Correspondence
rates for the individual endpoints are not presented. This finding is also consistent with no beneficial effect reported with anakinra in patients with STEMI2 and NSTEMI.3 In these studies2,3 anakinra also showed blunting of the inflammatory response, yet it did not prevent recurrent adverse events. Unfortunately, the incidence of heart failure after NSTEMI was not reported in this study.3 Both studies, of losmapimod1 and anakinra,3 showed a significant increase in C-reactive protein concentrations in patients 2 weeks after cessation of active treatment. The implications of this so-called rebound occurrence is unknown.4 We request that the authors1 report the incidence of heart failure as an individual endpoint in their groups to allow for comparisons with other studies. We also ask them to describe the group of patients with rebound after treatment to identify potential risk factors or predictors, and assess whether the rebound is predictive of (or even causes) long-term adverse events in patients with NSTEMI. AA reports grants from Novartis and Swedish Orphan Biovitrum, outside the submitted work. ACM and DCC declare no competing interests.
*Antonio Abbate, Allison C Morton, David C Crossman [email protected]
For the International New School of Medicine’s website see http://www.insomed.org
Virginia Commonwealth University, Richmond, VA 23298, USA (AA); University of Sheffield, Sheffield, UK (ACM); and University of St Andrews, Glasgow, UK (DCC) 1
2
3
4
2574
Newby LK, Marber MS, Melloni C, et al, on behalf of the SOLSTICE Investigators. Losmapimod, a novel p38 mitogen-activated protein kinase inhibitor, in non-ST-segment elevation myocardial infarction: a randomised phase 2 trial. Lancet 2014; 384: 1187–95. Abbate A, Van Tassell BW, Biondi-Zoccai G, et al. Effects of interleukin-1 blockade with anakinra on adverse cardiac remodeling and heart failure after acute myocardial infarction [from the Virginia Commonwealth University-Anakinra Remodeling Trial (2) (VCU-ART2) pilot study]. Am J Cardiol 2013; 111: 1394–400. Morton AC, Rothman AMK, Greenwood JP, et al. The effect of interleukin-1 receptor antagonist therapy on markers of inflammation in non-ST elevation acute coronary syndromes: the MRC-ILA heart study. Eur Heart J 2015; 36: 377–84. Abbate A, Dinarello CA. Anti-inflammatory therapies in acute coronary syndromes: is IL-1 blockade a solution? Eur Heart J 2014; 36: 337–39.
A 21st-century medical school In their Comment (Feb 21, p 672) about the so-called 21st-century medical school Hilliard Jason and Andrew Douglas explicitly invited “questions, suggestions, even expressions of scepticism”. As junior medical educators from five different continents, we applaud the premise of the International New School of Medicine (iNSoMed)— “helping to enhance the wellbeing of people and communities, as well as promoting economic growth in low-income and middle-income countries”. We approach this with cautious optimism because previous attempts at such development have led to reinforcement of paternalism, ethnocentrism, and universalism.2 We are keen to learn how the authors anticipate overcoming this common occurrence in global development initiatives and how they expect iNSoMed to be sustainable in lowincome and middle-income countries. The description and accompanying website, while attractive, lack specifics about methods of teaching, learning, and assessment. Details are missing on how iNSoMed intends to break with traditional approaches to student selection for medical education to fit their highly aspirational criteria (in view of the limitations of admission tools available)3 and on how the proposed individual pathways will be created and validated. Lastly, the medical educators advising iNSoMed are exclusively from western Europe and the USA, with seemingly little student and junior doctor engagement during the development process of iNSoMed.4 We wonder what effect such limited diversity could have on the implementation of change. Rhetoric aside, real change in medical education is hard to achieve. The “how can we get there”5 is precisely what is missing from the Comment, leaving it to read more like an advertisement for the programme than a description of educational innovation. 1
We declare no competing interests.
*Robbert J Duvivier, Matthew J Stull, Andrea Srur Colombo, Jirayu Phillip Chantanakomes, Chijioke Kaduru [email protected] Faculty of Medicine and Public Health, University of Newcastle, Callaghan, NSW 2308, Australia (RJD); Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA (MJS); Ministerio de Salud de Chile, Santiago, Chile (ASC); Saraburi Hospital, Bangkok, Thailand (JPC); and Young People for Global Health Issues, Abuja, Nigeria (CK) 1
2
3
4
5
Jason H, Douglas A. Are the conditions right for a 21st-century medical school? Lancet 2015; 385: 672–73. Hodges BD, Maniate JM, Martimianakis MA, Alsuwaidan M, Segouin C. Cracks and crevices: globalization discourse and medical education. Med Teach 2009; 31: 910–17. Hamdy H, Prasad K, Anderson MB, et al. BEME systematic review: predictive values of measurements obtained in medical schools and future performance in medical practice. Med Teach 2006; 28: 103–16. Stigler FL, Duvivier RJ, Weggemans M, Salzer HJF. Health professionals for the 21st century: a students’ view. Lancet 2010; 376: 1877–78. Skochelak S. A decade of reports calling for change in medical education: what do they say? Acad Med 2010; 85: S26–33.
Authors’ reply We are grateful to Robbert Duvivier and colleagues for their thoughtful questions in response to our Comment.1 Their questions give us an opportunity to add some information that we did not previously have space to include. We will make more detail available on our website in the near future, but for now, the site contains a list of our advisers and collaborating organisations, many of whom have had extensive experience working in low-income and middle-income countries. We are about to begin seeking the foundation and donor funds needed for this philanthropic effort. Our central commitment is to be the opposite of paternalistic. We aim to provide help at the request of and in collaboration with local leaders. Our goal is to strengthen self-sustaining health systems in multiple developing countries to meet their local needs. We will offer guidance, substantial resources and www.thelancet.com Vol 385 June 27, 2015
systems, as well as ongoing support, all at zero or very low cost, to assist with the development of local educational capacity, integrated within the global medical education community. “The future is about interdependence and co-development: Richer and poorer countries both need each other and can learn from each other”2 The centrepiece of the iNSoMed approach is adaptive learning, in which learning tasks are continuously responsive to the backgrounds, goals, readiness, and performance of individual learners. In other words, our learning approaches are similar to clinical care—diagnostic information is continuously gathered to guide decisions about what is most appropriate to suggest and do at any given time. With our collaborators, we will devise content and processes that are matched to their local circumstances: their culture, backgrounds, economies, and expectations. Our overriding mission is to help low-resource settings enlarge and enhance their capacities for educating doctors and other health professionals who are well suited for their local needs. We believe that new and emerging technologies, which provide memory support, learning process support, and continuous tracking of learners’ capabilities and achievements, make possible a level of individualisation of learning experiences that is overdue, but has not previously been affordable. Continuous formative assessment, constructive feedback, and adaptive learning experiences are the foundations of each iNSoMed student’s learning pathway. We will establish educational systems that achieve locally desired outcomes consistently, reliably, and affordably. We agree that meaningful change from traditional approaches is difficult. To help ensure that we can foster fresh approaches to medical education, iNSoMed and our collaborators are choosing to rely on evidence,3–5 not tradition, as our primary guide to www.thelancet.com Vol 385 June 27, 2015
the programmes we are pursuing. To help to achieve our mission, we are partnering with local health-care communities and students to ensure that learning experiences are the best for their setting and are locally owned. We welcome additional questions and seek potential collaborators from all parts of the world. We declare no competing interests.
*Hilliard Jason, Andrew Douglas [email protected] International New School of Medicine, Miami, FL 33143, USA 1
2 3
4
5
Jason H, Douglas A. Are the conditions right for a 21st-century medical school? Lancet 2015; 385: 672–73. Omaswa F, Crisp, N. African health leaders. Oxford: Oxford University Press, 2014: p 5. Medina J. Brain rules: 12 principles for surviving and thriving at work, home, and school, 2nd edn. Seattle: Pear Press, 2014. Herrington J, Reeves TC, Oliver, R. A guide to authentic e-learning. New York: Routledge, 2010. Strasser R, Worley P, Cristobal F, et al. Putting communities in the driver’s seat: the realities of community-engaged medical education. Acad Med 2015; published online May 20. DOI:10.1097/ACM.0000000000000765.
Responses to the Chief Medical Officer’s report 2013 The focus on public mental health in the 2013 Chief Medical Officer’s annual report1 was eagerly anticipated by not-for-profit sector organisations working in the field. The report has been welcomed for upholding and strengthening the principle of parity of esteem and for further opening up the debate about strategy and funding in this area. However, consensus is growing that one of the central themes of the recommendations needs to be challenged. We believe that the term wellbeing, and its validity as a model for prevention and intervention in mental health, needs to be developed further rather than dismissed. The report states that wellbeing initiatives should not form part of
public health strategy or receive the requisite funding. However, the term wellbeing, and the desire to create a society where wellbeing is valued, has been given credence at a national and global level. WHO define mental health as “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.”2 Nationally, the UK Government has honoured its pledge to include wellbeing as one of the wider determinants of health. Public Health England states that it will “work with the NHS, local authorities and other partners to help more people have good mental health, improve the physical health and wellbeing of those with mental illness”.3 In view of the few years that wellbeing has been recognised as a model for mental health prevention and intervention and the fact that many wellbeing therapies cannot be tested using a randomised controlled trial (RCT)-based approach, the existence of what the report refers to as insufficient evidence to prove its effectiveness is unsurprising. Many mental health professionals deem wellbeing interventions to be a powerful approach to support and improve quality of life. Indeed, research published in The Lancet Psychiatry4 reported that talking therapies reduced risk of suicide by 26%. However, many wellbeing therapies or initiatives do not lend themselves to this methodology, but rather than dismissing the validity of the wellbeing model on the basis of its inability to be tested by RCTs, we suggest that a new research framework is needed. We would welcome further research about how a person-centred approach to mental health can be researched by use of a person-centred framework. The Chief Medical Officer states that she won’t “take a leap of faith with people’s health” 1 and
Department of Health
Correspondence
For more about the iNSoMed approach see https://vimeo. com/100601365
2575
rates for the individual endpoints are not presented. This finding is also consistent with no beneficial effect reported with anakinra in patients with STEMI2 and NSTEMI.3 In these studies2,3 anakinra also showed blunting of the inflammatory response, yet it did not prevent recurrent adverse events. Unfortunately, the incidence of heart failure after NSTEMI was not reported in this study.3 Both studies, of losmapimod1 and anakinra,3 showed a significant increase in C-reactive protein concentrations in patients 2 weeks after cessation of active treatment. The implications of this so-called rebound occurrence is unknown.4 We request that the authors1 report the incidence of heart failure as an individual endpoint in their groups to allow for comparisons with other studies. We also ask them to describe the group of patients with rebound after treatment to identify potential risk factors or predictors, and assess whether the rebound is predictive of (or even causes) long-term adverse events in patients with NSTEMI. AA reports grants from Novartis and Swedish Orphan Biovitrum, outside the submitted work. ACM and DCC declare no competing interests.
*Antonio Abbate, Allison C Morton, David C Crossman [email protected]
For the International New School of Medicine’s website see http://www.insomed.org
Virginia Commonwealth University, Richmond, VA 23298, USA (AA); University of Sheffield, Sheffield, UK (ACM); and University of St Andrews, Glasgow, UK (DCC) 1
2
3
4
2574
Newby LK, Marber MS, Melloni C, et al, on behalf of the SOLSTICE Investigators. Losmapimod, a novel p38 mitogen-activated protein kinase inhibitor, in non-ST-segment elevation myocardial infarction: a randomised phase 2 trial. Lancet 2014; 384: 1187–95. Abbate A, Van Tassell BW, Biondi-Zoccai G, et al. Effects of interleukin-1 blockade with anakinra on adverse cardiac remodeling and heart failure after acute myocardial infarction [from the Virginia Commonwealth University-Anakinra Remodeling Trial (2) (VCU-ART2) pilot study]. Am J Cardiol 2013; 111: 1394–400. Morton AC, Rothman AMK, Greenwood JP, et al. The effect of interleukin-1 receptor antagonist therapy on markers of inflammation in non-ST elevation acute coronary syndromes: the MRC-ILA heart study. Eur Heart J 2015; 36: 377–84. Abbate A, Dinarello CA. Anti-inflammatory therapies in acute coronary syndromes: is IL-1 blockade a solution? Eur Heart J 2014; 36: 337–39.
A 21st-century medical school In their Comment (Feb 21, p 672) about the so-called 21st-century medical school Hilliard Jason and Andrew Douglas explicitly invited “questions, suggestions, even expressions of scepticism”. As junior medical educators from five different continents, we applaud the premise of the International New School of Medicine (iNSoMed)— “helping to enhance the wellbeing of people and communities, as well as promoting economic growth in low-income and middle-income countries”. We approach this with cautious optimism because previous attempts at such development have led to reinforcement of paternalism, ethnocentrism, and universalism.2 We are keen to learn how the authors anticipate overcoming this common occurrence in global development initiatives and how they expect iNSoMed to be sustainable in lowincome and middle-income countries. The description and accompanying website, while attractive, lack specifics about methods of teaching, learning, and assessment. Details are missing on how iNSoMed intends to break with traditional approaches to student selection for medical education to fit their highly aspirational criteria (in view of the limitations of admission tools available)3 and on how the proposed individual pathways will be created and validated. Lastly, the medical educators advising iNSoMed are exclusively from western Europe and the USA, with seemingly little student and junior doctor engagement during the development process of iNSoMed.4 We wonder what effect such limited diversity could have on the implementation of change. Rhetoric aside, real change in medical education is hard to achieve. The “how can we get there”5 is precisely what is missing from the Comment, leaving it to read more like an advertisement for the programme than a description of educational innovation. 1
We declare no competing interests.
*Robbert J Duvivier, Matthew J Stull, Andrea Srur Colombo, Jirayu Phillip Chantanakomes, Chijioke Kaduru [email protected] Faculty of Medicine and Public Health, University of Newcastle, Callaghan, NSW 2308, Australia (RJD); Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA (MJS); Ministerio de Salud de Chile, Santiago, Chile (ASC); Saraburi Hospital, Bangkok, Thailand (JPC); and Young People for Global Health Issues, Abuja, Nigeria (CK) 1
2
3
4
5
Jason H, Douglas A. Are the conditions right for a 21st-century medical school? Lancet 2015; 385: 672–73. Hodges BD, Maniate JM, Martimianakis MA, Alsuwaidan M, Segouin C. Cracks and crevices: globalization discourse and medical education. Med Teach 2009; 31: 910–17. Hamdy H, Prasad K, Anderson MB, et al. BEME systematic review: predictive values of measurements obtained in medical schools and future performance in medical practice. Med Teach 2006; 28: 103–16. Stigler FL, Duvivier RJ, Weggemans M, Salzer HJF. Health professionals for the 21st century: a students’ view. Lancet 2010; 376: 1877–78. Skochelak S. A decade of reports calling for change in medical education: what do they say? Acad Med 2010; 85: S26–33.
Authors’ reply We are grateful to Robbert Duvivier and colleagues for their thoughtful questions in response to our Comment.1 Their questions give us an opportunity to add some information that we did not previously have space to include. We will make more detail available on our website in the near future, but for now, the site contains a list of our advisers and collaborating organisations, many of whom have had extensive experience working in low-income and middle-income countries. We are about to begin seeking the foundation and donor funds needed for this philanthropic effort. Our central commitment is to be the opposite of paternalistic. We aim to provide help at the request of and in collaboration with local leaders. Our goal is to strengthen self-sustaining health systems in multiple developing countries to meet their local needs. We will offer guidance, substantial resources and www.thelancet.com Vol 385 June 27, 2015
systems, as well as ongoing support, all at zero or very low cost, to assist with the development of local educational capacity, integrated within the global medical education community. “The future is about interdependence and co-development: Richer and poorer countries both need each other and can learn from each other”2 The centrepiece of the iNSoMed approach is adaptive learning, in which learning tasks are continuously responsive to the backgrounds, goals, readiness, and performance of individual learners. In other words, our learning approaches are similar to clinical care—diagnostic information is continuously gathered to guide decisions about what is most appropriate to suggest and do at any given time. With our collaborators, we will devise content and processes that are matched to their local circumstances: their culture, backgrounds, economies, and expectations. Our overriding mission is to help low-resource settings enlarge and enhance their capacities for educating doctors and other health professionals who are well suited for their local needs. We believe that new and emerging technologies, which provide memory support, learning process support, and continuous tracking of learners’ capabilities and achievements, make possible a level of individualisation of learning experiences that is overdue, but has not previously been affordable. Continuous formative assessment, constructive feedback, and adaptive learning experiences are the foundations of each iNSoMed student’s learning pathway. We will establish educational systems that achieve locally desired outcomes consistently, reliably, and affordably. We agree that meaningful change from traditional approaches is difficult. To help ensure that we can foster fresh approaches to medical education, iNSoMed and our collaborators are choosing to rely on evidence,3–5 not tradition, as our primary guide to www.thelancet.com Vol 385 June 27, 2015
the programmes we are pursuing. To help to achieve our mission, we are partnering with local health-care communities and students to ensure that learning experiences are the best for their setting and are locally owned. We welcome additional questions and seek potential collaborators from all parts of the world. We declare no competing interests.
*Hilliard Jason, Andrew Douglas [email protected] International New School of Medicine, Miami, FL 33143, USA 1
2 3
4
5
Jason H, Douglas A. Are the conditions right for a 21st-century medical school? Lancet 2015; 385: 672–73. Omaswa F, Crisp, N. African health leaders. Oxford: Oxford University Press, 2014: p 5. Medina J. Brain rules: 12 principles for surviving and thriving at work, home, and school, 2nd edn. Seattle: Pear Press, 2014. Herrington J, Reeves TC, Oliver, R. A guide to authentic e-learning. New York: Routledge, 2010. Strasser R, Worley P, Cristobal F, et al. Putting communities in the driver’s seat: the realities of community-engaged medical education. Acad Med 2015; published online May 20. DOI:10.1097/ACM.0000000000000765.
Responses to the Chief Medical Officer’s report 2013 The focus on public mental health in the 2013 Chief Medical Officer’s annual report1 was eagerly anticipated by not-for-profit sector organisations working in the field. The report has been welcomed for upholding and strengthening the principle of parity of esteem and for further opening up the debate about strategy and funding in this area. However, consensus is growing that one of the central themes of the recommendations needs to be challenged. We believe that the term wellbeing, and its validity as a model for prevention and intervention in mental health, needs to be developed further rather than dismissed. The report states that wellbeing initiatives should not form part of
public health strategy or receive the requisite funding. However, the term wellbeing, and the desire to create a society where wellbeing is valued, has been given credence at a national and global level. WHO define mental health as “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.”2 Nationally, the UK Government has honoured its pledge to include wellbeing as one of the wider determinants of health. Public Health England states that it will “work with the NHS, local authorities and other partners to help more people have good mental health, improve the physical health and wellbeing of those with mental illness”.3 In view of the few years that wellbeing has been recognised as a model for mental health prevention and intervention and the fact that many wellbeing therapies cannot be tested using a randomised controlled trial (RCT)-based approach, the existence of what the report refers to as insufficient evidence to prove its effectiveness is unsurprising. Many mental health professionals deem wellbeing interventions to be a powerful approach to support and improve quality of life. Indeed, research published in The Lancet Psychiatry4 reported that talking therapies reduced risk of suicide by 26%. However, many wellbeing therapies or initiatives do not lend themselves to this methodology, but rather than dismissing the validity of the wellbeing model on the basis of its inability to be tested by RCTs, we suggest that a new research framework is needed. We would welcome further research about how a person-centred approach to mental health can be researched by use of a person-centred framework. The Chief Medical Officer states that she won’t “take a leap of faith with people’s health” 1 and
Department of Health
Correspondence
For more about the iNSoMed approach see https://vimeo. com/100601365
2575
