To introduce the student to the biopsychosocial conceptualization of illness and medical treatment.

Students will be able to:

• Distinguish between the biomedical and biopsychosocial models, and recognize the advantages of the latter as a model of the illness process.
• Recognize the biological, psychological, and social components in a case presentation.
• Discuss diagnostic issues and possible treatment interventions which reflect the biological, psychological, and social aspects of a simple case.
• Recognize psychological and behavioral factors which predispose an individual to certain illnesses.
• Discuss research on the influence of psychosocial variables on the course and outcome of illness.
• Discuss the epidemiology of common psychiatric disorders in primary care.
• Define the term “sick role”, and explain the “rights” and “obligations” of the ill person.

To provide an understanding of those behavioral variables within the doctor-patient relationship that impact on patient satisfaction, rapport, compliance, and treatment outcome.

Students will be able to:

• Discuss the importance of effective communication in medical diagnosis, patient satisfaction, and treatment outcome.
• Describe what empathy is, and is not, and demonstrate an appreciation of the importance of empathy in the doctor-patient relationship.
• Describe different physician styles of relating, and recognize the conditions under which each might be appropriate.
• Define the concept of “boundaries”, and recognize when there have been boundary violations, and what the consequences may be.
• Explain how the doctor-patient relationship can affect compliance, and those factors which impede and enhance compliance.
• Define the nature of transference and countertransference, and how these phenomena are best handled within the doctor-patient relationship.
• Discuss the importance of patient variables such as age, gender, and culture, in the doctor-patient relationship.
• Describe common “difficult situations” within the doctor-patient relationship, and how they are best managed.
• With reference to the mental status exam, cite examples of how the various mental functions are commonly assessed.

To understand the importance of behavioral and lifestyle variables in health and illness, and to delineate the mechanisms which mediate this relationship.

Students will be able to:

• Define the term “stress”, and understand how it influences disease and illness.
• Describe those factors involved in an individual’s coping response to stress.
• List the pathways and mechanisms that mediate the body’s response to stress.
• Describe research within the field of psychoneuroimmunology which addresses the relationship between behavior and illness.
• With reference to the DSM-IV diagnosis of “Psychological Factors Affecting Medical Condition”, cite medical examples where psychological or behavioral factors adversely affect an existing medical condition.
• Discuss why a biopsychosocial treatment intervention is indicated in the management of physical disorders which are influenced by psychological variables.

To examine the phenomenon of substance abuse, and its treatment, from a biopsychosocial perspective.

Students will be able to:

• Describe the typical profile of substance users.
• State the accepted alcohol consumption limits in the U.S. and explain methods of taking a substance-use history.
• Describe the schedules for controlled substances under the Controlled Substances Act and provide examples of each (mention the status of medicinal marijuana).
• Define intoxication, withdrawal, dependence and abuse (as per the DSM-IV) and distinguish between dependence with and without physiological dependence.
• Differentiate between the symptoms of intoxication and withdrawal for Drugs within and between the four classes of substances as discussed in lecture (i.e., Sedatives, Stimulants, Hallucinogens and Related Substances, and Opioids).
• Identify the most appropriate medication to use to treat alcohol, nicotine and opioid dependence (and opioid overdose) in a given clinical scenario and provide the rationale for its use.
• Describe the psychological treatment approaches for substance dependence and identify the potential role of vaccinations.
• Describe the relationship between drug use and participation in the Choking Game and list the physical and environmental warning signs of Choking Game participation.

To provide an overview of the major theoretical perspectives of human development across the lifespan.

Students will be able to:

• Describe normal developmental events in infancy and childhood that might cause concern to parents.
• Identify normal developmental stages of play, as well as specified developmental milestones in an infant’s gross motor, fine motor, language, cognitive, social/emotional, and self-help development.
• Assess a child’s developmental status using a recognized developmental scale, such as the Denver II.
• Identify developmental red flags in infancy and childhood.
• Discuss the major arguments in the nature vs nurture controversy in human development.
• Identify dimensions of temperament in infancy and explain how they might impact a child’s development.
• Discuss the importance of attachment in an infant’s development.
• Cite the four categories of attachment and describe the behaviors associated with each and also the parental conditions that might lead to each.
• Describe the primitive reflexes and capabilities of the “competent newborn”.
• Outline the stages of language development and the approximate age range for each.
• Describe the four language subsystems and identify childhood behaviors associated with each.
• Identify possible causes of language delay in children.
• Describe Piaget’s four stages of cognitive development, including the Piagetian concepts associated with each.
• Define object permanence, centering, and conservation, and describe how each exemplifies a child’s cognitive level.
• Describe the stages of moral reasoning outlined by Kohlberg, and assess a person’s stage when given a vignette.
• Describe ways in which poverty influences a child’s health.
• Cite the major causes of death for children under the age of 5 worldwide, and for children in the U.S. by age range.
• Recognize the primary developmental issues of adolescence.
• Cite and describe Erikson’s stages of psychosocial development, and their associated ego strengths.
• Discuss risk-taking among adolescents, explaining the relationship between the types of risks taken and the leading causes of death among adolescents.
• Identify the DSM-IV diagnostic criteria for selected developmental disorders of childhood and adolescence, including mental retardation, learning disorders, conduct disorder, attention deficit and hyperactivity disorders, and pervasive developmental disorders, and identity which disorder is most likely to apply in a given clinical vignette.
• Describe the major development issues of early, middle, and late adulthood.
• Identify specific areas of physical capacity that decline with age.
• Describe the effect of age on cognition.
• Differentiate between crystallized intelligence and fluid intelligence.
• Cite evidence that the “elderly” is a growing subgroup in the U.S. population.
• Discuss how the health problems of the elderly have changed over time.
• Cite the most commonly reported chronic conditions among persons over 70.
• Cite the leading causes of death in the US by age group, from childhood to adulthood.
• Describe the trends in suicide rates worldwide and in the U.S., identifying the direction of change by age and gender.
• Compare suicide rates with homicide rates in the US and discuss the reasons that suicide rates are not typically publicized.
• Identify the risk factors and warning signs for suicide.

To introduce the student to issues associated with end-of-life care.

Students will be able to:

• Describe factors that influence how one might perceive his or her own impending death.
• Describe the five stages of dying formulated by Kubler-Ross.
• Identify the major symptoms reported by terminally ill patients.
• Discuss how health care professionals can help to meet the major needs of dying persons.
• Describe palliative care and the hospice concept of care, and their impact on the end of life experience for patients and families.
• Delineate the stages of grieving and differentiate mourning behaviors by age group.
• Describe normal and complicated grief, and determine when the medical professional should intervene.

To examine the phenomenon of family violence, including domestic violence, child abuse and neglect, and elder abuse, recognizing the role of the physician in detection and management.

Students will be able to:

• Interpret the statement: The family can often be considered the “cradle of violence”.
• Describe how a social condition develops into a social problem.
• Describe each type of family violence, citing its definition, characteristics, explanatory models, risk factors, and consequences.
• Rank the forms of child abuse based on prevalence.
• Describe the role of the health care profession in combating family violence.

To emphasize the importance of culture in the practice of medicine, with emphasis on cultural variables in illness, the role of culture in the doctor-patient encounter, and the concept of cultural competency.

Students will be able to:

• Define culture and delineate aspects of life influenced by it.
• Describe ethnocentrism and overgeneralization, and their impact on understanding other cultures.
• Describe the American Medical Association’s position on cultural competence.
• Recognize the roles that bias, uncertainty, and stereotyping play in creating the conditions that lead to disparities in healthcare and health outcomes.
• Identify elements that are common to all ethnomedical systems across cultures.
• Describe how culture impacts a person’s ideas about illness, health, and healing.
• Explain culturally-specific theories of disease, such as the Hot-Cold Theory, and discuss how the associated beliefs might impact the experience of illness, the doctor-patient encounter, and compliance with treatment.
• Recognize culture-bound syndromes, including koro, amok, ataque de nervios, anorexia nervosa, susto, and taijin kyofusho.
• Explain the importance of the patient’s explanatory model of illness/disease, and describe the elements of Kleinman’s explanatory model, the ETHNIC model, the LEARN model, and the FIFE model.
• Identify the U.S.national standards for cultural and linguistic competence in health care.
• Define cultural competence, cultural humility, and culturally competent care and describe their importance to effective patient care.
• Identify the types of issues and challenges that are important in caring for patients of differing cultural backgrounds, such as language, religion, health beliefs, trust, etc.
• Compare various healing models, including Allopathic, Piman, Cuanderismo, and Chinese models, on specified elements such as goals and functions, roles of patient/family/society, etiology/diagnosis/treatment/prognosis, and practitioners.

To highlight the clinical relevance to allopathic physicians of patients’ use of Complementary and Alternative Medicine (CAM).

Students will be able to:

• Describe the common features of CAM techniques, reasons for the growing popularity of CAM and reasons why physicians need to be knowledgeable about CAM usage by their patients.
• Explain the general philosophy underlying the 5 NCCAM groupings of CAM and describe examples of therapies that fall within each group.
• Describe the regulatory control process over Dietary Supplements including the types of claims that a dietary supplement can make on their labels.
• Identify 3 potential general interactions between dietary substances and allopathic medicine and give specific examples of each interaction using dietary supplements highlighted in lecture.
• Explain the dosage system of homeopathic substances and explain the regulatory control process of homeopathic substances.

To introduce the student to the DSM-IV-TR classification system of mental disorders, and to provide an overview of the spectrum of disorders, with more detailed study of a few disorders.

Students will be able to:

• Discuss the ways in which the DSM system of classification differs from earlier systems, and what are its strengths and weaknesses.
• Given a brief patient vignette, use the five axis system to describe the patient.
• Recognize the terminology used in the 17 classes of disorders on Axes I and II.
• Given a brief patient vignette, to identify which of the DSM disorders is most likely to apply.
• Be able to recognize the detailed criteria for selected disorders (mental retardation, dementia, schizophrenia, major depressive disorder, bipolar disorder, PTSD).
• To describe how norm-referenced standard scores are derived and used.
• To be able to convert between different types of norm-referenced scales.

To provide an introduction to the field of learning theory and behavioral psychology, with emphasis on classical conditioning principles and their relevance within the field of medicine.

Students will be able to:

• List the basic assumptions of behavioral psychology, including the role of learning and the environment in abnormal behavior and its treatment.
• Explain through learning principles a child’s fearful response to physicians’ white coats, and a chemotherapy patient’s nausea upon simply entering the oncology ward.
• Explain how emotional responses may become conditioned to environmental stimuli and situations.
• Define conditioned immunosuppression, conditioned withdrawal, and conditioned tolerance.
• Discuss the role of classical conditioning in the placebo response, and in the etiology of selected disorders, including phobias and PTSD.
• With reference to psychoactive drug use and relapse, explain the importance of the drug-using environment, including the rationale underlying classical extinction trials in treatment.
• Describe the role learning may play in the acquisition of selected behavioral disorders, including deviant sexual behavior and male sexual dysfunction.
• Be familiar with the DSM-IV diagnostic criteria of the disorders presented, and able to apply these criteria when presented with a clinical scenario.

To provide an overview of operant conditioning principles, and their application in the modification of behavior.

Students will be able to:

• Describe how classical, operant and vicarious conditioning differ, and discuss the role played by the subject’s environment in each.
• Define the operant principles of contingency, reinforcement, punishment, extinction, shaping, and stimulus control.
• Explain why the schedule under which reinforcement is delivered is important in modifying the bedtime crying behavior of a 6-year-old child.
• Analyze a problem behavior, such as school bullying, in terms of those environmental conditions which elicit the behavior, and those conditions which follow and serve to maintain the behavior.
• Give examples of how the same problem behavior might be modified using each of the following methods:  positive reinforcement, negative reinforcement, punishment, and extinction.
• Explain how the ’reinforcement theory of drug use’can account for habitual use of psychoactive drugs even in cases where such substances are not be associated with physical dependence.
• Outline the role of operant conditioning in the avoidance behaviors seen in phobias, PTSD, and OCD.
• Explain to the parents of a young child why aversive techniques, such as punishment, are less desirable than reinforcement in dealing with the child’s tantrum behavior.

To provide a broad overview of the field of the cognitive and behavioral therapies, with specific emphasis on the application of behavioral procedures in the field of medicine.

Students will be able to:

• Describe commonly used cognitive-behavioral treatment techniques employing the principles of classical and operant conditioning, and recognize the basic learning principles which underlie these techniques.
• Discuss the use of relaxation, exposure, counterconditioning and reciprocal inhibition with reference to systematic desensitization.
• Be familiar with the diagnostic criteria for the psychological disorders discussed, and how problem behaviors are modified through CBT.
• Define aversive therapy, and give examples of when this technique might be appropriate.
• Discuss the rationale underlying behavioral approaches to pain management, and apply these principles to a clinical scenario.
• With reference to cognitive theory, discuss the role of thoughts and beliefs in the etiology of maladaptive behavior, and its modification through cognitive therapy.
• Explain the behavioral concept underlying modeling and vicarious reinforcement within the context of ‘social cognitive theory’.
• Be familiar with other therapies discussed that may employ cognitive-behavioral techniques, such as ‘dialectic behavior therapy’, family therapy, and mindfulness approaches.

To provide the student with an overview of the field of behavioral medicine and the modification of health behavior.

Students will be able to:

• Discuss the biopsychosocial assumptions underlying the behavioral medicine model, and distinguish how these assumptions differ from those of the biomedical model.
• Design an effective intervention to assist a patient in smoking cessation, addressing the physiological, psychological, and social determinants of this behavior.
• Given a health behavior such as smoking, be able to apply the ‘stages of change model’ to assess the patient’s motivation to change, and identify the health provider’s focus at each stage.
• Cite epidemiological data presented on smoking, and discuss the implications of this data with reference to health care.
• Be familiar with the differential effectiveness of counseling versus psychopharmacological intervention in the treatment of smoking.
• Describe the ‘relapse prevention model’, and be able to apply it within a clinical context involving health behavior change.
• Describe the main principles of ‘motivational interviewing’, and be able to identify and apply these principles when presented with a therapeutic scenario.

To provide an introduction to medically-relevant psychodynamic principles of human behavior and personality.

Students will be able to:

• Compare and contrast the psychoanalytic and behavioral models.
• From a psychoanalytic perspective, define the various components and principles of personality.
• Describe the role of intrapsychic conflict in anxiety, defense, and symptom formation.
• Explain the function of defense mechanisms, and identify them when presented with a case scenario.
• Explain the rationale for the treatment techniques of free association, dream analysis, and the analysis of resistance and transference.
• Conceptualize those disorders discussed within a psychodynamic framework, and arrive at a diagnosis when presented with a clinical scenario involving these disorders. 

To introduce the student to the field of psychological testing, with specific emphasis on intelligence and personality assessment.

Students will be able to:

• Provide a definition of a psychological test, and evaluate a test in terms of its standardization, reliability and validity.
• Explain how reliability is commonly established, and how criterion validity can be demonstrated in an aptitude test, and in a clinical test of depression.
• Discuss applications of psychological testing within the medical setting.
• Discuss the concepts of ‘intelligence’ and IQ, including calculation, range, distribution and assessment.
• Explain why a test such as the WISC-III might be a good predictor of how a young immigrant child would initially perform in a dominant-culture US school, but a poor indicator of the child’s actual ability and IQ.
• Recognize commonly used intelligence tests, neuropsychological tests and clinical/personality tests, and identify clinical situations where each might be appropriate.
• Be familiar with the MMPI-2 and the HAM-D, including the application of these tests within the medical setting.
• Discuss the purpose and nature of the Validity Scales of the MMPI-2.
• Define the “projective hypothesis”, and describe the importance of this principle in such tests as the Rorschach and TAT.

To provide a summary of the neuroanatomical areas associated with psychological functions, and with distinct neurotransmitters and receptors.

Students will be able to:

• Describe the brain areas where lesions have the greatest effect on:  reward, activation, fear responding, formation of long-term memories, and planning.
• Describe the nuclei, fiber tracts and cortical components of the limbic system, and related structures (locus ceruleus, nuc accumbens, amygdala, and the behavioral effect of lesions in these areas).
• Describe the structures and functions involved in the following three brain areas: reptilian, paleomammalian, neomammalian, especially the various association cortices.
• Describe the anatomical distribution and major metabolites of: acetylcholine, dopamine, nor-epinephrine, serotonin, GABA, and glutamate.
• Describe the components of the GABA receptor, and it’s relevance to the treatment of anxiety disorders
• Describe the functions of the NMDA receptor relevant to psychiatry.
• List the DSM-IV criteria for Post-Traumatic Stress Disorder, and use these criteria to identify the disorder from brief vignettes.
• Describe the treatments for PTSD which are listed as effective in systematic reviews.

To provide an introduction to Schizophrenia:  diagnostic criteria, other features, genetics, drugs helpful and otherwise, and the synaptic actions of these drugs.

Students will be able to:

• List the DSM-IV criteria for schizophrenia, and use these to identify cases from brief vignettes.
• Recognize the other features of schizophrenia, the prevalence, and the pattern of incidence over the life span, and genetic determination.
• List some drugs which make schizophrenia worse- and describe their synaptic effects.
• Describe the main synaptic effects of anti-psychotic drugs, (which transmitters, which receptors) and their side effects.
• List the warnings which must be given to patients before starting them on first generation (typical) anti-psychotic drugs.
• List the treatments which have been shown to be effective against schizophrenia in systematic reviews.

To provide an introduction to Affective Disorders:  diagnostic criteria for Major Depressive Episode, other affective disorders, genetics, helpful drugs, and the synaptic actions of these drugs.

Students will be able to:

• List the DSM-IV criteria for Major Depressive Episode, and use these to identify cases from brief vignettes.
• Describe the prevalence, gender differences, and genetic determination of Major Depressive Disorder, and Bipolar Disorder.
• Recognize other affective disorders and distinguish among these.
• Describe the main synaptic effects of anti-depressant drugs, (which transmitters, which receptors).
• Describe the procedure of ECT, the effectiveness, the side-effects, and the contraindications to its use.
• List the classes of treatments which have been shown to be effective against affective disorders in systematic reviews.

To provide an overview of the DSM-IV Sexual Disorders and Gender Identity Disorder, their causes and treatments.

Students will be able to:

• Identify the essential disturbance for a diagnosis of each of the Sexual Dysfunctions and Paraphilias and to clinically differentiate them.
• List the primary and secondary causes of Sexual Dysfunctions and describe the major hypotheses regarding the etiology of Paraphilias.
• Describe assessment techniques for Sexual Disorders.
• Describe the specific behavioral and pharmacological treatments for Sexual Dysfunctions and the Paraphilias.
• Discuss registration and notification laws and state the controversy pertaining to these laws.
• State the essential diagnostic features of GID and clinically differentiate this disorder from Sexual Disorders.
• State the hypothesized etiology of GID and the relevance of the bed nucleus of the stria terminalis in this theory.
• Describe the treatment of GID. Appreciate psychosocial/legal issues facing GID individuals.

To provide an overview of the DSM-IV Eating and Sleeping Disorders, their causes and treatments.

Students will be able to:

• List the essential diagnostic criteria for Anorexia Nervosa and Bulimia Nervosa and their subtypes and clinically differentiate these from Eating Disorder, NOS.
• Describe the general epidemiology, biopsychosocial risk factors, signs, and medical consequences of Anorexia Nervosa and Bulimia Nervosa.
• Describe the psychotherapeutic and pharmacological methods used to treat Eating Disorders and the general effectiveness of each method.
• List the essential diagnostic features of each of the Dyssomnias and Parasomnias.
• Identify the etiology and biology associated with each of the Sleep Disorders discussed in class.
• State the treatment(s) for each Sleep Disorder and explain the rationale for the treatment choice.
• Differentiate between various Sleep Disorders based on clinical symptomatology, paying special attention to the differential diagnosis of:
  • Primary hypersomnia vs. Narcolepsy
  • Obstructive vs. Central sleep apnea
  • Nightmare disorder vs. Sleep terror disorder
  • Restless leg syndrome vs. Periodic limb movements
  • Sleep Walking vs. REM sleep behavior disorder

To review neurological disorders commonly associated with aging.

Students will be able to:

• List the DSM-IV criteria for dementia.
• Recognize the various etiological theories for Dementia of the Alzheimer’s Type (DAT).
• Recognize the variety of treatments that have been proposed for DAT, and their relations to etiologies.
• List the treatments approved by the FDA in the US for the treatment of DAT.
• Recognize the interventions that help people with dementia stay out of hospitals.
• Distinguish among dementia, dementia syndrome of depression, and delirium.
• Distinguish among the above diagnoses for a case presented in a brief vignette.

To introduce the students to the tools and methods of evidence-based medicine – in learning situations and in clinical practice.

Students will be able to:

• Effectively search printed and on-line data sources and find answers to clinically relevant questions.
• Within the small-group setting, access, critically evaluate, and synthesize empirical information relevant to answering clinically-based diagnostic and treatment questions.

To provide an opportunity for students to discuss course-related materials in a structured, small-group setting.

Students will be able to:

• Apply principles and concepts from readings and lecture to problem-based learning scenarios.
• Share views and experiences on issues related to culture and doctor-patient interaction.

 To highlight board-relevant strategies (“rules of thumb”) for interviewing and responding ethically and legally within the context of a doctor-patient relationship.

Students will be able to:

• Appropriately utilize interviewing techniques for maximizing and clarifying information.
• Respond appropriately in truthful disclosure scenarios.
• Identify who the patient is and respond appropriately to that patient.
• Reply appropriately to patient’s stated health and religious beliefs.
• React appropriately to challenging patients including angry, seductive, non-compliant, anxious/fearful, rambling and bad-news patients (including use of the SPIKES protocol).
• Apply ethical/legal standards/rules pertaining to:
  • Informed consent (including decision making capacity) and confidentiality.
  • Decision making for competent and incompetent patients.
  • Treatment of minors (with and without parental consent).
  • Conflicts between maternal vs. fetal rights.
  • Obligation to treat scenarios (i.e., futile patients, brain-dead patients, non-patients in emergency settings).
  • Determination of malpractice.
  • Reporting of impaired colleagues.
  • Involuntary commitment
  • Insanity

MODULE 2:  BIOSTATISTICS, EPIDEMIOLOGY, HEALTH SYSTEMS   

To introduce students to basic descriptive and inferential statistical techniques and to explore their application and interpretation in medical research.

Students will be able to:

• Identify and use three measures of central tendency – mean, median, and mode.
• Identify and use three measures of spread – range, variance, and standard deviation.
• Know and use the proportions of the normal distribution that are inside and outside of 1, 2, or 3 standard deviations.
• Use and interpret the standard error of the mean.
• Calculate and use z-scores.
• Interpret confidence limits and calculate 95% confidence limits.
• State how sample size and precision are related.
• Describe the meaning of 95% confidence in an estimate of the true population mean.
• Interpret p-values and statistical significance.
• Use t-tests for comparing population means in both paired and unpaired samples, and ANOVA for comparisons involving more than two groups.
• State the null hypothesis and choose the appropriate statistical test for a given experimental situation.
• Define Type I and Type II errors in hypothesis testing.
• Define and interpret the concept of statistical power, citing methods to increase power and citing the consequences of using low-power tests.
• Calculate, use and interpret the chi-square test.
• State the meaning of the correlation coefficient and the coefficient of determination in regression analysis.
• Distinguish between correlation and causation.
• Construct and interpret plots of data including histograms and scattergrams.

To provide an overview of clinical epidemiology and measurements relevant to medicine.

Students will be able to:

• Describe the difference between validity and reliability (precision) of measurements.
  
• Explain normal variation in measures within and between patients and health care providers.
  
• Recognize ways to describe and measure normal/abnormal criteria.
  
• Recognize the impact of regression to the mean on testing situations.
  
• Describe population health variability factors (i.e., risk factors and protective factors).
  

To become familiar with methodologic issues in clinical observation.

Students will be able to:

• Describe the difference and distinguish between bias and chance.
  
• Discuss the two main types of bias found in epidemiologic observations and their potential impact on study results.
• Define confounding in epidemiologic observations and discuss the impact it may have on study results.
  
• Identify methods to control for confounding at different stages of a study.
  

To acquaint students with concepts and applications of diagnostic tests.

Students will be able to:

• Define a diagnostic test and describe the most useful situations for testing.
  
• Explain the purpose of tests in providing patient care.
  
• Discuss the characteristics (sensitivity, specificity, and predictive values) of diagnostic tests, how they are used, and how to interpret them.
• Explain what is meant by a gold standard and why it is important.
  
• Define and use the following terms in relation to diagnostic tests: pre-test and post-test likelihoods, cut-off values.
• Assess interrelationships of test characteristics as one of them changes.
  
• Define and interpret SPIN and SNOUT rules to help decide if patients have a disease.
  
• Describe a ROC curve, its characteristics, and how it is used in testing situations.
  
• Interpret a likelihood ratio (LR) and explain how it is used in testing situations.
  
• Compare serial and parallel testing strategies, in terms of use and strengths/limitations.
  
• Describe how to use diagnostic hypotheses in making testing decisions.
  

To understand and apply preventive medicine to practice situations.

Students will be able to:

• Explain and give examples of primary, secondary and tertiary prevention.
  
• Cite important criteria for screening in a population setting.
  
• Identify the potential for harm in screening situations.
  
• Describe specific biases related to screening test situations.
  
• Distinguish between diagnostic and screening situations when choosing tests.
  

To become familiar with interpretations of terms and measurements of frequency, effect and outcome used in clinical epidemiology.

Students will be able to:

• Define rates and ratios commonly used in epidemiology and biomedical literature.
• Explain measures of association between risk factors and disease.
• Define and interpret measures of frequency and risk (prevalence, incidence).
• Recognize and interpret the relationships between prevalence, incidence and duration.
• Define and use appropriately the following outcome measures:  crude mortality rate; age- sex- or cause-adjusted mortality rates; case fatality rate (ratio); proportionate mortality ratio; infant mortality rate.
• Calculate and interpret the meaning of odds ratios, risk ratios, rate ratios, and attributable risk.

To have basic knowledge of concepts of statistical inference and hypothesis testing as used in epidemiology.

Students will be able to:

• Define a confidence interval and describe how it estimates precision.  
• Interpret confidence intervals for measures of effect (especially RR, AR, OR) in epidemiology.
• Define the meanings of statistical significance and clinical significance, and explain how they might differ from each other in interpretation of treatment results in a study.
• Describe the impact of power and sample size on the results of a study.

To understand and apply concepts of epidemiologic study designs.

Students will be able to:

• Differentiate among various study designs, including case series, cross sectional, case-control, cohort, and randomized trials.
• Identify the appropriate measures of effect for each study design (incidence, prevalence, absolute risk, relative risk, attributable risk, odds ratio).
• Describe the elements of design of case reports and case series.  Discuss advantages and disadvantages of this design.
• Describe the elements of design of cross-sectional studies.  Discuss advantages and disadvantages of this design.
• Describe the elements of design of case-control studies.  Discuss advantages and disadvantages of this design.
• Describe the elements of design of cohort studies (prospective and historical).  Discuss advantages and disadvantages of this design.
• Describe the elements of design of clinical trials.  Discuss advantages and disadvantages of this design.
• Rank different study designs in terms of credibility of evidence.

To understand methodologic issues related to clinical treatment.

Students will be able to:

• Explain the meaning of terms and characteristics commonly used in experimental studies of treatments.
• Explain the main purpose of randomization in experimental study designs.
• Define efficacy and effectiveness trial designs, and contrast their role in clinical epidemiology.
  
• Explain the difference between analysis for an intention-to-treat approach versus an explanatory approach in a randomized clinical study.
• Evaluate the efficacy and safety of therapeutic, rehabilitative, and preventive regimens from published papers.
• Set up components of RR, OR, RRR, ARR, NNT and be able to interpret them when making clinical decisions for patient care.
• Define and explain the difference between relative risk reduction (RRR) and absolute risk reduction (ARR) in the interpretation of a treatment.
• Define and discuss the importance of number needed to treat (NNT) in the interpretation of a treatment for an individual patient.

To introduce basic principles of prognosis and survival.

Students will be able to:

• Define and explain the difference between risk and prognostic factors, patients, outcomes and rates.
• Describe a survival curve and explain how it relates to median survival and disease prognosis.
• Define 'censored' observations, ‘time-to-event’ analysis and Hazard Ratios (HR).
• Estimate simple survival curve probabilities with incomplete follow-up data (i.e., cumulative survival during an interval and over the duration of a study).
• Recognize how survival and time-to-event probabilities change over the duration of a study.

To understand the difference between association and causation

Students will be able to:

• Grade the quality of evidence based on type of study design.
• Describe criteria for building causal arguments with observational studies.
• Interpret study results that support causal inference.

To introduce the student to the concepts and practice of Evidence Based Medicine as a tool in clinical practice.

Students will be able to:

• Describe the concept of patient-centered research as a model for lifetime learning.
• Find and evaluate sources of best evidence, including systematic reviews.
• State the advantages and limitations of reading original peer-reviewed clinical articles.
• Demonstrate the ability to identify and find information relevant to a clinical problem using consultation, texts, evidence-based databases and the archival literature.
• Apply knowledge of population based and evidence based medicine in making patient management decisions.

To explore the complex environment of health care systems, focusing on basic principles of health policy.

Students will be able to:

• Discuss major problems of health care systems, emphasizing issues of excess and deprivation, quality, equality, and demographic changes.
• Review methods of health care financing, including out-of-pocket, individual private insurance, employer-based insurance, and government financing.
• Explain issues and conditions that facilitate or prevent access to health care.
• Discuss the role and impact of the pharmaceutical industry on the availability and cost of drugs, with emphasis on the drug trial process.
• Compare methods of physician and hospital reimbursement and associated risks of each.
• Describe various models of organizing health care delivery, including HMOs, PPOs, IPAs, etc.
• Discuss mechanisms for controlling costs in health care delivery systems.
• Compare health care delivery systems internationally.
• Describe health workforce policy.

MODULE 3:  JURISPRUDENCE & CLINICAL ETHICS  

To introduce students to the legal aspects of the physician-patient relationship, with emphasis on the commencement and termination of the relationship, the duty to render care, and informed consent.

Students will be able to:

• Recognize what acts initiate the contractual physician-patient relationship.
• Discuss abandonment and proper termination of the physician-patient relationship.
• Identify duties imposed on a physician who has accepted a patient for therapy.
• Describe and define the standard of care in medical practice.
• Explain the role of expert medical witnesses in malpractice trials.
• Comprehend the legal and ethical obligation to protect patient confidences.
• Identify at least four exceptions to the rule to protect patient confidences.
• Distinguish between confidential information and privileged information.
• Distinguish patient confidentiality from an individual’s right to privacy.
• Define and discuss the duty to warn and the duty to disclose.
• Discuss the basics of informed consent and the relation of informed consent to battery and the standard of care, and identify four exceptions to the requirement to obtain informed consent and discuss the circumstances under which they might apply.
• Elaborate on the duty to control pain and the conflicts that may arise with respect to that duty and the obligation to manage potentially addictive medications properly.
• Identify physician responsibilities with the respect to acquisition and use of medical devices for patient care.
• Discuss physician obligations with respect to the maintenance of patient records. 
• Define vicarious liability and give four circumstances under which it might arise.
• Recognize appropriate first measures to be taken when sued.
• Understanding of the first steps of a lawsuit, including “service of process,” jurisdiction, the statute of limitations, and the relationship between the summons, complaint, and answer.
• Define “discovery” and describe the principle methods of conducting it.

To explore the mechanics of a malpractice trial and the sources of civil liability, discussing the functions of the court and reviewing methods of risk management.

Students will be able to:

• Define a “motion” and describe its uses prior to, during and following a trial.
• Demonstrate familiarity with the basic structure and flow of a trial and the use of jury instructions.
• Identify and define torts, contracts, statutes, and fiduciary duties as sources of physician liability.
• Distinguish between occurrence based, claims based and “tail” malpractice insurance policies.
• Describe trial and appellate courts and the roles of each.
• Discuss risk management and how to reduce the risk of malpractice suits.
• Discuss the appropriate use of civil actions other than actions for damages such as suits for declaratory judgment, injunction, habeas corpus, guardianship, and civil commitment.
• Identify the grounds for civil commitment of the mentally ill and the governmental powers under which it may be conducted, and recognize the distinctions between insanity and incompetency.

To distinguish between criminal and civil law, and the role of administrative law in physician regulation and discipline.

Students will be able to:

• Distinguish between civil law and criminal law and identify the principal sources of criminal liability for physicians.
• Describe the role of administrative law and its relationship to physician regulation and discipline.
• Define a contract and discuss the enforceability of non-competition agreements, arbitration agreements, and agreements not to sue.
• Recognize constitutions, statutes, cases, and administrative regulations as sources of law and discuss their hierarchy.
• Describe the right to self-determination and its relationship to the right to refuse treatment and to execute advance directives.
• Discuss the limits to the right to self-determination with respect to minors, mature minors, emancipated minors and incapacitated or incompetent adults.
• Identify the legal and moral conflicts arising from a recognized right to self determination joined to a legal prohibition against physician assisted suicide and a terminal patient’s plea to die with pain-free dignity.
• Recognize that delivery of patient care may present the physician with both legal and ethical considerations.

To provide an overview of the history of medical ethics through an examination of Hippocratic and Non-Hippocratic codes.

Students will be able to:

• Use clinical case problems to explore ethical issues.
• Recognize that medicine can be practiced using many different ethical systems.
• Identify the major features of the Hippocratic Oath.
• Describe how various rewritings of the Hippocratic Oath have attempted to address problems in the original Oath.
• Identify and characterize codes of ethics that follow the Hippocratic moral principle while abandoning the Hippocratic wording.
• Explain why the Hippocratic tradition has been found untenable by most modern medical associations and how newer codes differ from the Hippocratic ones.
• Distinguish between subjective and objective bases for determining patient benefit.
• Distinguish between codes striving to maximize benefit and those striving to articulate professional duties.
• Distinguish between codes that focus on the individual patient and those that focus on societal concerns.
• Recognize that medical ethics is a subject of concern to both professional and non-professional (religious and governmental) groups and that their medical ethical codes differ significantly.

To explore the concept of moral standing, examining major areas of biomedical ethics such as definitions of death, abortion, and animal welfare.

Students will be able to:

• Discuss the concept of “moral standing”.
• Recognize that “moral standing” is critical to the subjects of the definition of death, abortion, and the moral status of nonhuman animals.
• Distinguish “full standing” and “limited standing”.
• Discuss the three major definitions of death.
• Connect the moral controversies over abortion to the concept of moral standing.
• Describe how the three definitions of death provide three parallel positions regarding the ethics of abortion.
• Distinguish between “capacity” and “potential” for moral standing and show how that distinction explains why proponents and opponents of abortion differ.
• Relate the controversies over the rights and welfare of animals to the concept of moral standing.
• Explain how Eastern and Western views on the moral status of animals are connected to their traditional belief systems.
• Be aware of regulations governing the care and use of nonhuman animals.

To discuss problems associated with “benefiting” and “avoiding harm” to patients.

Students will be able to:

• Explain the idea that benefiting patients and protecting patients from harm is both conceptually complex and morally controversial.
• Identify four major conceptual issues in identifying benefits and harms.
• Distinguish subjective and objective standards of benefit.
• Differentiate medical from nonmedical benefits and show why a physician pursuing either will face patient resistance.
• Identify four different kinds of medical benefits.
• Explore strategies for integrating these four kinds of medical benefit into an overall medical benefit assessment.
• Distinguish the moral objective of producing benefit from that of avoiding harm.
• Examine three alternative strategies for combining considerations of benefit and considerations of harm.
• Discuss the moral slogan “primum non nocere” and attempt to determine its origins and how it differs from the more traditional Hippocratic moral principle.
• Describe how the idea that ethics based on consequences differs from ethics based on duty.

To compare Consequentialist and Duty-based ethical principles.

Students will be able to:

• Distinguish between “consequentialist” and “duty-based” ethics.
• Discuss “Respect for Persons” as the overarching commitment of a duty-based ethics.
• Identify four specific principles derived from a “respect-for-persons” or duty-based ethic.
• Identify “fidelity” as the first principle.
• Describe how the ethics of confidentiality derives from the moral notion of fidelity and show how a physician’s problems of confidentiality are handled differently depending on whether his or her ethic is Hippocratic or non-Hippocratic.
• Identify “autonomy” as the second duty-based principle.
• Explain how the ethics of informed consent derives from the moral notion of autonomy and show how a physician’s problems of consent are handled differently depending on whether his or her ethic is Hippocratic or non-Hippocratic.
• Identify “veracity” as the third duty-based principle.
• Explain how the ethics of diagnosis disclosure derives from the moral notion of veracity and show how a physician’s problems of diagnosis disclosure are handled differently depending on whether his or her ethic is Hippocratic or non-Hippocratic.
• Identify “avoidance of killing” as a possible fourth duty-based principle.

To explore the major concepts in making ethical choices about the care of terminally ill competent patients.

Students will be able to:

• Connect the ethics of “euthanasia” and the care of the dying to themes previously developed in the course.
• Differentiate the moral problems in caring for competent patients from those involving incompetent patients.
• Identify and distinguish four major problems in the care of competent terminally ill patients.
• Examine moral arguments that attempt to support a difference between active killing and letting die (active and passive euthanasia).
• Distinguish between stopping treatment and not starting treatment.
• Differentiate “direct” from “indirect” killing as these terms have been used in law, philosophy, and theology.
• Describe the concepts of “ordinary” and “extraordinary” means of treatment and show how these concepts have been used in law, philosophy, and theology.
• Identify the language of “proportionality” as an alterative to the ordinary/extraordinary distinction and show how the medical profession is using this concept.
• Consider whether some treatments (provision of food, fluids, CPR, and medications) are by their nature always morally required or are sometimes expendable.

To explore the major types of cases requiring decisions regarding the care of terminally ill incompetent patients.

Students will be able to:

• Identify three different types of incompetent patients and what unique problem each of them poses.
• Describe the unique ethical, clinical, and policy issues raised by the formerly competent patient.

• Develop skills in using advance directives.
• Describe the unique ethical, clinical, and policy issues raised by the never-competent patient without family.
• Distinguish the substituted judgment standard from the best interest standard and show how they are used in the clinical setting.
• Describe the unique ethical, clinical, and policy issues raised by the never-competent patient with family.
• Develop an analysis of the role of the family in decision making for their incompetent members.
• Explain the “standard of reasonableness” as it is used in the clinical and judicial systems.
• Summarize the course by returning to the case that structures the course and show how all of the concepts developed thus far would apply to the case.
• Explain the concept of social ethics and show how it is necessary in the case used to structure the course.

To introduce students to the concept of social ethics.

Students will be able to:

• Differentiate more traditional clinical medical ethics from newer issues requiring a social ethical perspective (human subjects research, organ transplant, and cost containment).
• Identify how the St. George’s Academic Oath handles these problems.
• Identify problems associated with ignoring social ethics.
• Apply the concept of social ethics to the extended case study based on the DRG system of health rationing.
• Explain why traditional consequentialist and duty-based ethics cannot resolve the resource allocation problems of this case study.
• Describe two ethical principles at the social level (utility and justice).
• Explain how these principles in some cases lead to different allocations of scarce resources.
• Discuss the “scale of well-being” method of social resource allocation planning.
• Explain the various theories of how social ethical principles and ethical principles at the level of individual clinical decisions might be combined to lead to an overall ethical decision.
• Consider whether students should adopt an ethic that focuses exclusively on individual patients (thereby leaving social ethics to administrators) or should incorporate social ethics into bedside decisions (thereby abandoning patients in at least some marginal cases).