This week in the BMJ
Volume 329, Number 7469, Issue of 2 Oct 2004Tackle the hidden curriculum to improve medical schools
Tackle the hidden curriculum to improve medical schools
After recent reforms in medical school curriculums, attention should now focus on the hidden factors affecting students if the culture of undergraduate medical education is to change. Interviewing 36 undergraduate medical students, Lempp and Seale (p 770) found that students reported many examples of positive role models and effective, approachable teachers, but they also described a hierarchical and competitive atmosphere in the medical school, in which haphazard instruction and teaching by humiliation occur, especially during the clinical training years.
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Encouraging people to be active is not enough
Encouraging people to use alternative and healthier modes of transport may not be enough to improve the health of the population. Reviewing 22 studies analysing the effect of targeted behaviour change programmes, Ogilvie and colleagues (p 763) found that these programmes can be effective in changing the transport choices of motivated subgroups, but the social distribution of the effects of such programmes and their effect on the health of local populations is unclear. There is no strong evidence that other types of intervention have been effective.
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Health declines fast after 45 in Russia
The short life span in Russia reflects high levels of ill health and disability and is associated with a rapid, age related decline in physical functioning. Analysing 9489 randomly selected men and women from Sweden and 1599 from Russia, Bobak and colleagues (p 767) found that the decline in health and physical functioning is greater in older men and women in Russia than in Sweden. Survival without disability in middle aged and older Russians is about a third of that in Sweden.
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Off-site triage can work in primary care
Off-site triage of patients who need a same day appointment is feasible, but it doesn't save money. Richards and colleagues (p 774) randomised more than 4500 patients in primary care to off-site triage by NHS Direct or to triage by a nurse in the practice. They found that off-site triage took longer and was more expensive than standard triage; with off-site triage, patients were more likely to get an appointment. If NHS Direct could resolve as many calls by telephone contact or appointment with a nurse as practice based triage, costs would be comparable.
Fasting during Ramadan affects drug treatment
Extensive misuse of drugs during Ramadan may lead to therapeutic failure. On p 778 Aadil and colleagues analyse how the change of dosing time and schedule may affect the efficacy of treatment. Slow release formulations and a lower number of daily doses may improve the plasma concentration of some drugs, but the potential for toxicity is high for drugs with a narrow therapeutic range. During Ramadan patients arbitrarily modify their dosing schedules and even total daily dosage, often without medical advice. Patients often insist on fasting, even though those with chronic diseases are permitted not to fast and patients with acute diseases are allowed to stop fasting and make up for it after Ramadan.
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Academic medicine needs a global agenda
The BMJ and partners' campaign provides an opportunity to question the global relevance and responsibilities of academic medicine. In this week's theme issue, international authors provide a range of perspectives on how academic medicine can be promoted and revitalised. Schmidt and Duncan (p 753) describe the development of the Brazilian public health system, and how academic support is needed to support population health goals. Drawing on seven years as dean of Makerere University in Uganda, Sewankambo (p 752) suggests ways in which academic medicine can contribute to strengthen health systems. The campaign's working party set out its agenda and planned consultations for the next year (p 787), including an evidence based approach (p 789). On page 751 Clark and Tugwell ask: who cares about academic medicine?
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