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1.  Writing and reading in the electronic health record: an entirely new world 
Medical Education Online  2013;18:10.3402/meo.v18i0.18634.
Electronic health records (EHRs) are structured, distributed documentation systems that differ from paper charts. These systems require skills not traditionally used to navigate a paper chart and to produce a written clinic note. Despite these differences, little attention has been given to physicians’ electronic health record (EHR)-writing and -reading competence.
This study aims to investigate physicians’ self-assessed competence to document and to read EHR notes; writing and reading preferences in an EHR; and demographic characteristics associated with their perceived EHR ability and preference.
Fourteen 5-point Likert scale items, based on EHR system characteristics and a literature review, were developed to measure EHR-writing and -reading competence and preference. Physicians in the midwest region of the United States were invited via e-mail to complete the survey online from February to April 2011. Factor analysis and reliability testing were conducted to provide validity and reliability of the instrument. Correlation and regression analysis were conducted to pursue answers to the research questions.
Ninety-one physicians (12.5%), from general and specialty fields, working in inpatient and outpatient settings, participated in the survey. Despite over 3 years of EHR experience, respondents perceived themselves to be incompetent in EHR writing and reading (Mean = 2.74, SD = 0.76). They preferred to read succinct, narrative notes in EHR systems. However, physicians with higher perceived EHR-writing and -reading competence had less preference toward reading succinct (r= − 0.33, p<0.001) and narrative (r= − 0.36, p<0.001) EHR notes than physicians with lower perceived EHR competence. Physicians’ perceived EHR-writing and - reading competence was strongly related to their EHR navigation skills (r=0.55, p<0.0001).
Writing and reading EHR documentation is different for physicians. Maximizing navigation skills can optimize non-linear EHR writing and reading. Pedagogical questions remain related to how physicians and medical students are able to retrieve correct information effectively and to understand thought patterns in collectively lengthier and sometimes fragmented EHR chart notes.
PMCID: PMC3566375  PMID: 23394976
electronic health record (EHR); electronic medical record (EMR); reading; documentation; navigation
2.  Automatic Capture of Student Notes to Augment Mentor Feedback and Student Performance on Patient Write-Ups 
To determine whether the integration of an automated electronic clinical portfolio into clinical clerkships can improve the quality of feedback given to students on their patient write-ups and the quality of students’ write-ups.
The authors conducted a single-blinded, randomized controlled study of an electronic clinical portfolio that automatically collects all students’ clinical notes and notifies their teachers (attending and resident physicians) via e-mail. Third-year medical students were randomized to use the electronic portfolio or traditional paper means. Teachers in the portfolio group provided feedback directly on the student’s write-up using a web-based application. Teachers in the control group provided feedback directly on the student’s write-up by writing in the margins of the paper. Outcomes were teacher and student assessment of the frequency and quality of feedback on write-ups, expert assessment of the quality of student write-ups at the end of the clerkship, and participant assessment of the value of the electronic portfolio system.
Teachers reported giving more frequent and detailed feedback using the portfolio system (p = 0.01). Seventy percent of students who used the portfolio system, versus 39% of students in the control group (p = 0.001), reported receiving feedback on more than half of their write-ups. Write-ups of portfolio students were rated of similar quality to write-ups of control students. Teachers and students agreed that the system was a valuable teaching tool and easy to use.
An electronic clinical portfolio that automatically collects students’ clinical notes is associated with improved teacher feedback on write-ups and similar quality of write-ups.
PMCID: PMC2517906  PMID: 18612728
portfolio; feedback; medical education
3.  Exploration of GPs' views and use of the fit note: a qualitative study in primary care 
The British Journal of General Practice  2012;62(598):e363-e370.
Sickness certification constitutes daily clinical practice for GPs. In April 2010, the UK sickness certification system changed to reflect the evidence that work is generally good for health and a new Statement of Fitness for Work — the ‘fit note’ — was introduced. Sickness certification is a contentious topic among GPs and the proposed fit note generated mixed reviews.
To explore GPs' views and use of the fit note during its first year of operation.
Design and setting
Qualitative interview study of GPs based in different geographical locations across the UK.
GPs (n = 15), who were recruited from a national sample, participated in semi-structured telephone interviews which were subject to constant comparative analysis.
Overall, the fit note was well received. GPs recognised that work is generally good for health and felt the fit note facilitated using an earlier return to work as a negotiation tool. GPs perceive employers as the major obstacle to early return to work. There were reports of scepticism towards the system that negatively impacted on some GPs' operation of sickness certification. Feedback over the fit note's impact on employer behaviour and the return of a mechanism that enables GPs to request early independent assessments would be welcomed.
A revised approach is needed to address the scepticism towards the sickness certification system that persists among some GPs. New strategies need to be designed to engage employers in facilitating an early return to work and to enable the objectives of the medical statement reforms to be achieved.
PMCID: PMC3338058  PMID: 22546596
general practice; health policy; qualitative research; sick leave; sickness certification
4.  Manuscript Architect: a Web application for scientific writing in virtual interdisciplinary groups 
Although scientific writing plays a central role in the communication of clinical research findings and consumes a significant amount of time from clinical researchers, few Web applications have been designed to systematically improve the writing process.
This application had as its main objective the separation of the multiple tasks associated with scientific writing into smaller components. It was also aimed at providing a mechanism where sections of the manuscript (text blocks) could be assigned to different specialists. Manuscript Architect was built using Java language in conjunction with the classic lifecycle development method. The interface was designed for simplicity and economy of movements. Manuscripts are divided into multiple text blocks that can be assigned to different co-authors by the first author. Each text block contains notes to guide co-authors regarding the central focus of each text block, previous examples, and an additional field for translation when the initial text is written in a language different from the one used by the target journal. Usability was evaluated using formal usability tests and field observations.
The application presented excellent usability and integration with the regular writing habits of experienced researchers. Workshops were developed to train novice researchers, presenting an accelerated learning curve. The application has been used in over 20 different scientific articles and grant proposals.
The current version of Manuscript Architect has proven to be very useful in the writing of multiple scientific texts, suggesting that virtual writing by interdisciplinary groups is an effective manner of scientific writing when interdisciplinary work is required.
PMCID: PMC1180829  PMID: 15960855
5.  Getting back to work after injury: the UK Burden of Injury multicentre longitudinal study 
BMC Public Health  2012;12:584.
Injuries to working age adults are common and place a considerable burden on health services accounting for more than 10% of GP sick notes and 14% of those claiming benefits because they are unable to work in the UK. General practitioners (GPs) currently assess fitness to work and provide care and referral to other services to facilitate return to work (RTW). Recent UK recommendations suggest replacing GP sickness certification with independent assessments of fitness to work after four weeks sick leave. The impact of a wide range of injuries on RTW and subsequent need for independent fitness to work assessments has not been well studied in the UK. The aim of this study was to quantify RTW and factors predicting RTW following a wide range of injuries.
We used a multicentre longitudinal study, set in four acute NHS Trusts in the UK which recruited emergency department (ED) attenders and hospital admissions for injury and included those aged 16–65years that were employed or self-employed before the injury. Participants were followed up by postal questionnaire at 1, 4 and 12 months post injury to measure health status (EQ-5D), recovery, use of health and social services, time off work in the preceding month and work problems amongst those who had RTW. Multivariable Poisson regression with a robust variance estimator was used to estimate relative risks for factors associated with RTW.
One month after injury 35% of ED attenders had fully RTW. The self employed were more likely (RR 1.70, 95% CI 1.17 to 2.47 compared with employed) and the moderate/severely injured less likely to RTW (RR 0.48, 95% CI 0.32 to 0.72 compared with minor injuries). At four months, 83% of ED attenders had RTW and self employment and injury severity remained significant predictors of RTW (self employment RR 1.15, 95% CI 1.03 to 1.30; moderate/severe injury RR 0.79, 95% CI 0.68 to 0.92). At four months 57% of hospital admissions had RTW. Men were more likely than women to RTW (RR 1.94, 95% CI 1.34 to 2.82), whilst those injured at work (RR 0.49, 95% CI 0.27 to 0.87 compared with at home) and those living in deprived areas (most deprived tertile RR 0.59, 95% CI 0.40 to 0.85 and middle tertile RR 0.61, 95% CI 0.40 to 0.93) were less likely to RTW. Health status was significantly poorer at one and four months after injury than before the injury and was significantly poorer amongst those that had not RTW compared to those that had. Problems with pain control, undertaking usual activities, mobility and anxiety and depression were common and persisted in a considerable proportion of participants up to four months post injury.
Injuries have a large impact on time off work, including amongst those whose injuries did not warrant hospital admission. The majority of injured people would require an in-depth fitness for work assessment if recent UK recommendations are implemented. Many people will have on-going pain, mobility problems, anxiety and depression at the point of assessment and it is important that patients are encouraged to use primary care services to address these problems. A range of factors may be useful for identifying those at risk of a slower recovery and a delayed RTW so that appropriate interventions can be provided to this group.
PMCID: PMC3444403  PMID: 22853715
6.  “Writing in Neuroscience”: A Course Designed for Neuroscience Undergraduate Students 
Although neuroscience students may learn to write in a generic fashion through university writing courses, they receive little training in writing in their field. Here I describe a course that was created at the request of a Neuroscience Department with the intent to teach neuroscience students how to write well in their discipline. I explain the purpose for creating the “Writing in Neuroscience” course and offer a brief overview of the course curriculum, including pertinent pedagogical outcomes for such a course. I describe in depth the major assignment for the course, the literature review, and provide examples of paper titles that students wrote to fulfill the assignment. I briefly describe other relevant course assignments. I evaluate the course and include an overview of who should teach such a course, what support might be helpful, and what can be learned from formative assessment of the course. Using these insights can help others determine whether such a course is a good fit for them.
PMCID: PMC3598184  PMID: 23626493
writing in neuroscience; teaching writing; neuroscience genres; writing in the disciplines
7.  Writing Assignments with a Metacognitive Component Enhance Learning in a Large Introductory Biology Course 
CBE Life Sciences Education  2014;13(2):311-321.
Students score higher on postexam assessment topics learned via peer-reviewed writing, or when they correct exam questions initially answered incorrectly, compared with their nonparticipating peers.
Writing assignments, including note taking and written recall, should enhance retention of knowledge, whereas analytical writing tasks with metacognitive aspects should enhance higher-order thinking. In this study, we assessed how certain writing-intensive “interventions,” such as written exam corrections and peer-reviewed writing assignments using Calibrated Peer Review and including a metacognitive component, improve student learning. We designed and tested the possible benefits of these approaches using control and experimental variables across and between our three-section introductory biology course. Based on assessment, students who corrected exam questions showed significant improvement on postexam assessment compared with their nonparticipating peers. Differences were also observed between students participating in written and discussion-based exercises. Students with low ACT scores benefited equally from written and discussion-based exam corrections, whereas students with midrange to high ACT scores benefited more from written than discussion-based exam corrections. Students scored higher on topics learned via peer-reviewed writing assignments relative to learning in an active classroom discussion or traditional lecture. However, students with low ACT scores (17–23) did not show the same benefit from peer-reviewed written essays as the other students. These changes offer significant student learning benefits with minimal additional effort by the instructors.
PMCID: PMC4041507
8.  Want to Improve Undergraduate Thesis Writing? Engage Students and Their Faculty Readers in Scientific Peer Review 
CBE Life Sciences Education  2011;10(2):209-215.
One of the best opportunities that undergraduates have to learn to write like a scientist is to write a thesis after participating in faculty-mentored undergraduate research. But developing writing skills doesn't happen automatically, and there are significant challenges associated with offering writing courses and with individualized mentoring. We present a hybrid model in which students have the structural support of a course plus the personalized benefits of working one-on-one with faculty. To optimize these one-on-one interactions, the course uses BioTAP, the Biology Thesis Assessment Protocol, to structure engagement in scientific peer review. By assessing theses written by students who took this course and comparable students who did not, we found that our approach not only improved student writing but also helped faculty members across the department—not only those teaching the course—to work more effectively and efficiently with student writers. Students who enrolled in this course were more likely to earn highest honors than students who only worked one-on-one with faculty. Further, students in the course scored significantly better on all higher-order writing and critical-thinking skills assessed.
PMCID: PMC3105927  PMID: 21633069
9.  Factors affecting mental fitness for work in a sample of mentally ill patients 
Mental fitness for work is the ability of workers to perform their work without risks for themselves or others. Mental fitness was a neglected area of practice and research. Mental ill health at work seems to be rising as a cause of disablement. Psychiatrists who may have had no experience in relating mental health to working conditions are increasingly being asked to undertake these examinations. This research was done to explore the relationship of mental ill health and fitness to work and to recognize the differences between fit and unfit mentally ill patients.
This study was cross sectional one. All cases referred to Al-Amal complex for assessment of mental fitness during a period of 12 months were included. Data collected included demographic and clinical characteristics, characteristics of the work environment and data about performance at work. All data was subjected to statistical analysis.
Total number of cases was 116, the mean age was 34.5 ± 1.4. Females were 35.3% of cases. The highly educated patients constitute 50.8% of cases. The decision of the committee was fit for regular work for 52.5%, unfit for 19.8% and modified work for 27.7%. The decision was appreciated only by 29.3% of cases. There were significant differences between fit, unfit and modified work groups. The fit group had higher level of education, less duration of illness, and better performance at work. Patients of the modified work group had more physical hazards in work environment and had more work shift and more frequent diagnosis of substance abuse. The unfit group had more duration of illness, more frequent hospitalizations, less productivity, and more diagnosis of schizophrenia.
There are many factors affecting the mental fitness the most important are the characteristics of work environment and the most serious is the overall safety of patient to self and others. A lot of ethical and legal issues should be kept in mind during such assessment as patient's rights, society's rights, and the laws applied to unfit people.
PMCID: PMC2784741  PMID: 19925677
10.  Fit for purpose? Using the fit note with patients with chronic pain: a qualitative study 
The British Journal of General Practice  2011;61(593):e794-e800.
Staying in work may benefit patients with chronic pain, but can be difficult for GPs to negotiate with patients and their employers. The new fit note is designed to help this process, but little is known of how it is operating.
To explore GPs' views on the fit note, with particular reference to sickness certification for patients with chronic pain.
Design and setting
Qualitative study using semi-structured interviews in eight primary care trusts in south-west England.
In-depth interviews with 13 GPs.
GPs reported that the rationale behind the fit note is sound and that it may help patients with chronic pain to return to work earlier. However, GPs also reported barriers to successful fit note use, including the need to preserve doctor–patient relationships, inconsistent engagement from employers, GPs' lack of specialist occupational health knowledge, issues with fit note training, and whether a new form can achieve cultural shift.
While doctors agree that good work improves health outcomes, they do not think that fit notes will greatly alter sickness-certification rates without more concerted initiatives to manage the tripartite negotiation between doctor, patient, and employer.
PMCID: PMC3223777  PMID: 22137416
chronic disease; general practice; pain; sick leave
11.  Criteria and methods used for the assessment of fitness for work: a systematic review 
The main findings from reports published in scientific journals on the criteria and methods used to assess fitness for work were reviewed. Systematic searches were made using internet engine searches (1966–2005) with related keywords. 39 reports were identified, mostly from the US and western Europe. Assessment of fitness for work is defined by most as the evaluation of a worker's capacity to work without risk to their own or others' health and safety. It is mainly assessed at recruitment (pre‐offer or post‐offer), and when changes of work or health conditions occur. Five main criteria used by occupational doctors to evaluate fitness for work were identified: the determination of worker's capacity and worker's risk in relation to his or her workplace, as well as ethical, economic and legal criteria. Most authors agreed that assessment tools used need to be specific and cost‐effective, and probably none gives unequivocal answers. Outcomes from fitness for work assessments range from “fit” to “unfit”, with other possible intermediate categories such as “fit subject to work modifications”, “fit with restrictions” or “conditionally fit (temporarily, permanently)”. Workplace modifications to improve or adjust working conditions must always be considered. There is confusion about the decision‐making process to be used to judge about fitness for work. There is very scarce scientific evidence based on empirical data, probably because there are no standard or valid methodologies for all professions and circumstances.
PMCID: PMC2092557  PMID: 17095547
12.  Protocol for an HTA report: Does therapeutic writing help people with long-term conditions? Systematic review, realist synthesis and economic modelling 
BMJ Open  2014;4(2):e004377.
Long-term medical conditions (LTCs) cause reduced health-related quality of life and considerable health service expenditure. Writing therapy has potential to improve physical and mental health in people with LTCs, but its effectiveness is not established. This project aims to establish the clinical and cost-effectiveness of therapeutic writing in LTCs by systematic review and economic evaluation, and to evaluate context and mechanisms by which it might work, through realist synthesis.
Included are any comparative study of therapeutic writing compared with no writing, waiting list, attention control or placebo writing in patients with any diagnosed LTCs that report at least one of the following: relevant clinical outcomes; quality of life; health service use; psychological, behavioural or social functioning; adherence or adverse events. Searches will be conducted in the main medical databases including MEDLINE, EMBASE, PsycINFO, The Cochrane Library and Science Citation Index. For the realist review, further purposive and iterative searches through snowballing techniques will be undertaken. Inclusions, data extraction and quality assessment will be in duplicate with disagreements resolved through discussion. Quality assessment will include using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Data synthesis will be narrative and tabular with meta-analysis where appropriate. De novo economic modelling will be attempted in one clinical area if sufficient evidence is available and performed according to the National Institute for Health and Care Excellence (NICE) reference case.
PMCID: PMC3932001  PMID: 24549165
Systematic Review; Realist Review; Public Health
13.  Evaluation of Operative Notes Concerning Laparoscopic Cholecystectomy: Are Standards Being Met? 
World Journal of Surgery  2010;34(5):903-909.
Laparoscopic cholecystectomy (LC) is the most performed minimal invasive surgical procedure and has a relatively high complication rate. As complications are often revealed postoperatively, clear, accurate, and timely written operative notes are important in order to recall the procedure and start follow-up treatment as soon as possible. In addition, the surgeon’s operative notes are important to assure surgical quality and communication with other healthcare providers. The aim of the present study was to assess compliance with the Dutch guidelines for writing operative notes for LC.
Nine hospitals were asked to send 20 successive LC operative notes. All notes were compared to the Dutch guideline by two reviewers and double-checked by a third reviewer. Statistical analyses on the “not described” items were performed.
All hospitals participated. Most notes complied with the Dutch guideline (52–69%); 19–30% of items did not comply. Negative scores for all hospitals were found, mainly for lacking a description of the patient’s posture (average 69%), bandage (94%), blood loss (98%), name of the scrub nurse (87%), postoperative conclusion (65%), and postoperative instructions (78%). Furthermore, notes from one community hospital and two teaching hospitals complied significantly less with the guidelines.
Operative notes do not always fully comply with the standards set forth in the guidelines published in the Netherlands. This could influence adjuvant treatment and future patient treatment, and it may make operative notes less suitable background for other purposes. Therefore operative note writing should be taught as part of surgical training, definitions should be provided, and procedure-specific guidelines should be established to improve the quality of the operative notes and their use to improve patient safety.
PMCID: PMC2848728  PMID: 20112020
14.  Using a Modified Intervention Mapping Approach to Develop and Refine a Single-Session Motivational Intervention for Methamphetamine-Using Men Who Have Sex With Men 
The Open AIDS Journal  2010;4:132-140.
There is an ongoing need for the development and adaptation of behavioral interventions to address behaviors related to acquisition and transmission of infectious diseases and for preventing the onset of chronic diseases. This paper describes the application of an established systematic approach to the development of a behavioral intervention to reduce sexual risk behaviors for HIV among men who have sex with men and who use methamphetamine. The approach includes six steps: (1) a needs assessment; (2) preparing matrices of proximal program objectives; (3) selecting theory-based methods and practical strategies; (4) producing program components and materials; (5) planning for program adoption, implementation, and sustainability; and (6) planning for evaluation. The focus of this article is on the intervention development process; therefore the article does not describe steps 5 and 6. Overall the process worked well, although it had to be adapted to fit the sequence of events associated with a funded research project. This project demonstrates that systematic approaches to intervention development can be applied even in research projects where some of the steps occur during the proposal writing process rather than during the actual project. However, intervention developers must remain flexible and be prepared to adapt the process to the situation. This includes being ready to make choices regarding intervention efficacy versus feasibility and being willing to select the best intervention that is likely to be delivered with available resources rather than an ideal intervention that may not be practical.
PMCID: PMC2908891  PMID: 20657716
Intervention development; intervention mapping; motivational interviewing; formative work; methamphetamine.
15.  A test of written emotional disclosure as an intervention for posttraumatic stress disorder 
Behaviour research and therapy  2011;49(4):299-304.
This study examined the efficacy of the written emotional disclosure (WED) procedure with a sample of young adults who met diagnostic criteria for posttraumatic stress disorder (PTSD). Participants were randomly assigned to either WED or a control writing condition and were assessed at baseline and one month following the writing sessions. During each writing session, participants’ heart rate was recorded; participants also provided self-report ratings of emotional responding. Findings indicated no significant group differences for PTSD and depression symptom severity at follow-up assessment. Relative to control participants, WED participants displayed significantly greater heart rate activity and reported greater emotional responding during the first writing session; however, no reduction in emotional responding occurred for either condition from the first to the last writing session. Taken together, these findings indicate that WED may not be an efficacious intervention for PTSD. Suggestions are made for future work in this area.
PMCID: PMC3898617  PMID: 21367400
PTSD; Trauma; Depression; Written disclosure; Exposure therapy
16.  Latent class analysis of reading, decoding, and writing performance using the Academic Performance Test: concurrent and discriminating validity 
To explore and validate the best returned latent class solution for reading and writing subtests from the Academic Performance Test (TDE).
A total of 1,945 children (6–14 years of age), who answered the TDE, the Development and Well-Being Assessment (DAWBA), and had an estimated intelligence quotient (IQ) higher than 70, came from public schools in São Paulo (35 schools) and Porto Alegre (22 schools) that participated in the ‘High Risk Cohort Study for Childhood Psychiatric Disorders’ project. They were on average 9.52 years old (standard deviation = 1.856), from the 1st to 9th grades, and 53.3% male. The mean estimated IQ was 102.70 (standard deviation = 16.44).
Via Item Response Theory (IRT), the highest discriminating items (‘a’>1.7) were selected from the TDE subtests of reading and writing. A latent class analysis was run based on these subtests. The statistically and empirically best latent class solutions were validated through concurrent (IQ and combined attention deficit hyperactivity disorder [ADHD] diagnoses) and discriminant (major depression diagnoses) measures.
A three-class solution was found to be the best model solution, revealing classes of children with good, not-so-good, or poor performance on TDE reading and writing tasks. The three-class solution has been shown to be correlated with estimated IQ and to ADHD diagnosis. No association was observed between the latent class and major depression.
The three-class solution showed both concurrent and discriminant validity. This work provides initial evidence of validity for an empirically derived categorical classification of reading, decoding, and writing performance using the TDE. A valid classification encourages further research investing correlates of reading and writing performance using the TDE.
PMCID: PMC3748054  PMID: 23983466
Academic Performance Test; TDE; decoding; writing; validity
17.  Communication spaces 
Background and objective
Annotations to physical workspaces such as signs and notes are ubiquitous. When densely annotated, work areas become communication spaces. This study aims to characterize the types and purpose of such annotations.
A qualitative observational study was undertaken in two wards and the radiology department of a 440-bed metropolitan teaching hospital. Images were purposefully sampled; 39 were analyzed after excluding inferior images.
Annotation functions included signaling identity, location, capability, status, availability, and operation. They encoded data, rules or procedural descriptions. Most aggregated into groups that either created a workflow by referencing each other, supported a common workflow without reference to each other, or were heterogeneous, referring to many workflows. Higher-level assemblies of such groupings were also observed.
Annotations make visible the gap between work done and the capability of a space to support work. Annotations are repairs of an environment, improving fitness for purpose, fixing inadequacy in design, or meeting emergent needs. Annotations thus record the missing information needed to undertake tasks, typically added post-implemented. Measuring annotation levels post-implementation could help assess the fit of technology to task. Physical and digital spaces could meet broader user needs by formally supporting user customization, ‘programming through annotation’. Augmented reality systems could also directly support annotation, addressing existing information gaps, and enhancing work with context sensitive annotation.
Communication spaces offer a model of how work unfolds. Annotations make visible local adaptation that makes technology fit for purpose post-implementation and suggest an important role for annotatable information systems and digital augmentation of the physical environment.
PMCID: PMC3994845  PMID: 24005797
annotation; situated cognition; human-computer interaction; task-technology fit; clinical information system; augmented reality
18.  Predicting the Evolution of Sex on Complex Fitness Landscapes 
PLoS Computational Biology  2009;5(9):e1000510.
Most population genetic theories on the evolution of sex or recombination are based on fairly restrictive assumptions about the nature of the underlying fitness landscapes. Here we use computer simulations to study the evolution of sex on fitness landscapes with different degrees of complexity and epistasis. We evaluate predictors of the evolution of sex, which are derived from the conditions established in the population genetic literature for the evolution of sex on simpler fitness landscapes. These predictors are based on quantities such as the variance of Hamming distance, mean fitness, additive genetic variance, and epistasis. We show that for complex fitness landscapes all the predictors generally perform poorly. Interestingly, while the simplest predictor, ΔVarHD, also suffers from a lack of accuracy, it turns out to be the most robust across different types of fitness landscapes. ΔVarHD is based on the change in Hamming distance variance induced by recombination and thus does not require individual fitness measurements. The presence of loci that are not under selection can, however, severely diminish predictor accuracy. Our study thus highlights the difficulty of establishing reliable criteria for the evolution of sex on complex fitness landscapes and illustrates the challenge for both theoretical and experimental research on the origin and maintenance of sexual reproduction.
Author Summary
One of the biggest open questions in evolutionary biology is why sexual reproduction is so common despite its manifold costs. Many hypotheses have been proposed that can potentially explain the emergence and maintenance of sexual reproduction in nature, and currently the biggest challenge in the field is assessing their plausibility. Theoretical work has identified the conditions under which sexual reproduction is expected. However, these conditions were typically derived, making strongly simplifying assumptions about the relationship between organisms' genotype and fitness, known as the fitness landscape. Building onto previous theoretical work, we here propose different population properties that can be used to predict when sex will be beneficial. We then use simulations across a range of simple and complex fitness landscapes to test if such predictors generate accurate predictions of evolutionary outcomes. We find that one of the simplest predictors, related to variation of genetic distance between sequences, is also the most accurate one across our simulations. However, stochastic effects occurring in small populations compromise the accuracy of all predictors. Our study both illustrates the limitations of various predictors and suggests directions in which to search for new, experimentally attainable predictors.
PMCID: PMC2734178  PMID: 19763171
19.  No Time to Think: Making Room for Reflection in Obstetrics and Gynecology Residency 
Reflective practice may help physicians identify and connect with what they value and find meaningful in their work. There are many practical obstacles in teaching narrative skills and reflection to residents in surgical subspecialties. We aimed to assess the feasibility of designing and implementing a writing workshop series within an obstetrics and gynecology curriculum.
Materials and Methods
Between 2008 and 2009, a reflective writing workshop series was introduced into the didactic curriculum of an obstetrics and gynecology residency program. The course included reading fiction and creative writing. Workshops focused on topics residents identified. Residents answered a subjective questionnaire and also completed the Maslach Burnout Inventory and Interpersonal Reactivity Index to assess burnout and empathy.
Six 1-hour reflective writing workshops took place within the dedicated didactic time for residents. Of the 20 residents in the program, 10 junior residents and 8 senior residents evaluated the workshops. Ten residents participated in more than one workshop, an average of 3.6 workshops. Residents felt that the workshops were enjoyable, and some felt that they influenced their experience of residency, but few felt that it affected their work with patients. Trends in Maslach Burnout Inventory and Interpersonal Reactivity Index scores did not show statistical significance.
A practical curriculum for introducing reflective practice to obstetrics and gynecology residents is described. This model may be useful to educators looking to incorporate reflective practice into residency curricula and lead to collaborative work that may assess the impact of this work on the experience of residents and their patients.
PMCID: PMC3010949  PMID: 22132287
20.  Writing style of young physicians in the computer and internet era 
The objective of the current study was to analyze written language of native Hebrew-speaking medical residents, as reflected in admission notes and discharge letters for patients admitted to medical wards in a 700-bed university hospital.
Twenty admission notes and 20 discharge letters written by 40 native Hebrew- speaking residents with at least one year experience were analyzed. The residents worked in the Internal medicine departments of a 700-bed university hospital. Admission notes and discharge letters were randomly chosen for the analysis which was carried out using predefined linguistic criteria and the extent to which English or Latin terms were incorporated into Hebrew medical language such as the structure of sentences and paragraphs. (Complete list of the linguistic criteria can be found in the methods and results sections).
The most important findings were that the level of language was unexpectedly low. Many English or Latin medical terms were written using Hebrew letters. The creation of ‘new’ abbreviations was common. Sentences were telegraphic and lacked coherence, for example there were sentences written in internet language and short message service (SMS) messages. Texts were not organized and sometimes important details were missing.
The writing style of medical residents should be improved substantially in order for them to be able to write coherently. One possible solution is to incorporate a course in writing into the medical school curriculum.
PMCID: PMC4207182  PMID: 25341216
Writing Style; residents; medical documents; curriculum; admission notes; discharge letter
21.  Cardiovascular Fitness is Associated with Altered Cortical Glucose Metabolism During Working Memory in ε4 Carriers 
The possibility that ε4 may modulate the effects of fitness in the brain remains controversial. The present exploratory FDG-PET study aimed to better understand the relationship among ε4, fitness and cerebral metabolism in 18 healthy aged females (9 Carriers, 9 Non-carriers) during working memory.
Participants underwent VO2 max, CVLT and FDG-PET, collected at rest and during completion of the Sternberg Working Memory Task.
Resting FDG-PET did not differ between carriers and non-carriers. Significant effects of fitness on FDG-PET during working memory was noted in the ε4 carriers only. High Fit ε4 carriers had greater glucose uptake than the Low Fit in the temporal lobe, but Low Fit had greater glucose uptake in the frontal and parietal lobes.
We demonstrate that fitness differentially affects cerebral metabolism in ε4 carriers only, consistent with previous findings that the effects of fitness may be more pronounced in populations genetically at risk for cognitive decline.
PMCID: PMC3360109  PMID: 22226798
Apolipoprotein-E; ε4; Positron Emission Tomography; FDG-PET; Alzheimer’s disease; fitness; Sternberg working memory task; working memory
22.  Optimal communication from occupational physicians to GPs: a cross-sectional survey 
The British Journal of General Practice  2012;62(605):e833-e839.
Correspondence from occupational physicians to GPs is infrequent, despite evidence that good communication leads to earlier return to work of sick-listed patients and is cost effective.
To explore the circumstances, content, and preferred method of communication GPs would value from an occupational physician, following an occupational health consultation with one of their patients.
Design and setting
A cross-sectional survey in the UK.
A questionnaire was developed de novo, piloted, and sent to 600 GPs of consecutive employees undergoing occupational physician assessments. Descriptive data were generated using Excel®.
The response rate was 374/600 (62%). Demographic features of GP responders reflected national figures. A total of 372 (99.5%) GPs wanted information from occupational physicians. Most wanted information on diagnosis (303, 81%), clinical assessment (275, 74%), functional assessment (295, 79%), or advice on the timing (308, 82%) and adjustments 290 (78%) of any return-to-work plan. Over 80% wanted information following every occupational physician consultation, and over 90% wanted information on the timing of a return to work, adjustments suggested, or if different medical diagnosis or management was suggested. The preferred method of communication was letter by post 341/374 (92%). Brief, relevant information was valued and considered useful for completing ‘fit notes’.
Occupational physicians should send formal letters, by post, to the patient’s GP following occupational health assessments. This would assist the GP in completing the patient’s ‘fit note’ and ultimately increase the chances of their patient being rehabilitated back to work.
PMCID: PMC3505417  PMID: 23211264
communication; cross-sectional survey; general practitioners; occupational health physicians
23.  Evaluation of joint medical and nursing notes with preprinted prompts. 
Quality in Health Care  1997;6(4):192-193.
OBJECTIVE: To determine the views of doctors and nurses about two recent innovations in the structure of case notes: the use of preprinted prompts and the use of joint medical and nursing notes. DESIGN: Questionnaire survey of all doctors and nurses working on the children's wards. SETTING: Children's wards in a district general hospital. MAIN OUTCOME MEASURES: Whether or not respondents wanted to return to traditional notes; positive and negative aspects of the two innovations. RESULTS: There was an 81% response rate. 45 of 48 respondents (94%) did not want to return to traditional notes. Positive features of joint notes that were identified included: promotes team work (21/48 respondents), improves access to information (14/48), and reduces duplication (14/48). Negative features included uncertainty about identity of writer (8/48) and incompletely filled in sheets (7/48). Positive features of preprinted prompts included: less information omitted (29/48), easier to read and find information (28/48), and quicker to write (21/48). Negative features included: not enough space (19/48) and clerking too mechanical (16/48). CONCLUSION: Advantages of both innovations outweighed their disadvantages to the extent that only three out of 48 respondents wanted to return to writing traditional notes.
PMCID: PMC1055491  PMID: 10177033
24.  Inviting Patients to Read Their Doctors’ Notes: A Quasi-experimental Study and a Look Ahead 
Annals of internal medicine  2012;157(7):461-470.
Little information exists about what primary care physicians (PCPs) and patients experience if patients are invited to read their doctors’ office notes.
To evaluate the effect on doctors and patients of facilitating patient access to visit notes over secure Internet portals.
Quasi-experimental trial of PCPs and patient volunteers in a year-long program that provided patients with electronic links to their doctors’ notes.
Primary care practices at Beth Israel Deaconess Medical Center (BIDMC) in Massachusetts, Geisinger Health System (GHS) in Pennsylvania, and Harborview Medical Center (HMC) in Washington.
105 PCPs and 13 564 of their patients who had at least 1 completed note available during the intervention period.
Portal use and electronic messaging by patients and surveys focusing on participants’ perceptions of behaviors, benefits, and negative consequences.
11 797 of 13 564 patients with visit notes available opened at least 1 note (84% at BIDMC, 92% at GHS, and 47% at HMC). Of 5391 patients who opened at least 1 note and completed a postintervention survey, 77% to 87% across the 3 sites reported that open notes helped them feel more in control of their care; 60% to 78% of those taking medications reported increased medication adherence; 26% to 36% had privacy concerns; 1% to 8% reported that the notes caused confusion, worry, or offense; and 20% to 42% reported sharing notes with others. The volume of electronic messages from patients did not change. After the intervention, few doctors reported longer visits (0% to 5%) or more time addressing patients’ questions outside of visits (0% to 8%), with practice size having little effect; 3% to 36% of doctors reported changing documentation content; and 0% to 21% reported taking more time writing notes. Looking ahead, 59% to 62% of patients believed that they should be able to add comments to a doctor’s note. One out of 3 patients believed that they should be able to approve the notes’ contents, but 85% to 96% of doctors did not agree. At the end of the experimental period, 99% of patients wanted open notes to continue and no doctor elected to stop.
Only 3 geographic areas were represented, and most participants were experienced in using portals. Doctors volunteering to participate and patients using portals and completing surveys may tend to offer favorable feedback, and the response rate of the patient surveys (41%) may further limit generalizability.
Patients accessed visit notes frequently, a large majority reported clinically relevant benefits and minimal concerns, and virtually all patients wanted the practice to continue. With doctors experiencing no more than a modest effect on their work lives, open notes seem worthy of widespread adoption.
Primary Funding Source
The Robert Wood Johnson Foundation, the Drane Family Fund, the Richard and Florence Koplow Charitable Foundation, and the National Cancer Institute.
PMCID: PMC3908866  PMID: 23027317
25.  “Fit” inside the Work-Family Black Box: An Ecology of the Life Course, Cycles of Control Reframing1 
Scholars have not fully theorized the multifaceted, interdependent dimensions within the work-family “black box.” Taking an ecology of the life course approach, we theorize common work-family and adequacy constructs as capturing different components of employees' cognitive appraisals of fit between their demands and resources at the interface between home and work. Employees' appraisals of their work-family linkages and of their relative resource adequacy are not made independently but, rather, co-occur as identifiable constellations of fit. The life course approach hypothesizes that shifts in objective demands/ resources at work and at home over the life course result in employees experiencing cycles of control, that is, corresponding shifts in their cognitive assessments of fit. We further theorize patterned appraisals of fit are key mediators between objective work-family conditions and employees' health, well-being and strategic adaptations. As a case example, we examine whether employees' assessments on ten dimensions cluster together as patterned fit constellations, using data from a middle-class sample of 753 employees working at Best Buy's corporate headquarters. We find no single linear construct of fit that captures the complexity within the work-family black box. Instead, respondents experience six distinctive constellations of fit: one optimal, two poor, and three moderate fit constellations.
PMCID: PMC2757309  PMID: 19809532

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