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"WHAT TO DO WHEN A PATIENT LACKS CAPACITY - The degree and urgency with which to act on findings of impaired capacity depends on multiple factors, including the expected duration of impairment, the severity of the impairment, and the seriousness of the decision. Unless the urgency of a patient's medical condition requires that a substituted decision be made immediately, efforts should be made to identify and correct any reversible causes of the impairment [26]. This is particularly relevant in hospitalized patients with impaired capacity due to delirium. Treatment of the underlying causes of delirium may restore decision-making capacity. Patients with mild to moderate cognitive impairment that is not expected to fluctuate may benefit from more intensive efforts at education to improve understanding of the relevant facts, followed by reassessment of decision-making abilities. A randomized trial found that a memory and organizational aid given to patients with mild stage Alzheimer disease dementia (n = 80) improved performance on understanding, which in turn increased the likelihood of being judged capable of providing informed consent to enroll in a clinical trial [34]. This enhancement was also effective in a randomized trial with middle-aged and older adults with schizophrenia [35]. For patients whose impairments are severe enough that they are judged to lack the capacity to make a decision, there is a clear ethical obligation to seek out a substitute decision maker. Substitute or surrogate decision makers should ideally have been chosen by the patient in advance. In the absence of a designated surrogate, laws may vary in terms of which people can serve in this proxy role and their hierarchy; in general, the order is the spouse, adult children, parents, siblings, and other relatives. (See "Legal aspects in palliative and end of life care", section on 'Surrogate decision makers'.) When making a substituted decision, the proxy should take into consideration

How could this impact medical education?

Whereas present theories of transformative learning tend to focus on the rational and reflective actor, in this article it is suggested that spontaneous action may play a decisive role in transformative learning too. In the spontaneity of action, novelty finds its way into life, gains momentum, is respected by others and reflected by the actor. Such transformation processes are investigated both with the means of theoretical reflection and of empirical inquiry. Based on nine narrative interviews typical phases of transformative learning processes are identified. Owing to the comparative nature of the study, it was also possible to develop an age-related typology that overlaps certain phases of the transformation process. These empirical findings constitute the background against which the nexus of spontaneous action and transformative learning is reflected theoretically. Theories drawn upon include John Dewey's Pragmatism and George Herbert Mead's Social Pragmatism. Both scholars provide rich theoretical concepts for reflecting on the nature of that what so often eludes from the control of both educators and learners: the spontaneity of the beginning.

The Internet increasingly serves as a platform for the delivery of public health interventions. The efficacy of Internet interventions has been demonstrated across a wide range of conditions. Much more work remains, however, to enhance the potential for broad population dissemination of Internet interventions. In this article, we examine the effectiveness of Internet interventions, with particular attention to their dissemination potential. We discuss several considerations (characterizing reach rates, minimizing attrition, promoting Web site utilization, use of tailored messaging and social networking) that may improve the implementation of Internet interventions and their associated outcomes. We review factors that may influence the adoption of Internet interventions in a range of potential dissemination settings. Finally, we present several recommendations for future research that highlight the potential importance of better understanding intervention reach, developing consensus regarding Web site usage metrics, and more broadly integrating Web 2.0 functionality.

Ninety-seven articles were included from 182 full-text articles of the initial 2,001 hits. All studies were of average or good quality and the majority had an observational study design.Ninety-six studies provided insight into the effect of 'the level of experience of residents' on patient outcomes during residency training. Within these studies, the start of the academic year was not without risk (five out of 19 studies), but individual progression of residents (seven studies) as well as progression through residency training (nine out of 10 studies) had a positive effect on patient outcomes.

"Narratives have always been a vital part of medicine. Stories about patients, the experience of caring for them, and their recovery from illness have always been shared-among physicians as well as among patients and their relatives. With the evolution of "modern" medicine, narratives were increasingly neglected in favor of "facts and findings," which were regarded as more scientific and objective. Now, in recent years medical narrative is changing-from the stories about patients and their illnesses, patient narratives and the unfolding and interwoven story between health care professionals and patients are both gaining momentum, leading to the creation or defining of narrative-based medicine (NBM). The term was coined deliberately to mark its distinction from evidence-based medicine (EBM); in fact, NBM was propagated to counteract the shortcomings of EBM.1,2 But what is NBM? Is it a specific therapeutic tool, a special form of physician-patient communication, a qualitative research tool, or does it simply signify a particular attitude towards patients and doctoring? It can be all of the above with different forms or genres of narrative or practical approach called for depending on the field of application. "

Participatory medicine will owe part of its success to the technologies that have the potential to remove treatment, symptom management, administrative, and communications burdens from individuals and clinicians while maintaining the critical interpersonal interactions between them. Out of the steady stream of new devices, programs, gadgets, and applications, which will make a difference in the health and lives of patients? We hope to build the Journal as a resource for critical reviews of technologies that support and facilitate participatory medicine. We realize it will be no small undertaking to put together a process that will allow for the review of a substantial number of technologies over time, reflecting the experience of different types of users.

The AARP just met with the leadership of the Mayo Clinic, one of the most outstanding medical institutions in the country. They provide excellent care at a cost that is less than most other parts of the healthcare system - and with improved outcomes. We asked them about their secret to success. Mayo has an electronic medical record and all their patients have their information online. The physicians are on salary, so there's no incentive to order unnecessary tests or procedures, and Mayo has an ethic of patient-centered care, with a long history of attracting the best people and rewarding them. If Mayo can do it, why can't everyone else? The AARP believes that the potential is there for most communities to have excellent care - we must emulate the care delivery of institutions like the Mayo Clinic, and put in place payment and information systems that will coordinate care management better. It's a big job and will take some investment, but we have many opportunities to do a better job than we're doing today.

" The BEME Collaboration is a group of individuals or institutions who are committed to the promotion of Best Evidence Medical Education through: the dissemination of information which allows medical teachers, institutions and all concerned with medical education to make decisions on the basis of the best evidence available; the production of appropriate systematic reviews of medical education which reflect the best evidence available and meet the needs of the user; and the creation of a culture of best evidence medical education amongst individual teachers, institutions and national bodies."

" The SOC are based on the best available science and expert professional consensus. Because most of the research and experience in this field comes from a North American and Western European perspective, adaptations of the SOC to other parts of the world are necessary. The SOC articulate standards of care while acknowledging the role of making informed choices and the value of harm reduction approaches. In addition, this version of the SOC recognizes that treatment for gender dysphoria i.e., discomfort or distress that is caused by a discrepancy between persons gender identity and that persons sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics) has become more individualized."

"In conclusion, a relatively small percentage of students use multimedia (audio and video) that are provided as a duplication of lectures in the basic sciences. The distribution of frequency of access of both video and audio files was consistent across the various courses offered in the first two years of medical school. There were significant correlations in the frequencies with which individual students viewed videos of lectures from course-to-course. Finally, there was a trend for an inverse association between the frequencies with which students viewed lectures and the grades they received in the course. This is an important observation that requires further investigation since it may be indicative of a maladaptive learning strategy for some students. It also does not exclude the possibility that additional computer-aided resources may be detrimental to some students. "

"Using René Magritte's well-known painting The Treachery of Images (This is not a pipe), we argue that the current focus on competencies throughout medical education can sometimes lead educators to rely too heavily on scores, checkmarks, or other forms of assessment that come to be viewed as equivalents for the actual existence of what is being measured. Magritte insisted that the image he created on the canvas was not a pipe but rather a representation of a pipe, an important distinction for educators to remember as we seek ways to evaluate trainees' attainment of the fundamental knowledge and skills of the profession. We also urge that the focus on broader skills, values, flexibility, reflection, and insight development should fall outside the net of a competency orientation in a supportive environment spared from traditional assessment methods, using a classroom in undergraduate medical education as an example of working toward this end. "

The purpose of this website is to create a collection of free medical mindmaps in order to facilitate learning of complex topics. Mindmaping is a way of incorporating imagery, colour, and visual-spatial arrangement to your notes. These elements have been separately shown to improve recall of learnt material. Mindmapping allows for the whole topic to be displayed on a single page, which increases revision speed and allows you to see connections between different ideas more easily. The difficulty in using mindmaps for revision is that it often takes a fair amount of time to design them and there are many topics to be covered in medicine. In preparation for exams, it would be very difficult for a student to make a good mindmap for every topic. One of the aims of this website is to help you overcome this problem.

This study underscores the need for greater emphasis on the social determinants of health in medical education in the context of homelessness. These insights may help to inform the development and design of service-learning initiatives that integrate understandings of the social determinants of health, and thus potentially improve the readiness of clinicians to address the complex factors that shape the health of homeless populations.

"To describe the essential components of the medical model of substance use disorders. To delineate the interviewing skills necessary to screen effectively for substance use and abuse. To understand the high rate of psychiatric and medical co-morbidity and more effectively screen patients for these disorders. To demonstrate skills for evaluating patients' stage of change, readiness to accept the diagnosis, and readiness to undertake behavior change. To clearly and supportively recommend treatment to patients with substance use disorders. To describe the skills required for addiction prevention counseling. To define the skills that help set respectful limits on patient requests for prescription medication. To demonstrate awareness of how physician/clinician attitudes toward patients with substance use disorders impact recognition, diagnosis, and treatment of patients. To demonstrate knowledge of substance use disorder treatment standards and the ability to recommend appropriate referrals."

"as soon as information is acquired, is very rapidly replaced by still newer information. Our electrically configured world has forced us to move from the habit of data classification to the mode of pattern recognition. We can no longer build serially, block by block, step-by-step, because instant communication ensures that all factors of the environment and of experience coexist in a state of active interplay."

"The duty of the teacher in this model is not to judge and rate but, rather, to read and tell what is seen. Our teachers, having been trained in the acts of close reading, are equipped not with rating rubrics but, rather, with a reading guide that prompts the reader to attend to several narrative features of a text. The reader/coach can thereby first see and then show the writer what is contained in the written text, at least from that reader's vantage point, helping along the process not only of the writing but also of the reflection the writing birthed. Multiple readers swell and complicate the lessons learned. As a dividend, we have observed, the group of readers/writers form strong, trusting, collaborative teams. And so our training for reflection also fulfills other difficult missions of medical education in teamwork, peer learning, trust, and care."

"This series includes three Reviews about intensive care medicine. The papers describe the evolution of the specialty, the demand for and ability to supply appropriate levels of care, and some of the commonly faced ethical dilemmas and challenges. These topics are apt in this period of economic constraint. Intensive care medicine consumes a considerable proportion of health-care resources and these costs will need to be justified. The appropriateness and effectiveness of the care provided will need to be improved to ensure that these resources are directed to patients most in need of them. "

"All of the graduate students in the School of Nursing take some of their Master of Science courses online. A group of six School of Nursing faculty members and a graduate student received funding to determine best practices in online courses. The group developed an evaluation rubric to measure quality in the graduate online curriculum. They then applied the rubric to the core courses which are primarily offered online and are required for all graduate nursing students. The project had a positive impact on faculty by offering a tool useful for online course evaluation and development. Additionally it brought to attention the needs of faculty member development in online education."