This study examined the effects of short-term high-intensity interval training (HIT) and continuous moderate-intensity training (CMT) on left ventricular (LV) function in young, healthy men. Sixteen untrained men were randomly assigned to HIT (8-12 X 60:75 seconds cycling at 95-100%:10% V˙O2peak) and CMT (90-120 minutes cycling at 65% V˙O2peak) and assessed before and after six sessions of training. LV function was determined at rest and during submaximal exercise using two-dimensional and Doppler echocardiography. HIT and CMT improved V˙O2peak and induced plasma volume expansion to a similar magnitude. Although resting LV function did not change, increased exercise stroke volume and cardiac output was observed, secondary to increases in end-diastolic volume. Numerous ECHO-derived indices of diastolic performance were similarly enhanced during exercise in both groups. Short-term HIT and CMT elicit rapid increases in V˙O2peak and LV filling without global changes in systolic performance or cardiac morphology at rest.

This thesis seeks to evaluate the International Pediatric Emergency Medicine Elective (IPEME) as a case study of a peace-through-health initiative. Using the reasoning of Scolnik (2006), IPEME is first evaluated in terms of narrow, short-term outcomes and subsequently considered in terms of the greater body of peace-through-health work. A novel evaluation tool was designed to examine change in students’ ethical and professional attitudes over the course of the four-week elective. Supplementary qualitative data was collected to shed light on evaluation findings and provide insight into the advantages and disadvantages of the IPEME curriculum. Ethics and professionalism were defined in terms of the WHO 5 Star Global Criteria for Global Doctors conceptualized by the World Health Organization (Boelen, 1996). This research discusses these findings in light of the study’s limitations and considers their implications for IPEME as a medical elective and for its contribution to the greater body of peace-through-health work.

The world’s understanding of HIV/AIDS is grounded in biomedicine and shaped by cognitive psychology. Both biomedicine and cognitive psychology bonded with historically top-down development mechanisms to create ‘prevention’ strategies that obscured from vision the root causes of the pandemic. Within this hierarchy, bio-medicine and the cognitive psychological conception of human beings silenced indigenous voices and experiences of communities fighting HIV/AIDS. This is most certainly true in the case of Sub-Saharan Africa. This research explores the emergence of the Community Capacity Enhancement – Community Conversations prevention approach that places community dialogue, and the voices of communities, at the forefront of the battle to end HIV/AIDS and deconstruct and challenge the forms of structural violence that hold prevalence rates in their place. Within these spaces, oral traditions, indigenous knowledge, and resistance illustrate new and complex pictures of the viruses’ socio-economic impact and provide new foundations for community generated movements to curb the virus.

This study examined the effects of short-term high-intensity interval training (HIT) and continuous moderate-intensity training (CMT) on left ventricular (LV) function in young, healthy men. Sixteen untrained men were randomly assigned to HIT (8-12 X 60:75 seconds cycling at 95-100%:10% V˙O2peak) and CMT (90-120 minutes cycling at 65% V˙O2peak) and assessed before and after six sessions of training. LV function was determined at rest and during submaximal exercise using two-dimensional and Doppler echocardiography. HIT and CMT improved V˙O2peak and induced plasma volume expansion to a similar magnitude. Although resting LV function did not change, increased exercise stroke volume and cardiac output was observed, secondary to increases in end-diastolic volume. Numerous ECHO-derived indices of diastolic performance were similarly enhanced during exercise in both groups. Short-term HIT and CMT elicit rapid increases in V˙O2peak and LV filling without global changes in systolic performance or cardiac morphology at rest.

Patient safety experts identify changes in culture as critical to creating safer care (Flin, 2007; Leape, 1994; Reason, 1997; Vincent, Taylor-Adams & Stanhope, 1998). Yet there is limited understanding of how to best study, evaluate and make changes to patient safety culture. The literature on organizational culture, safety sciences and health services research suggests varying perspectives on studying culture and an evolving approach to creating tools to measure culture change. This thesis reports two projects. The first project used the Manchester Patient Safety Culture Assessment Tool, the Modified Stanford Instrument, and qualitative interviews to examine whether safety culture profiles varied by research method and instrument used to assess culture. Comparative assessment of the results suggests that while the quantitative measurement tools provide a high level organizational summary of safety issues, the qualitative interviews provide a more fine-grained understanding of the contextual and local features of the culture. The second research project used a multiple case study design to understand what hospitals have learned from trying to improve patient safety culture. Interviews in three organizations were used to determine how these organizations shifted their cultures. Although each organization had different experiences and used varying methods, they all created culture change through the simultaneous implementation of practice, policies and strategic framing of patient safety culture concepts in their everyday work. The third research paper examined how leaders measured changes in patient safety culture. Both leaders and front line workers look to both process measures (e.g., talking about safety and encouraging patient safety activities) together with outcome measures (e.g., adverse events, infection rates, and culture survey results) to evaluate their success in culture change. Overall this dissertation deepens our knowledge of how methods influence our assessment of patient safety culture and how leaders influence culture change. Future research needs to assess in more detail the roles of leaders and middle managers to understand how these individuals are able to reconcile the practice environment challenges while continuing to create a culture of patient safety.

Continuing medical education has been characterized as didactic and ineffective. This thesis explores the use of Knowledge Building theory, pedagogy, and technology to test an alternative model for physician engagement—one that emphasizes sustained and creative work with ideas. Several important conceptual changes in continuing medical education are implied by the Knowledge Building model—changes that extend the traditional approach through engagement in (a) collective responsibility for group achievements rather than exclusive focus on individual advancement and (b) work in design-mode, with ideas treated as objects of creation and assemblage into larger wholes and new applications, with extension beyond belief-mode where evidence-based acceptance or rejection of beliefs dominates. The goal is to engage physicians in “cultures of participation” where individual learning and collective knowledge invention or metadesign advance in parallel. This study was conducted in a continuing medical education End-of-Life Care Distance Education course, for family physicians, from 2004 to 2009. A mixed methods case study methodology was used to determine if social-mediated Knowledge Building improved physicians’ knowledge, and if so, what social network structural relationships and sociocognitive dynamics support knowledge improvement, democratization of knowledge, and a metadesign perspective. Traditional pre-/posttest learning measures across 4-years showed significant gains (9% on paired t-test = 5.34, p < 0.001) and large effect size (0.82). Social network analysis of ten 2008/2009 modules showed significant difference in density of build-on notes across groups. Additional results demonstrated a relationship between high knowledge gains and social network measures of centrality/distribution and cohesion. Correlation of posttest scores with centrality variables were all positive. Position/power analyses highlighted core-periphery sociocognitive dynamics between the facilitator and students. Facilitators most often evoked partner/expert relationships. Questions rather than statements dominated the discourse; discourse complexity was elaborated/compiled as opposed to reduced/dispersed. Themes beyond predefined learning objectives emerged and Knowledge Building principles of community responsibility, idea improvability, and democratization of knowledge were evident. Overall, results demonstrate the potential of collective Knowledge Building and design-mode work in continuing medical education, with individual learning representing an important by-product. There were no discernible decrements in performance, suggesting significant advantages rather than tradeoffs from engagement in Knowledge Building.

Context: The study of expertise in medical education has tended to follow the traditions of describing either the analytic processes or the non-analytic resources that experts acquire with experience. We argue that a critical function of expertise is the ability to transition from the automatic mode to the more effortful mode when required – a transition referred to as ‘slowing down when you should’. Objectives: To explore the phenomenon of ‘slowing down when you should’ in operative surgical practice and its role in intra-operative surgical judgment, and to develop conceptual models of the factors involved in the display of this transition in surgical operative practice. Design: In Phase 1A, 28 surgeons were interviewed about their views of surgical judgment in general and their perceptions of the role of this phenomenon in operative judgment. In Phase 1B, a subset of surgeons from Phase 1A was re-interviewed to explore their perceptions of automaticity in operative practice. In Phase 2, observational sessions (and brief interviews) were conducted of surgeons in the operating room to explore the nature of this phenomenon in its natural environment. Results: The surgeons in this study recognized the phenomenon of ‘slowing down’ in their operative practice and acknowledged its link to surgical judgment. Two main initiators were described and observed: proactively planned ‘slowing down’ moments occurring intra-operatively initiated by critical events anticipated pre-operatively and situationally responsive ‘slowing down’ moments initiated by emergent cues intra-operatively. Numerous influences of this transition were uncovered. A control dynamic emerged as surgeon’s negotiated ‘slowing down’ moments through trainees in their supervisory academic practice. Numerous manifestations of this phenomenon were observed in the operating room and considered using a cognitive psychology attention capacity model. Conclusions: This study offers a conceptual framework for understanding the role of ‘slowing down when you should’ in operative surgical practice, providing a vocabulary that will allow more explicit consideration of what contributes to surgical expertise. Consideration of this framework with its consequent ability to make surgical practices more explicit has implications for self-regulation in practice, surgical error, and surgical training.

Patient safety experts identify changes in culture as critical to creating safer care (Flin, 2007; Leape, 1994; Reason, 1997; Vincent, Taylor-Adams & Stanhope, 1998). Yet there is limited understanding of how to best study, evaluate and make changes to patient safety culture. The literature on organizational culture, safety sciences and health services research suggests varying perspectives on studying culture and an evolving approach to creating tools to measure culture change. This thesis reports two projects. The first project used the Manchester Patient Safety Culture Assessment Tool, the Modified Stanford Instrument, and qualitative interviews to examine whether safety culture profiles varied by research method and instrument used to assess culture. Comparative assessment of the results suggests that while the quantitative measurement tools provide a high level organizational summary of safety issues, the qualitative interviews provide a more fine-grained understanding of the contextual and local features of the culture. The second research project used a multiple case study design to understand what hospitals have learned from trying to improve patient safety culture. Interviews in three organizations were used to determine how these organizations shifted their cultures. Although each organization had different experiences and used varying methods, they all created culture change through the simultaneous implementation of practice, policies and strategic framing of patient safety culture concepts in their everyday work. The third research paper examined how leaders measured changes in patient safety culture. Both leaders and front line workers look to both process measures (e.g., talking about safety and encouraging patient safety activities) together with outcome measures (e.g., adverse events, infection rates, and culture survey results) to evaluate their success in culture change. Overall this dissertation deepens our knowledge of how methods influence our assessment of patient safety culture and how leaders influence culture change. Future research needs to assess in more detail the roles of leaders and middle managers to understand how these individuals are able to reconcile the practice environment challenges while continuing to create a culture of patient safety.

The purpose and focus of this work is to seek practical means by which local African-American congregations can minister to persons living with AIDS (PLWAs), and to institute an educational awareness model which emphasizes prevention of the HIV virus. The impetus for the study was a pastoral clinical education program which brought the researcher in contact with HIV/AIDS patients and their families. The study and resulting model for ministry is designed to inspire clergy and laity to institute sharing and caring ministries for PLWAs. Members of the faith community are challenged to respond to the Biblical mandate of Jesus Christ by developing compassionate outreach programs in their local communities. Having studied the literature, the time has come to demonstrate the practice of this ministry issue at the Antioch African Methodist Episcopal Church (A.M.E.C.) in Decatur, Georgia.

Spleen tyrosine kinase (Syk) plays a critical role in regulation of immune and inflammatory responses. This thesis investigated the role of Syk in the development of the asthma phenotype in acute and chronic mouse models of allergic airways inflammation. Airway hyperresponsiveness (AHR) to methacholine and inflammation increased significantly in HDM-induced compared with the saline control mice. We demonstrated that in vivo inhibition of Syk by selective Syk inhibitors, and genetic deletion of Syk using conditional Syk knockout mice attenuated AHR despite of inflammatory cell influx in the lung. Histological analysis showed airway remodeling in the chronic model, which was attenuated to some degree by deletion of Syk. This study identified a role of Syk in airway hyperresponsiveness and remodeling without significantly affecting leukocyte recruitment in HDM model of airways disease. My results support the improvement of therapeutic strategies in asthma by targeting the Syk pathway.