Residents and fellows want to engage in positive teaching interactions in the context of the clinical consult; however, multiple barriers influence both parties in the hospital environment. Many of these barriers are amenable to change. Interventions aimed at reducing barriers to teaching in the setting of consultation hold promise for improving teaching and learning on the wards.

This article provides detailed examples from written feedback obtained during collaborative peer observation to emphasize the richness of this combined experience.

As the U.S. health care system changes and technology alters how doctors work and learn, medical schools and their faculty are compelled to modify their curricula and teaching methods. In this article, educational leaders and key faculty describe how the Pathways curriculum was conceived, designed, and implemented at Harvard Medical School. Faculty were committed to the principle that educators should focus on how students learn and their ability to apply what they learn in the evaluation and care of patients. Using the best evidence from the cognitive sciences about adult learning, they made major changes in the pedagogical approach employed in the classroom and clinic. The curriculum was built upon 4 foundational principles: to enhance critical thinking and provide developmentally appropriate content; to ensure both horizontal integration between courses and vertical integration between phases of the curriculum; to engage learners, foster curiosity, and reinforce the importance of student ownership and responsibility for their learning; and to support students’ transformation to a professional dedicated to the care of their patients and to their obligations for lifelong, self-directed learning. The practice of medicine is rapidly evolving and will undoubtedly change in multiple ways over the career of a physician. By emphasizing personal responsibility, professionalism, and thinking skills over content transfer, the authors believe this curriculum will prepare students not only for the first day of practice but also for an uncertain future in the biological sciences, health and disease, and the nation’s health care system, which they will encounter in the decades to come.

The hospitalist-consultant interaction is viewed as important for both hospitalist learning and patient care. Multiple barriers and facilitating factors impact the interaction, many of which are amenable to intervention.

Awake craniotomy is indicated for surgical resection of tumors located near eloquent areas of the brain. The anesthetic technique is based on a combination of local anesthesia, sedation, and analgesia. Usually only clinical parameters are assessed and no other cerebral oxygenation monitoring techniques are applied. The authors report the use of brain tissue oxygen pressure monitoring during awake craniotomy. A 48-year-old right-handed man with a left temporoparietal mass was scheduled for awake craniotomy, cortical stimulation, and selective tumor removal. Monitoring included electrocardiography, pulse oximetry, end-tidal CO2, bladder temperature, invasive and noninvasive arterial pressure, and brain tissue oxygen pressure (PtiO2). The anesthetic technique consisted of continuous perfusions of 0.02 to 0.05 microg/kg/min remifentanil, propofol (target concentration, 0.5 to 1.2 microg/mL), and 25 to 50 microg/kg/min esmolol, and local anesthetic blockade of the head pin insertion sites and surgical incision area (a mixture of 0.2% ropivacaine, 1% lidocaine, and epinephrine, 1:200 000). Intraoperative cortical stimulation was performed to guide the resection according to the patient's verbal response. A change in PtiO2 was observed, gradually falling from 28 mm Hg at the beginning of the intervention down to 3 mm Hg. At this stage, surgical resection was concluded. On arrival at the intensive care unit, mixed dysphasia and slight weakness of the right arm were noted. Three weeks after surgery, the patient's speech is improving and the motor deficit has disappeared. This case suggests a possible role of PtiO2 in awake craniotomy as an aid in detecting intraoperative adverse events, but further experience with PtiO2 in this setting is needed.

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