Junior Faculty
Geriatrics Excellence in Teaching Series for Faculty and Fellows
at Duke University School of Medicine
| SUMMARY |
| Target Audience Geriatrics faculty and fellows Purpose Program History Operating Costs Outcomes Available Materials For More Information |
Program Overview
In 2005 the Duke University Division of Geriatrics and Aging Center established a year-long Geriatrics Excellence in Teaching Series (GETS) to help geriatrics faculty and fellows develop as clinician-educators. The program, which is also open to other health professionals at the Duke Aging Center, focuses on developing skills in teaching, curriculum development, and educational scholarship that are essential for succeeding in careers in geriatric academic medicine.
The program provides an innovative approach to training clinician-educators through a variety of active learning strategies that:
- expose participants to innovative, adult learning-centered approaches for enhancing learning and instruction in medical education
- provide a conceptual space for faculty and fellows to discuss contemporary issues in academic medicine.
Program Operations
The year-long program consists of ten one-hour sessions covering a variety of topics in medical education. The sessions occur monthly during the existing Geriatrics Grand Rounds program slot. Attendance ranges from 15 to 20 participants per session.
A PhD-level educator serves as the program director. Sessions are facilitated by the program director and one or two invited faculty or fellows from the Division of Geriatrics and Aging Center. Invited facilitators are identified based on their expertise in a given topic area or by their expressed desire to learn more about the topic to be covered; there is no financial incentive or compensation for their participation. The program director works closely with the cofacilitators in developing and implementing the sessions.
Topics for the series are determined by the program director, based on a review of the faculty development literature and contemporary issues in academic medicine, and on the results of an annual needs assessment conducted with faculty and fellows. All sessions are taught using active learning strategies (including small- and large-group discussion, video review, case discussion, role play, readings, and writing assignments) to foster learners’ participation. Sessions usually start with a discussion of participants’ perceived challenges in the topic area being considered. This information provides facilitators with an understanding of the needs of the group and helps them to focus the seminar on the participants’ interests. There is limited use of PowerPoint slides; sessions are interactive and focus on participants’ challenges and on constructing new knowledge.
Participants gain the skills to develop their academic careers; they learn how to improve their teaching practices and to develop effective educational programs and educational scholarship.
Cofacilitators have the opportunity to be mentored by a PhD educator to develop and implement educational programs, and to collaborate with peers in the development of educational activities.
Staffing Requirements
The following personnel are needed:
- Program director (5%) (Funded by the Reynolds grant)
- Invited faculty or fellows to teach the sessions—faculty are encouraged to participate; some volunteer to teach.
- Administrative staff (for preparation of handouts, course promotion, etc.)
Program Costs and Funding Sources
The costs involved are: the program director’s time; fellows/faculty time to plan, cofacilitate, and attend the sessions; light refreshments; and photocopying of teaching materials. Each one-hour session costs approximately $60, excluding faculty time.
The program is supported by a grant from the Donald W. Reynolds Foundation Aging and Quality of Life Program, but will be incorporated into the regular budget once the Reynolds grant expires.
Process and Outcomes Data
Participants assess each program session via a feedback form. They are asked to rate the quality of the session, usefulness of the content, and adequacy of interactive opportunities for questions and discussion. Participants also describe how they will apply what they learned in the session to their teaching practices.
An end-of-program survey is conducted to assess participants’ satisfaction with the program and to determine the impact of the series on their roles as educators. The survey asks participants to rate:
- the overall benefit of the series
- the utility of concepts and tools offered for their teaching practices
- whether or not they have used knowledge and skills taught in the program
- the degree to which the series helped them improve their confidence as educators/teachers.
The survey also asks participants to identify the session they found most beneficial, to name topics they would recommend for future sessions, and to provide general constructive feedback for improving the program.
All respondents agreed or strongly agreed that the GETS provided them with resources (concepts and tools) that they will be able to use in their teaching practices. All also reported to have used knowledge and skills learned in the series in their teaching practices.
88% agreed or strongly agreed that, as a result of their participation in this series, they were more confident in designing educational programs as well as teaching medical learners; 100% agreed that they would recommend the series to other faculty and fellows.
Some specific comments from participants regarding skills learned that were particularly helpful to them as teachers/educators include noting the importance of:
- Focusing on teaching as an important goal and a valuable skill that can be learned and practiced
- Principles of adult learning theory such as establishing the learner ‘need to know’: “The distinction between pedagogy and andragogy will help me design curricula and talks in the future”
- Matching instructional strategies and evaluation methods to learning objectives
- Providing feedback to learners
- Soliciting feedback for both the portfolio and self-development as a teacher
- Remembering to set learners’ goals at the beginning of encounter and then give specific feedback on these goals.
For more details on program outcomes, please see Available Materials.
Implementation Lessons
- A needs assessment of participants determined the topics deemed most relevant to participants daily lives as clinician-educators.
- Sessions were designed to be interactive and to promote skill development through actual practice of a variety of strategies.
- Open discussion time during sessions proved essential for allowing all attendees an opportunity to identify shared challenges and propose effective solutions.
- The program was offered in a time slot customarily reserved for a very traditional didactic Grand Rounds. This time proved convenient for both faculty and fellows.
- Participation of clinician-educators as coteachers was a particular strength of the program, as clinician-educators were able to practice planning and implementing educational skills sessions with a professional educator. Drawing on the existing expertise of the group, this collaboration among faculty positively impacted the quality of the GETS and the experience of faculty and learners alike.
Available Materials
Publications
- The Geriatrics Excellence in Teaching Series: An Integrated Educational Skills Curriculum for Faculty and Fellows Development
Pinheiro, S, Heflin, M
Journal of the American Geriatrics Society,
2008;(56)4:750 - 756
Website
- Slides, handouts, and references are available at http://careinaging.duke.edu
For More Information
Sandro O. Pinheiro, PhD
Mitchell T. Heflin, MD
Duke University School of Medicine
DUMC 3003 – 3502 Blue Zone
Durham, NC 27705
(919) 660-7563
sandro.pinheiro@duke.edu
hefli001@mc.duke.edu
One-Year Course in Research Methods and Design for Geriatrics Fellows and Junior Faculty
at Weill Medical College of Cornell University
| SUMMARY |
| Target Audience First- and second-year geriatrics fellows, as well as interested junior faculty from the Division of Geriatrics and Gerontology Purpose Program History Operating Costs Outcomes Available Materials For More Information |
Program Overview
This year-long course aims to teach first- and second-year geriatrics fellows, as well as interested junior faculty, core research methods and design skills. The course covers topics such as clinical epidemiology, research architecture, biostatistics, health services research, and qualitative methods, and provides training in data entry, analysis, and programming. Given the shortage of geriatrics clinician-investigators and clinician-educators, it is particularly important that geriatrics fellows receive a firm grounding in fundamental research skills to help ensure their success in academic geriatrics.
The course is mandatory for first- and second-year geriatrics fellows.
Program Operations
The course meets for one hour each week. Students are required to read journal articles that address points covered in weekly didactic lectures and are then asked questions about the articles that reinforce key concepts covered in each class. In 2009 the course will be offered to interested faculty and fellows throughout the Weill Cornell institution.
Staffing Requirements
Three core faculty teach the classes, including the Hartford Centers of Excellence Director. An administrative assistant distributes reading assignments and discussion questions to attendees on a weekly basis.
Program Costs and Funding Sources
Each session requires about 2.5 hours of preparation time; between the course director and the two faculty who participate, the total amount of effort over the course of the year is
5-7.5%. The administrative assistant requires approximately 1% FTE.
The seminar was developed and implemented under the Hartford Centers of Excellence grant.
Process and Outcomes Data
Participants are surveyed at the completion of the course regarding their likes/dislikes and what they would like to see changed in the future. The course was enthusiastically evaluated by the first cohort of fellows/junior faculty. Participants felt that the course was instrumental in helping them to conduct original research, strengthened and consolidated their understanding of biostatistics (particularly multivariable analysis), and helped them to develop and implement better age-relevant research questions/hypotheses. Many reported that the course helped to lay the foundation for further research training. Sections on research design and multivariable statistics were judged to be particularly important topics, and well presented.
Plans are underway to survey course graduates to determine how they have made use of the materials in their current positions.
Implementation Lessons
- Offering the course every other year is necessary as the division has two first- and two second-year fellows (two receive the course in their first year of training and two in their second year).
- Information covered has had to be somewhat general, given the diverse backgrounds of the learners. For example, some have had biostatistics and methodology courses, while others have not.
- The course is now offered to research assistants employed through the Division of Geriatrics, to help improve the overall quality and quantity of divisional research products.
- One goal for the future is to have additional faculty from both within and outside of the Geriatrics Division teach sections of the course, as a way to introduce these faculty members to ongoing research activities within the Division, thus promoting interdisciplinary research activities.
Available Materials
Tools/Resources
For More Information
Cary Reid, MD, PhD
Associate Professor of Medicine
Division of Geriatrics and Gerontology
Weill Medical College of Cornell University
525 East 68th Street, Box 39
New York, NY 10065
(212) 746-1729
mcr2004@med.cornell.edu
Grant Writing Seminar for Geriatrics Fellows and Junior Faculty
at Weill Medical College of Cornell University
| SUMMARY |
| Target Audience All geriatrics fellows as well as interested junior faculty in geriatrics Purpose Program History Operating Costs Outcomes Available Materials For More Information |
Program Overview
This 14-week seminar covers core topics in effective grant writing, including organization, formatting of hypotheses, presentation of preliminary data, organization of research design/methods, and tips on resubmission of NIH grants. Participants gain hands-on experience by writing an actual grant during the last half of the course.
All geriatrics fellows participate in the course, either in their first or second year of training, as do interested junior faculty in geriatrics.
The seminar was initially implemented in the
2006-07 academic year and will be given again in 2008-09. The course is designed to enhance the academic career development of clinical investigators in geriatrics.
Program Operations
The 14-week seminar is comprised of weekly one-hour classes. Didactic materials include Otto A. Yang’s Guide to Effective Grant Writing as well as previously submitted grants by diverse investigators. Homework is assigned weekly to promote skills acquisition in both grant writing and reviewing. Attendees are assigned several grants to read each week and then have to answer questions about the grants.
Participants gain important reviewing skills by critically evaluating the specific aim, background and significance, preliminary results, and research design and methods sections of the grants.
Staffing Requirements
Currently one faculty member (the Center of Excellence Director) teaches all of the sessions. Administrative staff distribute weekly reminders regarding reading and other homework assignments.
Program Costs and Funding Sources
The course director requires 2-3% FTE for weekly preparation and reviewing grants. The administrative assistant spends minimal time circulating materials.
The Hartford Center of Excellence grant fully supports this initiative.
Process and Outcomes Data
The course has been implemented once. Four fellows (two first- and two second-year) and three junior faculty (all instructors) attended the seminar. Two graduates of the seminar applied for and received Geriatrics Academic Career Awards (GACA). Both reported that the seminar was critically important in helping them to write compelling proposals. In addition, one graduate judged that the course enabled her to prepare a highly competitive (and ultimately funded) pilot grant application at her current institution.
Course attendees were surveyed about their likes/dislikes and suggested areas for improvement. The course was uniformly felt to be extremely helpful in terms of preparing participants for a career in academic geriatric medicine. The format of using actual grants with questions was also uniformly judged to be positive. The only suggested change was to extend the number of sessions to allow more time for participants to work on their own grants.
Implementation Lessons
- The course is offered every other year because the division has a two-year fellowship program. There were six participants in the first round (four fellows and two junior faculty). This was a manageable course size when reviewing/critiquing fellows’ grants.
- Offering the class in institutions with larger numbers of fellows would obviously increase the course director’s workload and could result in less effective group interaction.
- This course will be made available to nondivisional fellows/faculty in the near future, which could help to broadly showcase the rapidly growing expertise housed within the Geriatrics Division, as well as to foster new interdisciplinary initiatives between Divisional and non-Divisional faculty and fellows.
Available Materials
Tools/Resources
References
- Guide to Effective Grant Writing: How to Write a Successful NIH Grant
Yang, Otto A.
Springer, 2005.
For More Information
Cary Reid, MD, PhD
Associate Professor of Medicine
Division of Geriatrics and Gerontology
Weill Medical College of Cornell University
525 East 68th Street, Box 39
New York, NY 10065
(212) 746-1729
mcr2004@med.cornell.edu
Innovative Teaching Program for Clinician-Educators
at the University of Chicago
| SUMMARY |
| Target Audience Clinician-educator (CE) junior faculty and fellows in geriatrics Purpose Program History Operating Costs Outcomes Available Materials For More Information |
Program Overview
The Innovative Teaching Program is a dedicated approach to developing geriatrics clinician-educator fellows and junior faculty who are recognized locally—and eventually nationally—for their expertise in a specific area of clinical geriatrics and related academic and teaching endeavors.
Clinician-educator trainees select a specific clinical area or ‘niche’ on which to focus their teaching pursuits, similar to an area of concentration for clinician-researchers. Through this approach, clinician-educator fellows and junior faculty become the "go to" people for clinical expertise and innovative teaching in their defined areas. With this expertise, they help take the lead on developing new lectures, courses, and electives in their topic area.
Program Operations
Shortly after their arrival at the institution, each clinician-educator trainee meets with the Geriatrics Section Chief to develop a strategic career plan. An annual overview of faculty interests enables trainees to select an area of clinical focus and to identify mentors with expertise in that area. Areas of focus have included palliative care, geriatric oncology, dementia, pain management, polypharmacy, ethnogeriatrics, systems of care, and specific geriatric care settings such as long- term care
The strategic career plan forms the basis of the clinician-educator trainees applying for funding and presenting at meetings in their chosen area of expertise. Trainees are urged to keep complete records of courses they teach, lectures they give, and presentations they make, to build a record of accomplishment around their content area of choice.
To provide them with sufficient time to develop their teaching skills as well as expertise in their clinical niche, the Department of Medicine reduces the clinical time required of geriatrics clinician-educator trainees. This provides more time for clinician-educator faculty to teach geriatrics and serve as mentors to medical students and residents.
Mentees identify mentors through discussions with the Section Chief and the Fellowship Director, as well as at a transitions gathering at the beginning of the academic year. Mentors meet with mentees at least quarterly.
Staffing Requirements
There are no special staffing requirements necessary for the program. Geriatrics faculty are able to organize their interactions with the clinician-educator trainees through their identified area of interest. Faculty and staff from other areas, such as medical education, are engaged to advise on and assist with the educational programs that are being created by the geriatrics clinician-educators.
Program Costs and Funding Sources
The clinician-educator program is supported by the Hartford Center of Excellence, both through salary support for faculty within the section and through support for specific meritorious pilot grant funding awarded to faculty members. Clinician-educator trainees (junior faculty and fellows) are mentored by senior faculty who are at the Associate Professor and Professor levels. The Department of Medicine supports faculty time through a faculty funding agreement recognizing their efforts.
Further support for clinician-educator fellows and junior faculty came from the Reynolds Foundation Aging and Quality of Life Program Award, which supports the University’s Care of the Hospitalized Aging Medical Patient (CHAMP) education program. This award was granted in recognition of both the strategic alliances with faculty and staff across the Department of Medicine and the identified areas of expertise and targeted career development for clinician-educators. Five clinician-educator junior faculty have secured Geriatric Academic Career Awards (GACAs) as well.
Process and Outcomes Data
The program is designed to assist fellows and junior faculty in meeting the criteria for promotion as clinician-educators. Currently, three out of three junior faculty participants have been successfully promoted to the Associate Professor level (one at the University of Chicago, and two at other academic medical institutions). One is now Chief of General Medicine and Geriatrics at another university. Nine former fellows have been promoted to the Assistant Professor level.
Through the innovative teaching approach to training clinician-educators, new, formal teaching efforts in geriatrics now exist in multiple specialty areas, such as geriatric-oncology, palliative care, and urology. Medical students and residents also benefit from teaching efforts and many receive regular mentoring from geriatrics faculty on educational research projects.
Each participant is expected to write up their experiences for presentation at national meetings and for publication.
Implementation Lessons
- Engaging institutional stakeholders within the medical school early on helped to quickly: 1) identify faculty members as local experts who could serve as mentors for the clinician-educator fellows and junior faculty, and 2) identify and met the geriatrics educational needs of the medical school and residency programs. These stakeholders included the Dean for Medical Education, Associate Dean for Medical School Education (former Vice-Chair of the Department of Medicine), Assistant Dean for Curricular Innovation, and the Clinical Skills Course Director.
- The involvement of the above stakeholders also enabled geriatrics fellows and junior faculty interested in medical education to focus on career development in that area. For example, one faculty member received national recognition for the development of clinical training through his Observed Structured Teaching Exercise (OSTE) program.
Available Materials
Website
- Curriculum for Hospitalized Aging Medical Patient (CHAMP) http://www.champ.bsd.uchicago.edu.
For More Information
William Dale, MD, PhD
Interim Chief of Geriatrics
University of Chicago
Department of Medicine, MC 6098
5841 South Maryland Avenue
Chicago, IL 60637
(773) 834-0508
wdale@medicine.bsd.uchicago.edu
or
Stacie Levine, MD
Fellowship Director
University of Chicago
Department of Medicine, MC 6098
5841 South Maryland Ave
Chicago, IL 60637
(773) 834-8130
slevine@medicine.bsd.uchicago.edu
Manual Three: Managing Programmatic Growth and Development in Academic Geriatrics
Chapter I: Expanding Academic Geriatrics Programs
1. Internal Marketing to Institutional Stakeholders
2. Building Clinical Revenue
3. Fundraising Strategies
4. Using Consultants
5. Big Picture Perspectives on Expanding Geriatrics Programs
Chapter II: Managing Training and Research Activities
1. Build an Administrative Infrastructure
2. Centralize Grants Management: A Closer Look
3. Pool Resources to Fund Fellows and Junior Faculty
4. Develop a Strong Mentoring Program
5. Expand Opportunities through Interdisciplinary Research
6. Build Collaborative Programs
Chapter III: Training Subspecialty Physicians in Geriatrics
1. Joint Fellowships and Junior Faculty Support
2. Mini-fellowships in Geriatrics
3. Training Hospitalists in the Care of Older Adults
Chapter IV: Selected Profiles of CoE Directors and the Programs They Lead
1. Boston University Medical Center
2. Emory University/University of Alabama at Birmingham
3. Indiana University
Academic Faculty Scholars Program in Geriatrics for Non-geriatricians
at Boston University Medical Center
| SUMMARY |
| Target Audience Non-geriatrician academic physicians selected for their potential to become effective teachers of geriatric medicine Purpose Program History Operating Costs Outcomes Available Materials For More Information |
Program Overview
Boston University Medical Center has developed a unique faculty scholarship program to address the shortage of geriatrics-oriented health care providers and faculty, and to train academic faculty from various disciplines to teach geriatrics.
The program recruits clinician-educators from subspecialties, such as general internal medicine, family medicine, medicine subspecialties, surgical subspecialties, emergency medicine, and physical medicine and rehabilitation.
The goals of the program are to:
- attract outstanding physicians who are not geriatricians to careers as geriatrics-oriented faculty
- provide clinician-educators with the clinical and scholarship skills necessary to become effective leaders, providers, and teachers of geriatric medicine
- help faculty acquire the credentials needed for promotion and retention.
Program Operations
Four to six faculty scholars are accepted into the program each year. Recruitment methods include electronic distribution about the program to department chairs and section chiefs, personal contact and meetings by CoE directors, and alumni recruitment. Targeted faculty are those who have the necessary clinical and scholarship skills to become effective teachers of geriatric medicine.
The year-long program is divided into two parts:
For nine months, participants spend one half day a week in structured educational experiences. Scholarly skills for clinician- educators are taught in four modules designed specifically for the training of future faculty in geriatrics-related activities. These include Geriatrics Content, Clinical Teaching, Evidence-Based Medicine, and Health Care Systems. Scholars are also assigned a geriatrics advisor to oversee and help them develop a clinical, educational, administrative, or research project during the year.
The remaining three months of the year are devoted to developing the scholarly project and to precepted clinical visits with Geriatrics Section faculty members.
Geriatric Medicine, Oncology, Psychiatry, and Dentistry fellows also participate in the four modules in conjunction with the faculty scholars. This structured experience complements the fellows’ clinical training and equips them with the fundamental skills necessary for an academic career.
Staffing Requirements
The program is supported by two administrative staff (35% total time), the director and two codirectors (30% total time), and 16 faculty members from geriatrics and other relevant disciplines.
Program Costs and Funding Sources
Each scholar receives financial support for 10% of his or her time, supported in part by the Hartford Foundation CoE grant and other sources, such as the Donald W. Reynolds Foundation, and in part by scholars’ academic/clinical units.
Process and Outcomes Data
Through 2008, 54 faculty members have completed the program. Each module session is evaluated and, in addition, faculty scholars complete pre- and post-program evaluations of their knowledge and skills in each topic. The evaluative results from the first nine years of the program indicate that the program is effective in improving scholars’ clinical and teaching skills in relation to older adults. Scholars also have assumed new clinical, research, and leadership roles in geriatrics.
Implementation Lessons
- Sustained funding is required to provide such a training program.
- A critical mass of graduates and a track record helps to build momentum and create a continued source of trainees.
- A diverse group of faculty scholars by discipline coupled with fellow participation makes a rich learning environment.
- Although the components of the program sound quite disparate, together they create a composite curriculum that all trainees value.
- A robust evaluation strategy facilitates continued improvement.
Available Materials
Tools/Resources
Publications
- Faculty development in geriatrics for clinician-educators: A unique model for skills acquisition and academic achievement
Levine, SA, Caruso, LB, Vanderschmidt, H, Silliman, RA, Barry, PP
Journal of the American Geriatrics Society
2005;53(3):516-21
For More Information
Rebecca A. Silliman, MD, PhD
Chief, Geriatrics Section
Boston University Medical Center
88 E. Newton Street, Robinson 2
Boston, MA 02118
(617) 638-8383
rsillima@bu.edu
Manual Two: Approaches to Recruitment to Advanced Fellowship Training and Faculty Positions in Academic Geriatrics
An Introduction to Academic Geriatrics Recruitment and Career Development
Pre-Fellowship Decision Recruitment Strategies - Expose Residents to Geriatrics Fellowship and Career Opportunities
- Geriatrics Is Your Future: A Regional Resident Recruitment Program at Baylor College of Medicine
- Annual Resident Award Summit at the Southeast Center of Excellence in Geriatric Medicine (Emory University and the University of Alabama at Birmingham Schools of Medicine)
- Using Resident Applications to Identify and Engage Geriatrics Trainees at the University of Texas Health Science Center at San Antonio
Support Resident Research and Scholarly Projects in Geriatrics
- Scholarly Projects for First-Year Internal Medicine Residents at the University of Rochester School of Medicine
- Establishing an American Geriatrics Society Resident Chapter
Post-Fellowship Decision Recruitment Strategies - Provide Faculty and Peer Mentoring on Academic Careers
- Collaborative Grant Review and Mentoring for Clinician-Researcher and Clinician-Educator Trainees at Emory University/University of Alabama at Birmingham (Southeast Center of Excellence in Geriatric Medicine)
- Junior Faculty Mentoring in Aging Research at the Indiana University School of Medicine Center for Aging Research
- Aging-Related Research Career Development Core for Junior Investigators at the University of Michigan
Implement Programs that Promote Academic Career Preparedness
- One-day Career Development Retreat for First-year Medicine Subspecialty Fellows at the University of California, San Francisco School of Medicine
- Fellows’ One-Year Academic Career Development Course at the University of Rochester Medical Center
Approaches to Advancing Clinician-Educator Careers
- Academic Faculty Scholars Program in Geriatrics for Non-Geriatricians at Boston University
- Geriatrics Excellence in Teaching Series for Faculty and Fellows at Duke University School of Medicine
- Faculty Enrichment and Educational Development Program at the Indiana University School of Medicine
- Year-long Master Clinician-Educator Program in Geriatrics at Mount Sinai School of Medicine
- Area of Concentration for Clinician-Educators at the University of Chicago
- Knowledge and Skills in Cultural Competence and Minority Health Issues at the University of Pennsylvania
Approaches to Advancing Research Careers
- One-Year Course in Research Methods and Design for Geriatrics Fellows and Junior Faculty at Weill Medical College of Cornell University
- Grant Writing Seminar for Geriatrics Fellows and
Junior Faculty at Weill Medical College of Cornell University
- Advanced Aging Research Training Seminar Series at Harvard Medical School
- Clinical Investigator Training Enhancement Program at the Indiana University School of Medicine
- Scholarly Activities Clinic for Clinician-Educator Junior Faculty in Geriatrics at the Indiana University School of Medicine
- Interdisciplinary Academic Advancement Seminar for Junior Faculty Interested in Aging Research at the David Geffen School of Medicine at the University of California, Los Angeles
- Portfolio Structure for Fellows and Junior Faculty in the Academic Geriatrics Research Track at the University of Pittsburgh School of Medicine
