Introduction: Community-based educational opportunities can diversify and strengthen traditional clinical education. With growing diversity of patient populations and increasing life expectancy, it is imperative that medical students and residents prepare for practice within this context. The Center for Healthy Communities in the Department of Family and Community Medicine at the Medical College of Wisconsin, USA developed a community-based, service-learning program in healthy aging to address this need. Objectives: The goals of the Chat and Chew program are to: generate medical student/resident awareness of community health, aging, and diversity; train medical students/residents to present health information to older, minority community members; encourage medical students/residents to view community members as ''teachers'' as well as patients; and provide needed health information and socialization opportunities to elderly public housing tenants. Implications: Medical students and residents gain the opportunity to interact with community members about the health issues that concern them. They also bene.t from seeing community members in their real life context and learning about their healthrelated experiences. The housing tenants help shape how future patients will be understood and treated by the physicians who participated in the service-learning program. The purpose of this article is to: (1) provide an overview of service-learning and the Chat and Chew program, including reection components; and (2) discuss how this program has become an integral part of the family medicine residency curriculum.

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This article is based on a study of nine problem-based learning (PBL) groups with eight medical students and one tutor in each. The groups were observed at their two-weekly meetings for three weeks. The observations were recorded by video and written reports. Three illustrative examples of these observations are presented and discussed. The purpose of the study was to understand how processes in PBL groups correspond with the theory-based intentions for this type of learning and teaching and to discuss the theoretical foundations for problem-based learning. The observations con.rm the expectation that groups in the observed program would follow a systematic stepwise progression. The groups were also found to become more exible and self-directed in their use of PBL as they became more familiar with the approach, provided that the tutor did not dominate the interactions. It is argued that processes in problem-based learning should be understood not only in the light of theories focusing on individual learning and knowledge construction, but also from other theoretical perspectives. Socio-cultural perspectives with constructs such as collaborative learning, apprenticeship and modelling shed new light on what happens inside PBL groups in ways that will enhance learning and tutoring.

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Introduction: Few collaborations between universities in developed countries and medical schools in developing countries have been described in detail in the medical literature. We describe a collaboration between three medical schools, one in a developed country and two in developing countries based on shared challenges and missions. The Alliance: James Cook University School of Medicine (JCU), Fiji School of Medicine (FSM) and University of Papua New Guinea School of Medicine (UPNG) are all located within the tropical regions of the Southwest Paci.c. All schools serve vast geographical areas where much of the population lives in rural and remote communities with limited access to medical care. JCU's .rst class started in 2000 as the only complete medical school in Tropical Australia and was founded with a mission to meet the health care needs of rural, remote and underserved populations in the region. FSM educates medical students from most English-speaking developing Paci.c Island Nations. UPNG serves a predominantly rural developing nation where infectious diseases and other diseases of rural developing nations predominate. Based on their common challenges and goals, the three schools established an informal collaborative relationship called ''the Tropical Triangle'' in the late 1990s. Objectives, Activities and Challenges: These very different institutions are committed to an effective partnership based on mutual understanding and knowledge of each other's day-to-day challenges. Faculty development seminars on medical education have already been carried out in Fiji by JCU staff. JCU has also offered several PhD scholarships to FSM staff, three of which are in the process of being taken up. JCU has offered to make available its online teaching resources to FSM and UPNG. Student exchanges are planned, and FSM and UPNG have exchanged examiners on several occasions for the MBBS and postgraduate programs. The possibilities for collaborative research on regional problems are being explored. Conclusion: The Tropical Triangle Alliance is a special and perhaps unique alliance based on equality and shared challenges. The bene.ts from this alliance ow both ways. The alliance may serve as a model for other collaborations between health education institutions in developed and developing countries.

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Context: This prospective study compared group process literature to topics utilized in a yearlong family practice resident support group. Objectives: The basic hypothesis was that resident support groups function in ways that are similar to other groups to the extent that the literature on group process could contribute to our understanding of support groups for residents. Method: Ten possible discussion topics were grouped along a continuum from informational to interpersonal to intrapersonal. Analysis: Data were subjected to three repeated measures of analysis of variance (ANOVA). Findings: Results reected that informational topics did not decrease, interpersonal topics did increase signi.cantly, yet intrapersonal topics did not reect any signi.cant changes over the course of study. Discussion and Conclusions: The preliminary .ndings indicated the research literature on group process may have application to resident support groups. When more formalized groups like Balint groups are not available, support groups may offer a forum to facilitate the interpersonal and intrapersonal discussions and communications of residents. Recommendations derived from the support group experience and the research are given.

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Bioscience ethics acts as a practical interface between science and bioethics. It links scienti.c endeavour and its application into adaptive forms of bioethical consensus. Its major elements are increased understanding of biological systems, responsible use of technology, and curtailment of ethnocentric debates in tune with new scienti.c insights. This paper briey describes the students' learning experience gained from the vacation unit BIOL 240, Introduction to Bioscience Ethics, as taught in biology, Macquarie University. On the basis of our evidence students were overwhelmingly positive about their learning because the unit assisted them to better face dilemmas that arise from the application of science and technology. The structure also provided active engagement with the subject matter and preferred learning environments that supported and contested their understanding of concepts relevant to bioscience and bioethics.

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Context: Generally speaking, quality assurance in Dutch higher education consists of four parts: a self-evaluation, written by the faculty, a review committee, consisting of experts, the site visit, and a public report of the assessment outcomes. Task of the Review Committee: The organization, in which all universities are united, appoints a review committee for each educational program. Most educational programs are taught at different universities. Consequently, the review committee visits several universities. The task of the review committee is: to assess the overall quality of these educational programs in The Netherlands; and to assess the quality of each school separately. Method: The members of the review committee start their activities by formulating the evaluation criteria (standards) for the content of an educational program and for the educational process. This ends with a paper that will be used as a reference for the assessment. Then the review committee studies the self-evaluation reports. The faculties write these reports along established guidelines. In cases where the self-evaluation is not completely clear, or not suf.cient, the committee formulates questions and asks for additional information. Then the committee visits the faculties. These visits take usually two days each. During these visits, the committee gets information from the dean of the faculty, the program committee, teachers, students, and from other employees of the faculty. In addition, the members of the committee inspect the facilities of the faculty, e.g. the library. Result: Directly after the visit, the chair of the committee gives, orally, a .rst impression of the .ndings. After visiting all faculties, the committee starts their deliberations, which result in a report of the assessment of the overall quality of the educational programs. The committee also assesses the quality of each faculty separately, often ending with recommendations. Conclusion: The Dutch system of quality assurance in higher education is much copied by other countries. The essence is the self-evaluation on one hand, and the site visit on the other. Committees try to act as consultants, and not as executioners. Therefore, the way the members of the committee play their role is very important.

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Objective: The main objective of the problem-based teaching unit reported in this paper was to introduce psychosocial and psychiatric concepts to .rst year medical students using an integrated approach. Method: A total of 131 undergraduate students studied a case of delirium. Students were encouraged to understand the problem from a number of perspectives and approaches. In particular, the patient's view was emphasised. This was partially achieved by employing a standardised patient, who answered students' questions about what it was like to be unwell and hospitalised. Both quantitative and qualitative evaluations of the teaching project were conducted. Results: Overall, the teaching project was well received. However, as an introduction to a complex and unfamiliar area, students were concerned that material was dif.cult to grasp. Conclusions: As a foundation for future teaching in psychiatry, the case and our methods appear appropriate. However, this initial teaching should be reinforced and expanded upon in all years of the medical curriculum.

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Clinical practice is not always user-friendly. Specialisation fragments patient care across different investigations and modes of management. Increasing hospital throughput, especially by day surgery, diminishes the time available for students and other health professionals in the team to interact with the patient and verify the appropriateness of the care plan. Patients are at a serious disadvantage in ensuring that their concerns are understood, and in negotiation of which management plan would optimise the outcomes they seek.

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The words ''knowledge'', ''skills'' and ''attitudes'' are given different meanings by health personnel when discussing educational issues. Ambiguity is known as a handicap to ef.cient communication. In the design of a curriculum the quality of the de.nition of learning objectives plays a fundamental role. If learning objectives lack clarity, learners and teachers will face operational dif.culties. As Robert Mager said, ''If you are not certain of where you are going you may very well end up somewhere else and not even know it''. Knowledge is not only memory of facts but what you do with it. The complexity of human behaviour should not be underestimated. This is why educational objectives need active non-ambiguous verbs in order to achieve better communication between teachers and learners and to assess that complexity. This is why I suggest using the expression intellectual skill (or competence) as meaning ''a rational decision or act''. Sensomotor skill (or competence) would replace ''skills'' as presently used and cover only ''acts which require a neuromuscular coordination''. Interpersonal communication skill (or competence) would replace ''attitude(s)'' and be limited to ''verbal and non-verbal relation between persons''. As the level of validity of assessment of learners' competencies is linked to the clarity of learning objectives, it is hoped that the above suggestions will raise the overall level of validity of the evaluation system. This is why it is important that everybody understands, in the same manner, the meaning of a learning objective. It will help learners to focus their learning efforts on the right target. It will help teachers to ensure the relevance to health needs of their teaching and the validity of assessment instruments. In both cases it will be bene.cial to the health of the population.

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Objective: To examine the scope of intern prescribing practices by determining: the proportion of prescriptions that interns chart compared with other medical staff; the proportion of intern-charted prescriptions for which interns are sole decision-makers; whether or not intern-initiated prescribing varies with respect to the specialty to which they are attached, the shifts they are working and the types of charts they are using; the types of clinical conditions for which interns initiate prescribing decisions; and the drug classes that interns use for their self-initiated prescribing. Design: Prospective study of a random sample of intern-charted prescriptions. Setting: Two teaching hospitals of the Hunter Area Health Service, Newcastle, Australia. The study was conducted from the .fth to the eighth month of the intern training year. Main Outcome Measures: The proportion of prescriptions charted by interns that resulted from their own decision-making, the circumstances relating to this, clinical conditions for which they prescribe and drugs prescribed. Results: A total of 17,895 prescriptions were examined-3437 (19%) were interncharted. Interns reported they were the sole decision-makers for 19% (95% CI: 14 - 24%) of prescriptions they had charted. Interns were more likely to initiate decisions in accident and emergency (OR=7.5, 95% CI: 2.2 - 25.2) and obstetric and gynaecology (OR=2.3, 95% CI: 1.6 - 3.2) rotations than in medicine and were more likely to initiate decisions on night (OR=7.3, 95% CI: 3.4 - 15.5) and weekend (OR=1.7, 95% CI: 1.0 - 3.2) shifts than during the day. They were also more likely to prescribe on the ''as required'' (OR=36.6, 95% CI: 20.6 - 65.0), ''statim'' (OR=26.1, 95% CI: 17.0 - 40.1) and ''intravenous'' (OR=7.2, 95% CI: 4.3 - 12.3) charts compared with ''regular'' charts. A total of 52% of intern-initiated prescriptions were for symptom relief; pain, insomnia and nausea; and 75% of the drugs for which interns made independent decisions were analgesics, antithrombotic agents, psycholeptics, antispasmodics, laxatives and anti-asthmatic agents. Conclusion: Interns have a limited role with respect to independent prescribing and take the sole responsibility for only one-.fth of the prescriptions they chart. This limited, albeit safe, approach to prescribing may impact signi.cantly on an intern's opportunity to acquire the skills necessary to become an independent, rational prescriber.

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Purpose: Early Clinical Exposure (ECE) programs are an increasingly widespread component of undergraduate medical education. Little systematic research exists on the topic. This report compares the approach and cost/bene.ts of two parallel ECE programs at the Sackler School of Medicine, Tel Aviv University. Method: The two ECE programs were compared using student questionnaires, faculty questionnaires, focus groups and participant-observations. Results: ECE for American medical students in Israel was based upon a semi-structured mentoring relationship with a hospital-based specialist, in which students were able to practice interviewing skills. ECE for Israeli students emphasized structured exposure to a wide variety of primary care settings and informal patient contact. Both ECEs were supplemented by campus-based small group discussion. Students, preceptors and group leaders in both ECEs all reported very high levels of satisfaction and perceived impact on medical training. Conclusion: There appears to be no ''best'' way to conduct ECE. The ECE should be tailored to the speci.c needs and goals of the student population. Further research and international comparison is needed.

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The Greater Murray Clinical School (GMCS) was founded with two main aims in mind one, to provide a community-based learning environment offering diversi.ed clinical educational experiences, and two, by doing so, to help address the doctor shortage for Australians living in rural and remote areas. The GMCS is a community-orientated and community-based clinical school, which has replaced the typical discipline-based curriculum with a longitudinal, patient-centred one. Students are attached to patients— called ''the longitudinal patient''— whom they follow through all stages of their care. They share with patients their experience of illness and disease, their varying care needs, and how these are addressed by different service providers. The philosophy of the course, its implementation and our initial experiences are described.

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