interviewed face-to-face were smaller on average than mail respondents among those who agreed to contribute . Leggetton paper . SimilarPortugal . These rl safety , while Ll safety . The surWhile those studies concentrate mainly on the differences in responses based upon how the survey is administered , this research examines how values differ when all respondents take the survey the same way , but are recruited in different ways  and complete the survey at different locations . We find that the manner in which potential respondents are recruited, the likelihood of respondents to self-select into or out of the survey, the costs in time and effort imposed by the survey, and the diligence with which respondents complete the survey task each can affect the estimated value of the good.The substantive focus of the survey is the valuation of improvements in inland water quality. In particular, how much do people value increases in the quality of lakes, rivers, and streams? The quality dimensions of interest include the recreational uses of swimming and fishing, and also include ecological benefits to plants, fish, and wildlife that are associated with clean water. People may value many of these benefit components regardless of whether they visit lakes and rivers. While ecological benefits are mostly associated with non-use, we found non-use values for all the water quality features. The estimated values combine use and non-use values of the features. As a consequence, attempts to elicit monetary values of water quality based on recreational visits to lakes and rivers cannot capture all the benefits associated with water quality. To obtain these values, some kind of survey approach that can elicit meaningful measures of water quality is essential. Because the survey structure we have designed involves an interactive computer-based valuation task, the survey mode must be able to both accommodate computer implementation and create a context in which a representative sample of respondents can give thoughtful responses to the valuation task.To examine the influence of survey mode, we investigate the differences in responses to an interactive computer survey using four survey modes: central location, mall intercept, phone-mail, and Internet panel. These modes differ in terms of the manner of recruitment, the costs they impose on the respondent, and the environment in which the survey is administered. The range of survey modes examined here is not intended to be exhaustive. For example, we do not consider door-to-door surveys because of the increasingly high cost of obtaining a representative sample of respondents to an interactive computer survey based on door-to-door visits by a survey firm representative.We find substantial differences across the four modes in terms of monetary values of water quality. Differences arise both because of who responds to the survey and how they respond. Our examination of the differences in demographic characteristics of participants highlights the effect of the survey mode on the selection of respondents into the sample pool. By analyzing the predicted environmental benefit values controlling for demographic mix we also can demonstrate that there is an important selectivity effect that biases the empirical estimates in the econometric model. Our review of the performance of the survey modes also indicates substantial differences in the rates of inconsistency in answering the survey questions, which is one measure of how the survey mode affects respondents’ ability to give meaningful answers to the valuation task.We also consider several important objectives of a successful survey administration and examine how well each survey mode fostered those objectives. In particular, we conclude that a probability based Internet panel is best suited to the objective of tapping a representative sample of potential respondents. Internet panels mitigate the effects of respondents self selecting disproportionately into particular topics, such as the environment, in which they have strong interest; they limit the time and travel costs associated with completing the survey, and they enable the survey to be taken at home where the respondent is comfortable completing the survey. Phone-mail, central location, and mall intercept modes have favorable features with respect to some of these objectives and may be preferable if cost is a major concern, but are problematic with respect to one or more of survey evaluation criteria.We begin by describing the survey instrument since the instrument will affect which survey modes are feasible and their relative merits in eliciting benefit values. We then examine the various modes used for fielding the survey. Following this discussion, we review the key dimensions on which surveys should be judged. Using these criteria, we analyze the valuation results obtained using each of the survey modes. Then follows an analysis of the extent of inconsistent responses in each survey mode, an important measure of the degree to which the survey mode helps or hinders the generation of accurate and useable individual valuations.The representativeness of a survey sample can be assessed in two ways. First, for each survey mode it is possible to compare the sample characteristics with the national adult population. Second, since the Internet panel collects demographic information on all panelists, for that survey mode the presence of any sample selection effects can be estimated. We examine demographic effects in terms of the choice to participate in the Internet panel survey and compare those effects with the demographics of the other survey modes to reveal the extent to which each mode experiences sample selection effects. Our concluding discussion reviews the reasons that we believe that a nationally representative Internet-based panel drawn using a probability sample of the U.S. population is the most meaningful approach.2.http://water.epa.gov/lawsregs/guidance/cwa/305b/index.cfm).The survey used in this analysis focuses on the value of water quality for inland water—lakes, rivers, and streams. Specifically, the survey elicited the monetary value of lake and river quality in a respondent’s region. These dimensions, shown in The dimensions are whether fish caught in the lake or river were safe to eat, whether swimming in the water could make one ill, and whether the lake or river supported a healthy environment of plants, fish, and other aquatic life. The safety of water for drinking is explicitly excluded as a matter of concern since respondents are told that water treatment facilities address drinking water quality issues.In order to avoid focusing on idiosyncratic aspects of the respondent’s region that could not be monitored and might affect responses in unpredictable ways, the survey asked respondents to think about a hypothetical move to one of two new regions that resembled their own region in terms of number of water bodies and general characteristics. The goal of this multiple-question set is to obtain a meaningful point valuation for each individual respondent for an unfamiliar, non-market good using a few relatively simple choices. The survey approach uses a series of iterative paired comparisons patterned after the approach pioneered by Viscusi, Magat, and Huber . These aAs part of this iteration process, subsequent questions either reduce the difference in water quality between the two regions or reduce the difference in cost of living between regions to estimate the point at which the respondent is indifferent between the presented options. Even if the respondent does not indicate strict indifference between the options, the survey generates a bounded value for the dollar value of improved water quality that lies between the tradeoff rates for the answers to the two sequential questions bracketing the last switch. There is only an upper or lower bound where the respondent reaches a corner of the iterated question set without ever switching. In those cases valuation is estimated econometrically using censored regression models.For those respondents who reached a corner solution we include other questions to test for the rationality of the choice. In the question following the final question iteration -Design-Summary-Description.pdf.Knowledge Networks conducted the Internet panel mode between 2001 and 2004. This sample consisted of people previously recruited by nationwide random digit dialing to join a panel to take surveys online. KN invited a group of panel members to participate in our survey. Additional information on the characteristics of the KN panel can be found on the KN website at While the survey questions were similar throughout the modes, there were some differences. First, the starting cost and quality differences between regions presented to respondents differed both within the Internet panel administration as well as between survey modes. For instance, respondents in the Internet panel were presented starting cost-to-quality ratios between $5 per 1% quality difference and $30 per 1% quality difference. Thus, depending on which starting ratio the respondent received, the initial questions asked whether the respondent was willing to pay at a rate of $5 or $30 per 1% improvement in water quality. The central location mode had a starting tradeoff ratio of $4, and the phone-mail and mall intercept had a starting tradeoff ratio of $10. As described in Huber, Viscusi, and Bell, higher starting ratios can result in higher final valuations . AccordiAdditionally, the survey modes differed in terms of the range over which the water quality differences spanned. The lowest, or baseline percentage of water rated of good quality, presented water quality rated good as ranging from 20% to 75% in the Internet panel and mall intercept, while the central location and phone-mail presented 50% as the baseline water quality. Previous research in Huber, Viscusi, and Bell found that these starting points influence values, with higher baseline quality leading to lower cost-quality tradeoff values as levels of water quality have a diminishing marginal value to respondents . Even thFinally, the phone-mail and Internet panel surveys contained a slightly larger question set. If respondents in those surveys continued to choose the option with higher cost and higher water quality, they were asked one additional question relative to the other modes before being presented with the dominated choice. Using 4.Ability of investigators to contact a potential respondent,Interest of a potential respondent in the topic,Total time and effort cost for a respondent to complete the survey, andAbility of a respondent to be comfortable in the location where the survey is completed.Survey participation is a function of:The most desirable mode will increase the performance on dimensions (1) and (4), will promote survey participation independent of dimension (2), and minimize the time and effort cost dimension (3).We investigate how responses to survey questions vary among recruitment modes. All respondents answered the survey analyzed here electronically, either via the Internet or with a computer recording responses to a disk. Because of this similarity in administration, as well as the collection of personal characteristics of every respondent, the differences between survey responses can be measured largely on the basis of how and whether a respondent was recruited to participate and the relationship of each mode to the four factors listed above.An objective of any survey is to get a representative sample of a target universe so as to obtain unbiased valuations of water quality. In our case, an objective was to have a sample representative of the adult U.S. population. There was, of course, no expectation that the results from a survey administered in a single region such as North Carolina or Colorado would reflect national preferences. These regional surveys served to explore how people would respond to the survey questions. The discussion below highlights some of the regional differences that arise. However, our main interest here is with potential selection biases in the four recruiting modes that limit the ability of the researcher to project the results to any target universe. The limitations based on selective regional coverage are not inherent shortcomings of the survey mode as one could, following the previous example, use mall intercepts throughout the country.et al. found age, gender, urban/rural, and health related effects between early and late responders to a 1981 health-related survey in Spain using mail recruitment, with multiple telephone and in-person follow-ups for non-respondents [Differences between respondents and non-respondents are also of concern and have been evident in previous survey research. For instance, Rodes pondents .et al. found that a non-panel Internet sample had much smaller response rates than a mail survey, and that the Internet respondents were wealthier, younger, and had better expertise on the survey subjects (farming and river recreation) despite having less experience in those subjects [Interest in the survey topic can be a significant determinant of survey participation. This has been previously noted as a factor in survey participation for mail surveys in Martin and Roberson and Sundstrom ,12. We asubjects . Howeversubjects .et al. found that compared to results from a central location administration, Internet respondents had less knowledge of the subject (skin cancer), had more survey questions left unanswered, either rushed or took breaks during the survey, and failed the scope test whereby people should have higher valuations for greater delays in the onset of the skin cancer [In research using the KN Internet panel, Dickie n cancer . Our sur5.Because the survey modes differ in terms of their ability to reach the target population, one can expect differences in the demographic characteristics between survey modes. In each case we use the U.S. Census adult population as the reference point for determining the representativeness of the sample. et al. [Since a large majority of the full sample was drawn from this Internet panel, the full sample matches the U.S. adult population to a greater extent than might be expected considering the differences evident in the other modes. The close match is also due to the fact that potential respondents are already known to be willing to take surveys by their participation in the panel, making their participation more likely than it would be when the demographic effects of respondent interest in the survey topic are taken into account. This willingness could lead to other differences related to panel membership, such as whether the taking of multiple surveys affects answers to the next survey, discussed in Taylor et al. . HoweverThe other survey modes perform much less well in terms of matching the respondents to national population characteristics. It should be noted again that these modes had much smaller sample sizes than the Internet panel, so larger deviations should be expected as a matter of course. Even so, there were several statistically significant demographic differences from the adult U.S. population that are strongly related to the mode used. For instance, compared to the rest of the full sample which closely matched the U.S. adult population, the phone-mail sample included dramatically fewer respondents under 35 years of age (t = 4.89), comparing the subsample with the remainder of the data, as do the rest of the reported t-tests), almost no respondents with less than high school education (t = 3.61), twice as many college graduates or higher (t = 5.61), fewer minorities (t = 3.05), many more married respondents (t = 3.15), and few respondents with incomes below $15,000 (t = 2.92). These differences are as expected; older, married, wealthier, and more educated respondents should be more likely to be contacted, to receive the mailed survey materials, to complete the survey, and to mail it back.Unfortunately, the phone-mail sample had a much higher frequency of respondents who have visited a lake or river in the last year than other modes (t = 4.24), indicating that there was substantial self selection with respect to valuation. The bottom of http://www.researchtriangle.org/uploads/pdfs/RTRP_Region.pdf).This self-selection effect is also problematic for the central location sample, also a mode where the sample was recruited by telephone. As with the phone-mail mode, that sample had a high 89% (t = 4.53) of respondents reporting a visit to a lake or river in the last year. The central location sample had disproportionately fewer respondents in the youngest group of 18–24 (t = 1.95), though it had more of the next age group of 25–34 (t = 1.92). The central location respondents were much less likely to be Hispanic (t = 2.82), were wealthier, and were more educated than the other modes (t = 12.60 for the highest education level). Presumably, some of these differences are due to the same factors as phone-mail, but are also due to the location of the survey, Research Triangle Park in North Carolina. That area has a higher portion of college educated professionals, especially among those reachable by phone and who were able to easily make the trip to the survey location. Over 75% of the central location respondents had a college degree, even higher than the 47% with that level of education in that region overall , has the highest rate of participation among black respondents , and is the only mode with a majority of unmarried respondents (t = 5.93). The mall intercept sample is also less educated (t = 3.18) and less wealthy (t = 4.40 and 6.51 for the two lowest income groups) than either mode first contacted by phone. These characteristics are not surprising, as respondents were recruited from the subsample of people visiting a shopping mall with enough time to interrupt their shopping trip to take 25 minutes to complete the survey. However, this sample seems to suffer much less from the self selection based on interest in the topic of lakes and rivers, as 75% of respondents report having visited a lake or river in the last year (t = 1.97). This percentage is still higher than the 68% among the Internet panel sample, where panelists’ general participation in various surveys in general appears to minimize this self selection for a particular topic (t = 5.60). Presumably the largest self-selection factors for the mall intercept sample were the inclination to visit a mall and the ability to spare the time.Overall, in achieving the four goals of a successful survey implementation mentioned in Section 4, the two modes that first contact respondents by phone  tend to have difficulties in the ability to contact potential respondents, as those who agree to participate are older, wealthier, and more educated than the target population overall. The mall intercept mode also has difficulties, as it reaches a greater number of younger, less wealthy, less educated, and unmarried respondents. The Internet panel does not have such difficulties in terms of demographics, since the characteristics of potential respondents are known in advance of any particular survey invitation. The two modes using telephone contact also perform poorly on minimizing the influence of potential respondents with a particular interest in the survey topic, as measured by their significantly higher use of environmental amenities than the other modes. The mall intercept and Internet panel did better by that measure.6.Because each mode generated samples with different demographic characteristics, one would expect differences, to the extent that those water quality valuations are driven by demographic factors. We used the two-tailed Tobit regression analysis shown in Their actual value could be much lower than the assigned low value or much higher than the assigned high value. The use of Tobit regressions accounts for that indeterminacy. As the results in While the regression accounts for systematic differences between the modes, there appear to be differences in participation not reflected in the demographic, visitation, or survey text differences that increase valuations for phone-mail and mall intercept surveys. Since all the surveys were implemented on computers, the differences likely arise largely from self selection and the physical environment where computers were used. This latter factor is discussed below in an examination of the inconsistency of responses.7.Aside from substantial differences in valuation of water quality, the four different survey modes differed in terms of how often respondents passed the consistency test. A consistency test is important because it is a measure of the extent to which respondents understand and are attentive to the survey task, and accordingly minimize irrational or protest responses.For this survey, a respondent was treated as being inconsistent if the respondent continued to choose the lower cost or the higher quality region even when it became a dominated option. For respondents on either extreme side of the decision tree, the survey provided a dominated choice, where the region they had consistently chosen was made to be clearly worse than the other option. This choice either had the same water quality in both regions with one having a higher cost of living  or had the same cost of living with one having a higher water quality (for respondents who had been choosing lower cost of living). If the respondent then chose the dominated region, the respondent was informed about that inconsistency. If the respondent still persisted in that choice, that respondent was deemed inconsistent and not included in the regular analysis.The demographic characteristics of inconsistent respondents are reflected in the probit regressions in The relatively large percent of inconsistent respondents for the mall intercept sample is cause for concern. These respondents were invited to interrupt their shopping to take a survey in a room within a mall. If these respondents were more likely to be uncomfortable, impatient, rushed, or in some way affected by participating in the survey due to their attention being focused elsewhere, then this survey mode may be inappropriate, particularly for more complicated surveys.The lower levels of inconsistency in the Internet panel and the phone-mail samples illuminate this possibility. For these samples, respondents generally completed the survey in their own homes at a convenient time of their choosing. This comfort may have resulted in better attention, less hurriedness, and therefore more thoughtful and fewer inconsistent responses.Since Internet panel and phone-mail respondents were generally able to complete the survey in their own homes, the lower rate of inconsistency is understandable. The central location and mall intercept respondents may have felt hurried or simply not completely comfortable in a foreign environment. For their parts, central location respondents may have outperformed mall intercept since the former committed to a specific trip to participate. Mall intercept respondents were merely convinced to participate during an already planned outing, and thereby may not have given the survey as much attention as the central location group. In terms of the last factor in a successful survey implementation from Section 4, the Internet panel and phone-mail sample perform best, while the central location and mall intercept modes have difficulty in ensuring a comfortable environment in which to take a survey.8.Unfortunately, it is difficult to precisely identify effects of survey modes when non-response is involved. Except for the Internet panel, little information is available about those who declined to participate. The Internet panel sample provides insight about the characteristics of those who declined to participate in that survey. While offering little information about people who refuse to be part of the panel, it is instructive to identify those panel members who declined the invitation to participate in this particular survey. Knowledge Networks’ Internet panel has a broad set of basic demographic characteristics that is collected independently of our survey. Comparing The central location mode only corresponded with non-response expectations in terms of years of education and Hispanic ethnicity. Otherwise, these respondents were somewhat younger, possibly due to the travel requirement to participate at a central location.The mall intercept mode also accorded with expectations in terms of education and Hispanic ethnicity. However, these respondents were younger, more likely to be black, had lower incomes, and were less likely to be married than respondents in the Internet panel. This could be due to the demographic characteristics of shoppers at the mall where the respondents were recruited, as well as mall shoppers who had enough time available to complete a survey.So, generally, each mode’s demographic makeup corresponds, to some extent, to the factors seen in the Internet panel that affected participation, but each also has participation affected by features of its own sampling characteristics. The consistent effects of such factors on survey participation are cause for concern in terms of achieving a nationally representative sample and provide a reason to use modes that are less affected by self selection.9.We examined two ways in which four survey recruiting modes might influence the valuation outcomes of an environmental good. First, we showed that survey mode influences the characteristics of those who choose to respond to the survey. Second, we demonstrated that the different survey modes affect whether the survey elicits their preferences accurately.There are significant and large differences in the valuation of an environmental good across recruitment modes of survey administration. These differences persist even when demographic and survey question differences are accounted for, and are most likely associated with self selection by respondents who are interested in the topic when recruited by phone. This effect seems to be smallest for the probability sampled Internet panel, where respondents agree in advance to take a number of surveys on a range of topics.Further research might investigate other modes, such as door-to-door surveys, to compare the trade-off in inconsistency associated with location comfort against time constraint, as well as non-response characteristics. In addition, interest in environmental goods and issues could be assessed in surveys on unrelated topics to determine the extent of self selection by topic even among the Internet panel. Such an assessment would serve to determine a baseline to measure how the level of interest affects participation.What features are best suited for assembling a representative and unbiased sample? A survey mode for a study should have characteristics that lead to as representative a sample as feasible, including factors that maximize the ability to project the sample to a well-defined universe, minimizing self selection in participation by those with particular interest in or disinclination towards the survey topic, minimizing and compensating for the costs incurred by respondents to complete the survey task, and maximizing the ability of the respondent to be comfortable in the manner and location in which the survey is administered.Other survey modes perform well with respect to one or more of these factors, but none perform overall as well as the Internet panel. For instance, while phone-mail allows most respondents to complete the survey in their home at a convenient time, this survey mode requires additional software or requires non-computer users to take the survey elsewhere. Mall intercept minimizes travel time since respondents are already at the survey location, but their lack of consistency may derive from feeling rushed by the interruption of their trip or lack of comfort in an unfamiliar survey environment.Inconsistency in responses to survey questions can also indicate problems with a particular survey mode, as it indicates lack of attention and thoughtfulness toward the survey task. The mall intercept sample was most often associated with inconsistent responses in the survey, perhaps due to rushed or uncomfortable respondents. Phone-mail and the Internet panel modes, where respondents were most able to complete the survey at a time and place of their choosing, had the least such inconsistency.Non-response, as measured using invited Internet panelists who declined to participate, is associated with a variety of demographic characteristics, and those characteristics are reflected to some extent in the make-up of each of the other survey modes. Those differences were most similar to the phone-mail mode, where respondents were reached by random digit dialing as in the original recruitment of the Internet panel. Other modes had some such similarities, which were somewhat confounded by characteristics particular to each survey mode.In general, it is clear that the choice of survey recruitment mode can affect the estimation of the value of an environmental good. The Internet panel seems to minimize such effects among survey modes investigated in this research.


KIST Medical College is a new medical school in Lalitpur, Nepal. In Nepal, six basic science subjects are taught together in an integrated organ system-based manner with early clinical exposure and community medicine. Correlation seminars are conducted at the end of covering each organ system. The topics are decided by the core academic group  considering the public health importance of the condition and its ability to include learning objectives from a maximum number of subjects. The learning objectives are decided by individual departments and finalized after the meeting of the core group. There are two student coordinators for each seminar and an evaluation group evaluates each seminar and presenter. Correlation seminars help students revise the organ system covered and understand its clinical importance, promote teamwork and organization, and supports active learning. Correlation seminars should be considered as a learning modality by other medical schools. In Nepal, a developing country in South Asia, the undergraduate medical  course is of four and half years duration followed by one year of compulsory rotating internship. The basic science subjects of anatomy, physiology, biochemistry, pathology, microbiology, and pharmacology are taught in an integrated organ system-based manner during the first two years of the course. KIST Medical College (KISTMC) is a new medical school in the Lalitpur district of the Kathmandu Valley committed to excellence in holistic healthcare, education, and research. The first class of students was admitted to its program in November 2008 and the third class was admitted in November 2010.The college is affiliated with the Institute of Medicine (IOM) at Tribhuvan University for the MBBS course. The curriculum stresses community-based learning and early clinical exposure . The topCorrelation seminars in basic sciences are an approach that brings together learning objectives from different basic science subjects, community medicine, and relevant clinical subjects using a common/prevalent disease condition within a particular organ system. In Nepal, correlation seminars were initiated at the IOM, the oldest medical college in the country, to promote integrated, active learning among students and highlight the importance of basic sciences in clinical medicine. At Duke University in the United States, a program to integrate cognitive and affective approaches into medical education was tried . ClinicaCorrelation seminars are conducted at the end of covering each organ system during the first and second year. During a correlation seminar, a common disease or problem involving the organ system just covered is selected. The college has created an academic core group consisting of faculty members from each of the basic science departments, community medicine, the academic director, and the clinical and program coordinators. The topics for correlation seminars are selected following discussion and deliberation among group members. Topics are selected based on the importance of the condition, its public health relevance, and its ability to integrate learning objectives from the maximum number of subjects. Following the selection of topics, departments are asked to generate two or three learning objectives for each seminar topic, if possible. Some departments may not be able to generate a learning objective in relation to certain topics. After three or four days, there is another meeting of the academic core group where the objectives are discussed and modified as required. The wording of the objectives receives careful attention to ensure they are as objective and unambiguous as possible. Previously, one topic was selected for each organ system, but from November 2010 onward, three topics have been chosen to involve a greater number of students in the seminars. For the most recent of the correlation seminars on the gastrointestinal system, the conditions selected were peptic ulcer, diarrhea, and hepatitis. After learning objectives have been framed and agreed upon by faculty members, they are distributed to students by the program coordinator. The college admits 100 students to the MBBS course each year. As between 40 to 50 learning objectives are framed for each set of correlation seminars, each objective is distributed to a small group consisting of two to three students. We also select two students as overall coordinators for the seminar. These students have the responsibility of organizing the seminar in an appropriate sequence, introducing different topics and ensuring proper execution of the seminar. All students who are assigned a particular learning objective prepare for a five minute presentation of that objective using the college library, text books, and help from faculty members of the relevant departments. Students use assigned textbooks, reference books available in the library, notes from faculty lectures, and articles and images obtained through Google searches. We stress the importance of citing the source of their material on their slides to make them aware of plagiarism and intellectual property rights. The students have found the college library with textbooks, reference books, and access to biomedical journals through HINARI to be adequate. Students assigned clinical objectives obtain help from relevant clinical departments. The final presentations are approved by faculty members of different departments.An evaluation group consisting of one faculty member from a basic science department and one faculty member from the department of community medicine is formed for each of the correlation seminars. A senior faculty member is entrusted the responsibility of being the team leader. Each member of the evaluation team assesses each student presenter. The student presenters are selected on the basis of their past record of presentations by using a draw of lots. Students who have not presented before or have presented a smaller number of times are usually selected. The assessment of the student presenters includes the appearance of the presenter and the slides, clear presentation of objectives, interest and enthusiasm, audiovisual aids, voice, organization of the presentation, adhering to the allotted time, summarizing the presentation, answering questions, and an overall grade for the presentation. For each of these categories, the evaluator is required to choose one of five values: 0, 0.25, 0.5, 0.75 or 1 (with 0 representing the worst performance and 1 the best). The mean grading of different evaluators is calculated and is made available to the student presenter for feedback and further improvement. The overall scores have been satisfactory up to the present time. The scores are added to the formative assessment of students. The team leader also provides a brief 100-word report on the seminar, which is made available to all students.Most students present using Microsoft PowerPoint slides. Despite encouragement to use them, use of an overhead projector and white board is not common. Students have often been interested in using slides similar to those used by faculty members during their lectures. Faculty members from each department are required to check and comment on the slides prepared by students and approve them before they are used in the final presentation. In about 20% of cases this checking procedure has not been strictly followed by both students and faculty. Many objectives used during seminars were not covered in detail during theory classes. A certain degree of academic plagiarism continues despite our efforts, and could be considered a weakness of the correlation seminars. One of the problems noted has been the use of slides with diverse backgrounds, some of which were noisy and not easily readable. To ensure the uniformity of presentations, we have recently developed guidelines for presentation. Informal feedback obtained from students suggests that correlation seminars have been effective in promoting self-learning and active learning among students. Students also seem to obtain a holistic view of the disease and understand its clinical implications. We plan to collect formal feedback in the future.Correlation seminars help students review the organ system covered in lectures and understand its clinical importance, promote team work and organization, and support active learning. Correlation seminars should be considered as a learning modality by other medical schools in south Asia.


Modic changes (MCs) have been identified as a diagnostic subgroup associated with low back pain (LBP). The aetiology of MCs is still unknown and there is no effective treatment available. If MCs constitute a specific subgroup of LBP, it seems reasonable to expect different effects from different treatments. The objective of this systematic critical literature review was therefore to investigate if there is evidence in the literature that the presence of MCs at baseline is associated with a favourable outcome depending on the treatment provided for LBP.The databases MEDLINE and EMBASE were searched for relevant articles from 1984 to December 2010. A checklist including items related to the research questions and quality of the articles was used for data extraction and quality assessment. Of the 1650 articles found, five (six studies) were included in this review but because the studies were so heterogeneous, the results have been reported separately for each study.The treatments studied were: lumbar epidural steroid injections (n = 1), lumbar intradiscal steroid injections (n = 2), lumbar disc replacement (n = 1), fusion surgery (n = 1) and exercise therapy (n = 1). One of the two studies investigating treatment with intradiscal steroid injections and the study investigating fusion surgery reported that MCs were positively associated with the outcomes of pain and disability. The other study on lumbar intradiscal steroid injections and the study on lumbar epidural steroid injections reported mixed results, whereas the study on lumbar disc replacement and the study on exercise therapy reported that MCs were not associated with the outcomes of pain and disability.The available studies on the topic were too few and too heterogeneous to reach a definitive conclusion and it is therefore still unclear if MCs may be of clinical importance when guiding or prescribing the 'right' treatment for a patient with LBP. Low back pain (LBP) is a large problem in the Western world. It has considerable financial consequences both for the individual person and for society. Currently, less than 15% of patients seeking care for LBP are thought to have specific causes of LBP . One expOne such possible subgroup, Modic changes (MCs), have recently been associated with LBP . MCs appThere are two main theories as to why MCs develop - a biomechanical theory and an infection theory. The first theory is that MCs are caused by mechanical stress . The degThe second theory is that the inflammation and oedema in the vertebral endplate are caused by a bacterial infection in the associated disc . FollowiIf MCs constitute a specific subgroup of LBP, one would expect different outcomes with different treatments for this condition. However, this would depend on the etiology of this pathology, which remains contentious. If the mechanical theory is correct, one would expect alleviation of symptoms with rest, because immobility might be necessary to heal any micro-fractures, whereas vigorous weight bearing exercise might prevent micro-fracture healing. Similarly, a good outcome might also be expected from fusion surgery, because fusion may neutralize the biomechanical dysfunctions in the vertebral segment . PerhapsIn other words, the presence of MCs may have an impact on outcome, either positively or negatively, for various types of treatments. In order to synthesise the evidence, we performed a systematic critical literature review. The objective was to investigate if the presence of MCs at baseline is associated with outcomes from different kinds of treatments for LBP.The databases MEDLINE and EMBASE were searched using the following MeSH terms and/or as free text: 'MRI', 'vertebral endplate' and 'lumbar spine'. See additional file Articles were considered for inclusion if they were original articles from peer reviewed scientific journals published in English, French, German, Spanish, Swedish, Norwegian or Danish. The inclusion criteria were:Studies of living human adults diagnosed with LBP, with endplate changes (MCs) described at baseline and who received a described treatment and were not diagnosed with malignancy, tuberculosis, any type of traumatic fractures, or systemic inflammatory disease.Any intervention or combination of interventions targeting LBP.Any clinical outcome, including (but not restricted to) pain, disability and return to work.Prospective studies and retrospective studies, with not less than 50 participants at baseline, providing it were possible to extract relevant data to compare treatment outcomes either 1) in patients with or without MCs, or 2) in patients with different types of MCs.Relevant articles were reviewed according to a checklist in which the authors defined a set of criteria consisting of descriptors, quality items and study results that were considered essential for this review. A checklist that included the items described below was devised, tested and improved before being used for data extraction.• Study characteristics: aim, study design and description of MCs at baseline.• Participants and treatment characteristics: age, sex, number of participants, drop-out rates, origin of population, disease characteristics and type of treatment.• Method: type of recruitment procedure, time and number of follow-ups and outcome measures used.• No fixed set of generally accepted quality criteria were found that suited this type of literature review and therefore quality criteria were chosen in consideration of factors important for a systematic review of prediction of treatment outcome. We concentrated on the following issues: 1) the generalisability of the study sample, and 2) the trustworthiness of both the MRI findings of MCs and the outcome variables. A systematic evaluation was conducted regarding eight specific quality check-list items applied to each study forming the basis for an overall interpretation of the credibility of the study results, see Table • Conclusions on whether MCs were found to be associated positively, negatively, or at all, with treatment effect.In all, 1650 references were obtained and examined by the first author on title and abstract according to the inclusion criteria. Articles written in French were evaluated by the second author. Of the 1650 references, 96 articles were retrieved in full text as hard copy and further screened by the first author according to the inclusion criteria. Six studies reported in five articles were found to meet the inclusion criteria and were independently assessed by the two authors following the checklist. The first author compared the pair of completed checklists for consistency for each article. In the case of inconsistencies, consensus between the two authors was reached through discussion. The flowchart of the review process can be seen in Figure The six studies included in the review were all outcome studies, published in English, explicitly designed to investigate associations or predictors of treatment effect. All studies included both men and women, with the reported mean age between 41 and 52 years, and all the patients were recruited from secondary care although the procedure for recruitment differed. One study used advertising , four usThe treatments studied were: lumbar epidural steroid injections , lumbar In general, the quality of the studies was unacceptable to fair. All studies reported their drop-out rates but it was mostly unclear how the drop-outs were accounted for and if the patients who dropped out were different from those remaining. A reference for the validity of outcome measures was mostly reported, but only a few of the studies reported on reproducibility of their MRI evaluation protocol, information on the evaluator, blinding (if relevant) and if standardised MRI protocols were used. The quality score of each individual study is shown in Table The outcome measures of pain and disability were reported in all included studies. We therefore chose to use only pain and disability as outcome measures in this review. Because the studies were so therapeutically and methodologically heterogeneous, results are reported separately for each article.Buttermann  investigIn the same article, Buttermann  reports Also, Fayad et al.  investigSiepe et al.  tested tEsposito et al.  tested tIn a prospective study, Kleinstück et al.  tested tFor a summary of the results, see Table The studies identified in this review were too few and too heterogeneous to reach a definitive conclusion as to whether MCs can be used to guide optimal treatment in patients with LBP. In addition, only 1 of the 6 studies was considered to be of good quality. The results of that study, which investigated the effect of exercise, were not particularly helpful, as they failed to differentiate MCs into sub-categories. Obviously, this is important, if various stages of MCs require different types of treatments.The other studies, of varying quality that never exceeded fair, provided a confusing picture. Results varied for different types of treatments, at different times of follow-up and for different outcomes, in a manner that could not easily be interpreted. The only treatment investigated in two separate studies was lumbar intradiscal steroid injections but the results did not concur. Furthermore, results could not be obtained from enough studies to make a systematically reporting of the standardised effect size or another uniform measure meaningful.For those reasons, it was also not possible to interpret the findings relative to the main theories on the etiology of MCs. There was not enough weight of evidence in favour of the biomechanical theory and we found no studies that could directly cast any light on the bacterial theory.A potential weakness of this study is that it is possible that we missed some studies on this subject, even though the search was comprehensive and included several languages other than English. Also, some relevant studies may have been overlooked, as the initial screening of abstracts and titles was undertaken by only one of the authors. Furthermore, as we were unable to find any broadly accepted quality check-lists for this type of study, we designed our own. The presence of other quality criteria could have resulted in another judgment of the quality of this study, although it is unlikely this would have changed the interpretation of the results.The weaknesses identified in this review make it relevant to comment on the need for future studies to respect certain methodological criteria. Two types of study designs would be suitable. 1) The one arm prospective outcome study with internal control groups i.e. the presence/absence of MCs. 2) A better design is the randomised controlled trial (RCT). RCTs should be conducted and reported according to general recommendations . In ordeIn conclusion, the studies in this review were too few, too heterogeneous and often lacking in adequate methodological rigour, to make a definitive conclusion as to if and how MCs are an indication for specific therapies for LBP. Therefore, although MCs may be associated with pain, it remains unclear if MCs are of clinical importance for prescribing treatment for a patient with LBP and more high quality research on the topic is needed. It also seems necessary to differentiate the types of MCs in any future analysis of treatment effects involving patients with MCs.The authors declare that they have no competing interests.RKJ participated in conception and design, carried out the data collection and the analysis, and wrote the main parts of the manuscript. CLY participated in conception, design and data analysis and made substantial contributions to the manuscript. Both authors have read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2474/12/183/prepubMEDLINE search strategy. Details of the search strategy used in the MEDLINE database.Click here for fileDetails of the six included studies. Details on design, number of participants, number of participants with Modic changes at baseline, intervention procedure and drop-out rate of the six included studies.Click here for file


The University of Michigan School of Nursing and the Health System partnered to develop an undergraduate clinical education model as part of a larger project to advance clinical education, practice, and scholarship with education serving as the clinical bridge that anchors all three areas. The clinical model includes clusters of clinical units as the clinical home for four years of a student's education, clinical instruction through team mentorship, clinical immersion, special skills preparation, and student portfolio. The model was examined during a one-year pilot with junior students. Stakeholders were largely positive. Findings showed that Clinical Faculty engaged in more role modeling of teaching strategies as Mentors assumed more direct teaching used more clinical reasoning strategies. Students reported increased confidence and competence in clinical care by being integrated into the team and the Mentor's assignment. Two new full time faculty roles in the Health System support education, practice, and research. Crossing the Quality Chasm: A New Health System for the 21st Century, recommended that leaders in health professions should develop strategies for “restructuring clinical education to be consistent with the principles of the 21st-century health system throughout the continuum of undergraduate, graduate, and continuing education for medical, nursing, and other professional training programs” . The recent consensus report of the RWJF in collaboration with the IOM, “Initiative on the Future of Nursing: Leading Change, Advancing Health” [Over the past several years, schools of nursing have been called upon to restructure education programs to better prepare graduates for increasingly complex and rapidly changing health care environments –3. Accor Health” , emphasiRecently, partnerships between schools of nursing and service settings in hospitals and other health care agencies led to the development of new approaches to improve clinical learning. The goal of these partnerships is to facilitate students' understanding of both the responsibilities of the nurse and the environments in which nurses work as they acquire clinical knowledge and proficiency necessary for competent practice. One common approach in hospital settings is the Dedicated Education Unit (DEU). Pioneered in Australia , DEUs arOutcomes of the DEU concept of clinical education for undergraduate nursing students are not extensive, and the concept continues to be explored. Extant findings , 12, 13 In 2007, the University of Michigan School of Nursing (UMSN) and nursing services at the University of Michigan Health System (UMHS) formed a partnership called The Initiative for Excellence in Clinical Education, Scholarship and Practice. The partnership was designed to leverage the resources and expertise of both organizations to advance all three mission areas.n = 120) included members from all levels of staff nurses and nurse administrators, all levels of faculty including administrators and graduate student nursing instructors, nursing and medical students, physicians, patients, financial and human resource representation, and the vice-chair of the nurses' collective bargaining unit at UMHS. At a two-day retreat called an Event [To begin the work, the partnership engaged in an extensive change process using Danemiller Tyson Associates' Whole-Scale Change . Whole-San Event , stakehoDeveloping a clinical education model became the first priority for our work. By embedding students in the clinical setting with faculty who have clinical and research expertise education becomes the clinical bridge that anchors and connects all three mission areas. This link is critical both to advancing practice and solving clinical problems to improve patient outcomes. The purpose of this article is to describe the first phase of our collaboration, the development of the Clinical Education Model, with attention given to the recommendations put forward by the IOM, RWJF, and others.A three-member Project Team consisting of two faculty from the UMSN and one Health System nursing director was charged to use the themes from the Event to develop a new clinical education model that was vetted and ready for pilot implementation in one year. In developing the new model, it was explicitly stated that the proposed model must align with values and goals of each organization and with current economic resources, that existing contractual and other legal and regulatory requirements must be honored, and that the model must align with the current undergraduate course curriculum. In addition, the new model was to reflect recommendations of organizations calling for change in how nurses were educated in order to better prepare them for current health care environments. An Advisory Committee to the Project Team was formed comprised of members from both organizations including the Dean, the CNO of the Health System, and students. The role of the Advisory Committee was to provide advice, consultation, feedback, and recommendations throughout development of the model and plan for pilot implementation.That this is a true partnership between our organizations was demonstrated as the Project Team consulted with various faculty, students, and clinical partners in the Health System including Clinical Nurse Specialists, Educational Nurse Coordinators, Supervisors, and staff nurses for suggestions and endorsement throughout development of the model. Feedback from these stakeholders was instrumental in revising ongoing work. Circling back allowed stakeholders to see how their suggestions and concerns were handled. This approach to the work also permitted participants in the process to develop relationships over time and increase knowledge of Health System units, patient populations, nursing practice, student instruction, and the curriculum. Over the year of model development, 18 presentations and interactive sessions were held with various stakeholder groups. Final vetting occurred with both organizations including the nurses' collective bargaining unit in the Health System. The new model consists of five components: Clinical Unit Clusters, Clinical Teams, Student Skill Development, Clinical Immersion, and Student Portfolio.Maximizing UMSN student placement capacity at UMHS was highly desired as the environment provides strong evidence-based practice and quality of care is paramount. At the time of model development, many UMSN students received clinical education in multiple hospitals and agencies. In the new model at UMHS, all 36 inpatient clinical units, comprised of adult acute care, pediatrics, ICUs, and specialty services, were used to construct three multiunit clusters see  comprisiUpon admission to the School of Nursing in the freshman year, students are assigned to one cluster and will have diverse clinical experience designed to meet all clinical course objectives across the four years of the curriculum. Students who transfer from community colleges at the junior level are entered into clusters when admitted. The assignment to clusters familiarizes students with a defined set of units, their operations, and the work of nurses as the context for clinical learning . In addiIn the model, a clinical team see  is the rAll members of a clinical team are expected to develop strong relationships and function as an integrated group rather than through a hierarchical structure of accountability. Clinical Faculty are matched as much as possible where their clinical skills and knowledge are compatible with unit patient populations as they are responsible not only for clinical education but for participation in scholarship and practice development on these units as well. They may provide direct instruction of the student but are more likely to facilitate the student's learning through work with the Clinical Mentors. Importantly, they model appropriate teaching strategies, clinical expert practice, and an understanding of evidence-based practice and its application. The Clinical Mentor assumes a direct role in student education while using Clinical Faculty for guidance in conducting the student's experience.In addition to preparation for the role of Clinical Mentor, a document developed by nursing staff and clinical unit leaders, with added input from the Project Team, specifies essential characteristics guiding the transition into the Mentor's new responsibilities. This document charts the growing responsibilities of Mentors as they mature in the role. Members of the clinical team together provide a rich environment in which to nurture and support student growth in clinical competence.In reframing the student's role as a team member, new approaches were needed for skill preparation for clinical courses. Faculty were aware from prior nursing staff feedback that increased skill preparation for students was necessary for successful student integration into the clinical team. Following an intensive workshop for faculty and clinical partners on simulation use in student education, new simulations were designed and embedded in clinical courses to improve clinical reasoning in the delivery of patient care. Planned laboratory time provides for practice and evaluation of student competence in relevant skills. Successful completion increases the students' ability to participate in patient care as an integral member of the clinical team.Increasing the number of hours devoted to clinical practice is important for gaining competence and feeling confident in providing care. Over time, nursing curricula have included more didactic content and fewer clinical hours. In addition, student clinical assignments often have been limited to the care of one or two patients not only early in clinical experience but throughout the entire curriculum . CurrentA paper portfolio consisting of course descriptions, Clinical Unit Profiles, Student Skills Checklists for both completed skills and those to be achieved, and Midterm and Final Student Clinical Evaluation Forms is given to students. A Clinical Mentor Feedback Form to serve as a communication tool between the Mentor and student about the student's performance and to provide written documentation for Clinical Faculty is also included. Clinical course materials for subsequent courses are added as the student progresses in the curriculum. The portfolio is designed to be utilized by all Clinical Team members to facilitate student learning and performance. Transition to an electronic portfolio is to be determined by the patterns of use, value of current materials, and compatibility with UMHS systems.The clinical education model was pilot tested in the junior year of the generic undergraduate program from September, 2008 through April, 2009 when the academic term ended. Since it was not reasonable at the outset to test the model for all four years of the curriculum, the decision was that the pilot would include only students in the junior year when they were enrolled in specialty clinical courses.n = 31) enrolled concurrently in medical-surgical and pediatric nursing courses participated during the fall term pilot. They continued in the pilot during the winter term when enrolled in psychiatric and obstetrical nursing courses. An additional 30 students who completed the psychiatric and obstetrical nursing courses in the fall joined the pilot for the first time in the winter term for a one-term pilot experience. By the end of the winter term, half the junior class (n = 61) had experience in the new clinical education model. The selection of clinical units to participate in the pilot was decided following conversation with unit leaders and staff. The decision was that highly enthusiastic units would be asked to participate as the likelihood for demonstrating success of the clinical model would occur with units that were more positive about change and willing to work to enhance the success of our partnership. In the fall term pilot, three medical-surgical units and one large pediatric unit participated. During the winter term, the large women's birthing unit and one adult and one child psychiatric unit were added. All units were in the Blue Cluster. Half the students  across the entire term. The Clinical Faculty member on the unit was largely responsible for selecting patient assignments, monitoring student performance, and assessing performance. Nonpilot students were not part of a clinical team, and they did not use a student portfolio. Clinical Faculty solicited input from staff about students' performance and provided this feedback to students and used it as needed in written evaluations.Throughout the pilot of the clinical model, Project Team members visited clinical units to monitor the learning environment. Discussion occurred with Clinical Faculty, Mentors, and students to solve problems, answer questions about team functions, or work one on one with team members to support their respective roles in the Clinical Team. Occasionally, clinical unit meetings were held to further explain the model and respond to questions.Clinical Faculty, Clinical Mentors, Clinical Resources, and pilot students participated in clinical model evaluation. Nonpilot  were not asked about their experiences in the traditional model or their thoughts about how not having the pilot opportunity influenced their perception of their education.N = 23, Fall and 25 participants Winter) constituted the method for data collection during and following the pilot. On average, representation was approximately 4 representatives from each pilot unit including the Clinical Faculty member. The number of attendees per unit attending the discussions is acceptable given that time away from the unit needed to be negotiated in advance to cover staffing and students. Prior to the discussion sessions, attendees talked with others on their respective units to gather information in order to bring as many perspectives as possible to the discussions. Components of the clinical education model—Clinical Teams, student skills preparation, clinical immersion, and student portfolio guided discussions.Feedback regarding the clinical cluster arrangement was gathered during meetings of unit representatives from each cluster group—Clinical Resources, Mentors, and Clinical Faculty. Clinical Cluster meetings were typically held twice a year, once per term, for discussion and confirmation of upcoming clinical placements. Data from two discussion sessions with Clinical Faculty, Clinical Leaders, and Clinical Mentors (N = 25) for the Fall term pilot students  and at the end of the Winter term from this same group of students (N = 25) now enrolled in Obstetrical/Psychiatric Nursing courses. Feedback from the one-term Winter pilot students (N = 24) in Medical-Surgical/Pediatric Nursing courses was also obtained at the end of the term. The one-hour focus groups were led by a skilled facilitator who was unknown to the students thus reducing worry about being candid. Faculty were not present in order to maintain an unbiased and nonthreatening environment. This number exceeds that typically recommended for sessions [Focus groups with pilot students were designed to elicit information about each of the components of the clinical mode. Feedback was obtained at term's end , Sophomore, and Senior students who need or select placements in our health system. The full potential of clusters supporting education of students housed within them, and in promoting clinical research, continues to be developed.The clinical team approach to educating UMSN students is new. The traditional faculty role of primary supervision of students changed to that of facilitating and supporting the Mentor who, in turn, took greater responsibility for student learning. Some faculty, early on, were not convinced that this shift in responsibility was appropriate. However, as they participated in the clinical team, they adapted to the new role that included an increase in role-modeling instructional strategies and support for Mentor activities. Clinical Mentors varied in how quickly they accommodated to their revised role in student education, most assumed the new role fairly quickly and easily. Annoyance was expressed by some Mentors who indicated that education of students took too much time and tended to be a burden. With support from unit leadership, the Project Team, and faculty, most became experienced team members. In our model students, as part of a designated clinical team, participate in the Mentor's entire assignment. The relationship among team members provides a rich environment for student learning. Students in the pilot stated that clinical experiences enhanced their learning and that working with the Mentor and other unit leaders gave them a strong sense of contributing to the work of the team while learning. Additional support that the team approach to clinical education worked is that our findings were similar to those found using the DEU. For example, students in our model, like those in the DEU approach, felt they were included in the clinical team, supported by Mentors, more confident in providing patient care and able to assume more responsibility for their own learning , 12, 13.The clinical immersion was rated highly by students. They benefitted from continuity of patient care, became more confident of their capabilities, and began to experience more fully the work of the staff nurse. Student skill preparation has been changed, based on student and faculty input, to include greater emphasis on clinical unit relevant skills in addition to general skills taught in conjunction with courses. Preliminary evidence in the pilot showed that this approach is working.Although the clinical education model was pilot tested with half of the Junior students, the pilot was not conducted as an experimental study to compare the views and outcomes between pilot and nonpilot students. As a result, nonpilot students were not asked to provide their views about being a student in the traditional program while peers were receiving a different approach to clinical education. Information from nonpilot students may have been useful to understanding their thoughts about the merits of the different approaches, or how being treated differently from their peers influenced their views about the quality of education they were receiving. Comments expressed by nonpilot students in informal venues revealed a mix of responses. Some were angry that they were not asked how things were going for them clinically. Some expressed relief from not having to attend the intense skill preparation sessions or complete the four-day clinical immersion which they stated seemed exhausting for their classmates. Some also mentioned that having fewer clinical obligations at the end of the term left them more time to study. A number commented that they were happy not to be part of an “experiment” and felt comfort in knowing that the traditional curriculum was known to faculty and nurses in UMHS with whom they worked. Although nonpilot student comments may have been informative, they would not have changed the decision to move forward with the new clinical education model. The clinical education model is part of a larger vision of the partnership between the UMSN and UMHS about how we will work together in advancing the missions of excellence in education, research, and practice, with education as the anchor for advancing the other two missions. The new education model is consistent with calls from the IOM and RWJF to restructure education programs to be consistent with 21st century health systems , 5, and Full implementation of the model for all junior students and to all 36 clinical units in UMHS in 2009 followed the pilot. Some changes in the model have occurred. Because it became difficult to structure faculty workload to accommodate both the two-day and four-day clinical immersion over the term, a different approach to clinical immersion was taken. The undergraduate clinical curriculum was revised and approved to add and progressively increase clinical hours from freshman through senior year culminating in a three-day per week capstone clinical practicum over the term supported by seminar. To ensure skill readiness for beginning clinical work, students must be checked off each term on skills they learned in clinical courses the previous term before they can begin the new term's clinical experience. Failure to pass requires repeat testing that may delay the start of clinical work.Last, and very important, two new clinical track faculty roles are now in place. Clinical Cluster Leads are faculty educators who provide full-time leadership and education to faculty, staff, and students in a cluster. Responsibilities include supporting coordination of clinical placements in the cluster, facilitating faculty in clinical education and practice, and engaging in and leading others in the conduct of clinical research. Clinical Educators are clinical faculty who, in addition to providing supervision and education of students in the clinical setting, will build strong partnerships with Clinical Mentors and through these partnerships conduct scholarly work designed to improve patient outcomes and advance nursing practice. The Clinical Educator now becomes the Clinical Faculty in the model. These two roles require doctoral preparation. Clinical Cluster Leads and Clinical Educators are embedded full time in the clinical setting. These faculty and students comprise the structure of the clinical bridge that anchors and connects the mission areas all three mission areas.The vision for a new clinical education model has become a reality and the partnership between UMSN and the UMHS became stronger as the model was developed and implemented in the Health System. It continues to be a work in progress with the goals of preparing nurses to provide state-of-the-art care to patients and families, adapt to new approaches in rapidly changing health care environments, use evidence to ground practice, and participate in exploring nurse sensitive solutions to clinical problems.


Machiavellianism is a personality trait characterized by interpersonal manipulation and associated with specific patterns of emotional and social cognition skills. The aim of this study was to investigate its socio-cognitive characteristics by determining its association and predictors on the basis of a multidimensional approach to Machiavellianism. We used Mach IV scale to assess “Machiavellian Intelligence” skill of participants (Christie and Geis,  Machiavellianism is a concept that has been accorded a growing level of interest, especially in the field of personality studies  . These participants had all obtained at least a High School diploma. Participants were excluded if they reported any history of head injury, neurological disease, or psychiatric disorders. These data were collected by an in-house questionnaire, and participants had to fill in past or present disorders. All successfully completed all the items in all the questionnaires. Informed consent was obtained and the study was designed in accordance with the Declaration of Helsinki.One hundred and seven native French participants , recruited from the general population volunteered to take part in the study. Participants were recruited via opportunity sampling from the French general public and students from the University of Reims and Paris Ouest Nanterre la Défense . They were tested in their homes and classrooms in University campus. They were aged between 18 and 30 years, with a mean age of 23.9 years . The TAS-20 [. The SHAPS . Depression was evaluated with the BDI II scale (QD-2A short form) . The STAI [Spielberger, Basic Empathy Scale (BES). The BES scale . First, we explored the correlations between the emotional/cognitive variables and Machiavellianism. Second, we analyzed the Machiavellianism total score and the three subscales as subdimensions assessed using the Mach-IV, and analyzed the predictors  that could indicate the core emotional composition of this particular personality.Averages are reported as means (with SD) Table . PearsonDescriptive statistics for the emotional and cognitive dimensions for the overall sample are presented in Table Intercorrelations between Machiavellianism, affective ToM, cognitive and affective empathy, alexithymia, anhedonia, depression and anxiety calculated using Bravais-Pearson correlations are shown in Table F > 4 and p < 0.05, that constituted a classical threshold enough restrictive. This permitted to ensure that the selected regressors are not overestimated and only significant variables are retained  and to determine the specific effect of each one because it takes into account the relations between the various predictors entered in the regression Howell, . We therThe use of deceit (Mach-IV-I), a cynical view of humanity (Mach-IV-II) and lack of morality (Mach-IV-III) were predicted at different levels by anhedonia, difficulties in describing feelings (DDF) (DIF and DDF), cognitive or affective empathy and ToM (Eyes Test). This point emphasizes the fact that an examination of the dimensional aspects of Machiavellianism has made it possible to show that different combinations of socio-cognitive components are involved in Machiavellian traits.The results are presented in detail in Table The aim of this study was (1) to explore the emotional characteristics of Machiavellianism and (2) to determine which of these are predictive of the different dimensions of Machiavellianism. First of all, we found that Machiavellianism was negatively correlated with cognitive and affective empathy. A number of studies have demonstrated similar results  component of alexithymia and the Mach-IV total score or subscales could refer to a concrete and logical mode of thought which does not take account of emotional reactions. Nevertheless, the general Machiavellianism score appeared to be predicted by difficulties in describing feelings. This observation emphasizes the emotional impairments present in Machiavellian persons.Second, anhedonia was also found to be positively associated with Machiavellianism and negatively associated with empathy: people who find it difficult to feel physical pleasure should therefore be more Machiavellian and less empathic (at the level of both cognitive and affective empathy). To date, no study has addressed and investigated this question. Increased levels of anhedonia were found to be associated with trait-anxiety as well as with difficulties in cognitive empathy, affective ToM and in describing feelings, and also seemed to be related to cynicism. This finding could be seen as proof of the emotional difficulties that lead to Machiavellian behaviors.In addition, state-depression and trait-anxiety scores were also found to be positively correlated with Machiavellianism scores. In accordance with our hypothesis, the individuals with high scores for depression and/or anxiety symptoms obtained high Machiavellianism scores. Trait-anxiety, which reflects negative affectivity, was a predictor of the Mach-IV-I subscale. This result, which emphasizes the relationship between temperamental anxiety and Machiavellianism, could reflect an awareness of negative consequences. This point could help highlight differences between the “Machiavellian mind” and other personalities and disorders considered to be related to social maladjustment . In other words, people are prompted to perform Machiavellian actions in response to their unusual patterns of social cognition, and other assessments could be able to underline it in a stronger way. Despite this, they act as a function of the consequences they risk and of which they are aware. Their level of negative affectivity, which is underpinned by their trait anxiety, would lead them to act if the feedback and negative consequences were limited  empathy and affective ToM, and a positive association between Machiavellianism, levels of alexithymia, anhedonia, depression, and anxiety. The results of the predictions suggest that statistical tools should be used as part of a dimensional approach  in addition to the category analysis tools.Moreover, our results emphasize the role of these different emotional components in vulnerability to Machiavellian traits. Future research should investigate clinical and non-clinical populations suffering from depression, schizotypal personality disorders or schizophrenia in order to evaluate the potentially aggravating impact of emotional deficits on Machiavellianism. This type of study could lead to the development of accurate evaluation systems and appropriate therapeutic support and care as a function of the socio-emotional profile of the patient.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Arthrogryposis multiplex congenital is a rare condition defined as contractures in multiple joints at birth due to disorders starting in fetal life. Its etiology is associated with many different conditions and in many instances remains unknown. The final common pathway to all of them is decreased fetal movement  due to an abnormal intrauterine environment. Causes of decreased fetal movements may be neuropathic abnormalities, abnormalities of connective tissue or muscle, intrauterine vascular compromise, maternal diseases, and space limitations within the uterus. When the cause of arthrogryposis is space limitations in uterus, the most common etiology is oligohydramnios. The same can result from intrauterine tumours as fibroids, although to our knowledge there are only two papers reporting cases of fetal deformities related to uterine leiomyomas. We describe a well-documented exceptional case of arthrogryposis associated with the presence of a large uterine fibroid. It could illustrate the importance of a careful and appropriate assessment of uterine fibroids before and in the course of a pregnancy considering that they can cause both serious maternal and fetal complications. Arthrogryposis multiplex congenital is a rare nonprogressive condition defined as contractures in multiple joints at birth, due to disorders starting in fetal life. Although antenatally diagnosed, arthrogryposis results often in prenatal death, many children with this disease survive and its overall prevalence is 8.5 per 100,000, without difference in sex ratio . 37% cas When the cause of arthrogryposis is space limitations in uterus, the most common etiology is oligohydramnios, which will limit the movements of the fetus, especially when it occurs early in gestation. The same can result from twin pregnancies, deformities of the uterus, and, theoretically, from intrauterine tumours as fibroids, although nowadays very few cases have been described proving this association . There aA 33-year-old pregnant woman was admitted to our department in the 16th week of her first gestation because of suspicion during a routine ultrasound of decreased fetal movements and fetal malformation consisting of postural deformity of both lower limbs associated with a uterine fibroid. The family history was unremarkable and the mother's medical history nonsignificant except for the presence of two intramural uterine myomas diagnosed before the current pregnancy and smaller than 47 mm in maximum diameter in previous control one year before gestation.  Our ultrasound investigation verified the presence of an intramural-submucosal tumor with a muscular echogenic pattern and a size of 110 × 88 mm in the anterior uterine wall near to the internal cervical os and another intramural one with a size of 28 × 21 mm in the uterine fundus. Fetus presented a normal heart rate pattern and was observed with absent movements and displaced to the right uterine wall in an abnormal position, with hyperextension of head and strongly flexed lower limbs . Fetal mAccording to the Spanish legislation, the parents decided the elective termination of pregnancy. A vaginal delivery was induced with local prostaglandins without complications. At the time of birth, the fetus had not cardiac activity and showed external male genitals, a weight of 105 g and a length of 125 mm. His position consisted of internal rotation of the shoulders and stiffness of the limbs with symmetrically flexed and fixed elbows and wrists and severe equinovarus deformities of the feet . The pathology report concluded that internal organs of the fetus did not present abnormalities. Histopathological examination reported extraconnective tissue developed around the joints and tissue between the muscle fibers swollen with the presence of red blood cells. Chromosomal analysis was normal and the study of fetal DNA excluded the spinal muscular atrophy because there were no deletions of the SMN1 gene.The movement seems to be necessary for normal growth of the limbs and joints during intrauterine life. If the fetus stops moving, the joints become stiff. It is then difficult for them to stretch and resume normal movement in utero . This is Congenital arthrogryposis usually occurs as a sporadic event, but a proportion of cases have a genetic origin involving autosomal dominant, recessive, or X-ligated mechanisms, being a component of a number of genetic syndromes. So it is important to try to determine a specific diagnosis with the objective of establishing the mode of inheritance and risk of recurrence for the purpose of counseling family members and also in following the natural history, which may be quite variable within a family , 3.  Prenatal ultrasound diagnosis of arthrogryposis is focused on diminished fetal movements and the presence of fixed articular contractures and abnormal positioning of extremities. Nevertheless, these signs are very difficult to detect during the first trimester of pregnancy. For this reason, multiple congenital contractures are usually diagnosed during the second trimester. Ultrasound diagnosis of them is based on observation of scarce or absent fetal movements, which should lead to careful examination of the joints and detection of the anomalies that allow prenatal diagnosis. When the joints of the upper limbs are affected, the shoulders are usually in internal rotation, the forearms are pronated, and there is congenital wrist and radius dislocation with flexion of the hands in a fixed position. If the legs are affected, there may be hip flexion with congenital dislocation. The knee joints may be closed to each other in a hyperextended position and the feet are in varus position. The classical image is that of strongly flexed hands, pes equinovarus and the fetus in a Buddha-like position . Prenata Space restriction in uterus, mainly, secondary to oligohydramnios, has been reported as a cause of fetal deformities, but very few cases related to the presence of leiomyomas have been described until now. Leiomyomas of the uterus are detectable in approximately 2% of pregnancies and cause complications in the course of pregnancy or delivery in 1 of 10 diagnosed cases. These complications include premature rupture of membranes, premature birth, placental abruption, necrosis, postpartal hemorrhage, puerperal sepsis, compression on the maternal organs, fetal malpresentation, and increased incidence of abortions and cesarean sections . Less we The medical literature generally advocates conservative therapy for leiomyomas during pregnancy. Nevertheless, it is important to be aware of the possibility of complications and to consider myomectomy prior to the gestation because the growth of the leiomyoma cannot be predicted. Even, surgical intervention in pregnant patients should be assessed because, in addition to classical complications, spatial restrictions could have a deleterious effect on human embryos and fetuses.


A quantitative measurement of inequality in geographic accessibility to pediatric care as well as that of mean distance or travel time is very important for priority setting to ensure fair access to pediatric facilities. However, conventional techniques for measuring inequality is inappropriate in geographic settings. Since inequality measures of access distance or travel time is strongly influenced by the background geographic distribution patterns, they cannot be directly used for regional comparisons of geographic accessibility. The objective of this study is to resolve this issue by using a standardization approach.Travel times to the nearest pediatric care were calculated for all children in Oita Prefecture, Japan. Relative mean differences were considered as the inequality measure for secondary medical service areas, and were standardized with an expected value estimated from a Monte Carlo simulation based on complete spatial randomness.The observed mean travel times in the area considered averaged 4.50 minutes, ranging from 1.83 to 7.02 minutes. The mean of the observed inequality measure was 1.1, ranging from 0.9 to 1.3. The expected values of the inequality measure varied according to the background geographic distribution pattern of children, which ranged from 0.3 to 0.7. After standardizing the observed inequality measure with the expected one, we found that the ranks of the inequality measure were reversed for the observed areas.Using the indicator proposed in this paper, it is possible to compare the inequality in geographic accessibility among regions. Such a comparison may facilitate priority setting in health policy and planning. A scarcity of pediatricians has recently emerged as a major problem for child health care and welfare in Japan ,2. HowevAs warnings of a potential collapse of the Japanese medical system for children has been given , it is cA number of studies on geographic accessibility of health care have been published; some of them have presented sophisticated and complex techniques for measuring accessibility, making use of with higher-performance computational environments and advanced geographic information systems (GIS). For example, the floating catchment area method -8 is a GMean travel time does not consider the distribution of travel time, i.e., whether the travel times are roughly equal amongst children or widely varying from the mean. A particular concern is that it can hide a number of people with considerably longer travel times than the average. Therefore, when describing geographic accessibility, not only the mean travel time but also the inequality indicator of travel time should be specified. This is analogous to specifying standard deviation along with a mean when summarizing a quantitative variable.For measuring inequality in access to health care, researchers have proposed some indicators such as the Gini coefficient and Atkinson distributional measure ,12. ThesUnlike one-dimensional economic measures, our proposed inequality measure for travel time varies according to the two-dimensional distribution pattern of the location of children. Figure For priority setting in health policy and planning, it is extremely important to compare accessibility to pediatric facilities among many regions. For this purpose, we suggest that the indicator be standardized. The objective of this study is to develop a standardized method for measuring inequality in geographic accessibility to health care.Oita Prefecture is located on Kyushu Island, in the southwestern part of Japan. It is almost entirely covered by mountains and has narrow coastal plains. Its population as of October 1, 2005, was 1.21 million, and its population density was 191 per square kilometer.The prefecture was divided into six secondary medical service areas: Chubu, Hohi, Hokubu, Nambu, Seibu, and Tobu. In Japan, a secondary medical service area, which comprises one or more minor municipal districts , is regarded as the basic unit for health care planning and administration.Patients aged 0-14 years are officially defined as pediatric patients. Therefore, we collected population data for children aged 0-14 years in Oita Prefecture, as of October 1, 2005, in the block level from the 2005 Population Census of Japan, reported by the Statistical Survey Department, Statistics Bureau, Japanese Ministry of Internal Affairs and Communications . A blockA list of pediatric clinics and hospitals whose practicing pediatricians are certified by the Japan Pediatric Society was procured from the database service provided by the Oita Prefectural Government .The road network data for the Oita Prefecture was derived from the digital national land information  releasedAlthough aggregation error is problematic if the zone area is too large ,20, eachIn Oita Prefecture, a mother and her child would usually travel to the nearest pediatric facility in the family car. If the facility is very close to their residence, the mother will travel on foot with her child, since bicycles are not very popular in this area and the public buses are not a very practical option in this case. Therefore, multiple modes of transport are not accounted for and car travel times are used for all individuals. While this will underestimate travel times for those on public transport or walking, for the reasons explained above we expect the number of people in this category to be small.D. This is the mean of the pairwise differences divided by the sample, orFor measuring statistical dispersion in this study, we use the relative mean difference n denotes the population size, i x is the travel time between the ith child and the nearest pediatric facility, j xis the corresponding travel time for the jth child, and Here D is mathematically equal to twice the value of Gini coefficient )In this study, we focused on the variations in proximity and did not consider personal, organizational, and financial barriers. Evidently, geographic accessibility is only one factor affecting accessibility to health services ; howeverD with the others. However, we would expect the results to be similar because previous studies have reported very high correlations among these measures [As mentioned in the background, various inequality measures of income distribution, apart from relative mean difference (Gini coefficient), have been proposed by many economists: the decimal ratio, Robin Hood index , Atkinsomeasures .The methodology presented here has a number of limitations and simplifying assumptions, and the studies of geographic accessibility to health care may have only limited impact on the alleviation of inequalities in this health. Nevertheless, we believe that these findings are meaningful and the objectives of this type of research are of value to society.D with an expected value under CSR. We concluded that adjusting the background geographic distribution pattern makes it possible to examine the regional differences in the inequality in geographic accessibility to health care. Furthermore, a comparison of regions by considering the mean travel time and the proposed indicator may assist in setting of priorities for ensuring fair access to pediatric facilities.In this paper, we successfully demonstrated the standardization of The authors declare that they have no competing interests.The contributions of each author in this study are specified as follows: ST conceived the study, participated in its design and coordination, and performed the statistical analysis. MS participated in its design and coordination. Both the authors have read, revised, and approved the final manuscript and have agreed to its submission for publication.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/11/163/prepub