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doi:10.1111/jpc.12775
VIEWPOINT
Dedicated paediatric teaching remains critical to the undergraduate medical curriculum Ralph Pinnock,1* Paul Monagle,2 Jennifer Couper,3 Ian Wright,4 Innes Asher,5 Peter Jones,6 Peter van Asperen,7 Joerg Mattes8 on behalf of the Paediatric Professorial Heads Committee of Australia and New Zealand† 1
Child and Adolescent Health, James Cook University, Townsville, 6Bond University, Gold Coast, Queensland, 2Paediatrics, University of Melbourne, Melbourne, Victoria, 3Paediatrics, University of Adelaide, Adelaide, South Australia, 4Paediatrics and Child Health, University of Wollongong, Wollongong, 7Paediatrics and Child Health, University of Newcastle, Newcastle, and 8Paediatrics, University of Sydney, Sydney, New South Wales, Australia and 5Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
Paediatrics, the branch of medicine responsible for the health and medical care of infants, children and adolescents from birth to young adulthood, is a relatively recent speciality with its origins in the mid-19th century.1 Unlike many other areas of practice, the population it serves is unable to advocate for itself. This often results in paediatrics being overlooked in planning services and education. One should note that a long protected childhood is unique to our species and essential for human mental and physical health.2 Dedicated paediatric teaching in the undergraduate/ postgraduate medical curriculum is essential, irrespective of the intended area of practice for the doctors in training. The reasons for this are as follows.
Correspondence: Associate Professor Ralph Pinnock, Department of Women’s and Children’s Health, Dunedin School of Medicine, PO Box 56, Dunedin 9054, New Zealand. Fax: +64 3 4709066; email: ralph.pinnock@ otago.ac.nz *Current address: Department of Women’s and Children’s Health, Dunedin School of Medicine, Dunedin, New Zealand. † Paediatric Professorial Heads Committee of Australia and New Zealand: Prof Paul Monagle, University of Melbourne, Melbourne, Victoria; Chair. Prof Innes Asher, University of Auckland, New Zealand; Prof Sean Beggs, University of Tasmania, Australia; Assoc Prof Mark Coulthard, University of Queensland, Queensland; Prof Jennifer Couper, University of Adelaide, Adelaide, Australia; Prof Anne Cunningham, University of Western Sydney, Sydney, New South Wales; Prof Andrew Day, University of Otago, Christchurch, New Zealand; Prof Dawn Elder, University of Otago, Wellington, New Zealand; Prof Syed Fasihullah, Griffith University, Brisbane, Australia; Prof Kevin Forsyth, Flinders University, Adelaide, South Australia; Prof Nick Freezer, Monash University, Melbourne, Victoria; Prof Adam Jaffe, University of New South Wales, Sydney, Australia; Prof Peter Jones, Bond University, Gold Coast, Australia; Prof Peter Le Souef, University of Western Australia; Prof Jeorg Mattes, Newcastle University Australia; Prof Fleming Nielsen, University of Notre Dame, Australia; Assoc Prof Ralph Pinnock, James Cook University, Townsville, Australia; Prof Graham Reynolds, Australian National University, Canberra, Australian Capital Territory; Prof Barry Taylor, University of Otago, Dunedin, New Zealand; Prof Peter van Asperen, University of Sydney, Sydney, Australia; Prof John Whitehall, University of Western Sydney, Sydney, New South Wales; Prof Ian Wright, University of Wollongong, Australia. Conflict of interest: We declare no conflicts of interest. Accepted for publication 8 June 2014.
Normal and Abnormal Growth and Development and Holistic Care Knowledge of normal growth and development in children including the limits of normal variation is essential in recognising abnormalities in growth and development that require further investigation and management. Because this growth and development occur within a family construct, paediatric medicine is the most obvious example for students when considering the holistic environment in which medical care is trying to be delivered.
The Spectrum of Disease Paediatrics includes a wide spectrum of diseases and developmental disorders, many of which are unique to childhood. It differs from other specialities in that the manifestations of the same disease will differ at different ages. The clinical skills required to assess a newborn, a 6-month-old infant, a 6-yearold child and a sixteen-year-old adolescent differ considerably. The spectrum of disease has changed from a focus on infections and under-nutrition to include disorders in development, behaviour and over-nutrition. Paediatrics, more than any other speciality, provides students with the opportunity to apply their knowledge of advances in genetics, metabolism, systems biology and immunology. Paediatrics also provides the most training and exposure to disability and its impact on the family. These important lessons are relevant to medicine throughout the patient’s life.
The Origins of Adult Diseases Preventative care, in the form of vaccination policy and practice, has dramatically modified the health of the world, and infancy and childhood are the ideal window for intervention. However, commencing prevention during childhood is relevant for more than just infectious disease. Many serious physical and mental disorders of adulthood have modifiable precursors in childhood.3,4 Studies to identify the risk and the protective processes of chronic diseases of adulthood will come from life course epidemiology which examines how biological programming in utero and later lifestyle factors interact to produce the
Journal of Paediatrics and Child Health 50 (2014) 949–951 © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians).
949
Dedicated paediatric teaching
R Pinnock et al.
non-communicable disease epidemics of adulthood particularly diabetes, hypertension and cardiovascular disease.5 Indeed, the first signs of the metabolic syndrome and vascular disease, and their risk factors, can be detected and treated in childhood. Any effective intervention on life-long smoking, diet and exercise habits must start in childhood, as is also the case for sun exposure and other cancer risk factors. Further, survivors of childhood cancer, cardiac disease and other major illnesses are now constituting new and large populations entering the adult health care system. More recently, the study of fetal programming has provided evidence that the major chronic diseases of adulthood have their origins in a compromised intrauterine environment.6 There is a large body of evidence suggesting that good health in pregnancy and the first 3 years of life are critical for later health during adult life.
Life Cycle Concept Identifying risk and resilience factors must start in childhood. There is substantial evidence that a good start in the early preschool years promotes resilience and mental health in later childhood and adolescence.7 The current increase in mental health problems across all age groups will best be modified by interventions in early life. Similarly, when prescribing therapeutics, considering side-effects of treatments that have a lifetime in which to manifest themselves is peculiar to paediatrics. This again highlights the importance of understanding health in the context of the whole life cycle.5
Disproportionate Impact of Social Disadvantage In no other area of practice are the social determinants of health as apparent as in paediatrics. The improvement in childhood mortality and morbidity rates over time, the increased rates in the socially and economically disadvantaged within a country, and the differences in rates between developed and developing countries all attest to the critical influence of social and economic factors on child health. Children, and especially young children, are more likely to live in poverty than any other age group.8
Critical Thinking and Process Skills Paediatrics requires some unique physical and cognitive clinical skills. Many students learn their history-taking and examination skills in a particular pattern, with a defined start and end point to their system. The ability to take a history from a parent, older children and at times from teachers and others; the skill of communicating with individuals at different stages of cognitive and emotional development from newborns to adolescents; the necessity to perform physical examinations in non-co-operative or just constantly moving toddlers; understanding of the fears common at different ages; and the awareness of the different risks and apprehension of investigations at different ages forces students to have a complexity of thinking that can only enhance their diagnostic and reasoning skills, whatever field of medicine they intend to eventually practice within. 950
In summary, in addition to providing access to the knowledge and skills to manage sick children, a paediatric rotation also provides students with opportunities to understand • What is normal and what is abnormal growth and development • The origins of and the potential to prevent chronic and debilitating adult diseases • The importance of the life cycle in health and disease • The relevance of the explosion of knowledge in the basic sciences • How the family is integral to patient management • The social determinants of disease in both a local and global context • The rationale behind the systems of history taking and examination, and how to critically determine the salient features in each case. To realise these advantages, the paediatric curriculum must be designed with these outcomes in mind. Hence, the educational concepts for paediatrics and child health outlined 14 years ago in a statement from this group remain relevant.9 The curriculum should include emphasis on: • Normal growth, development and behaviour • Disease recognition and management • The child in the family and society • Population health and health policy • Childhood origins of adult disease • Indigenous child health Many curricula merely pay lip service to this final important aspect of child health that should be taught following collaboration with indigenous colleagues. Formal assessment is required.9 We envisage a dedicated paediatric curriculum as providing the opportunity for the doctor of the future to learn much more than the diseases of childhood. However, there are currently many challenges to paediatric teaching within medical curricula. Some of these are unique to paediatrics, while other issues are generic to all aspects of medical teaching. For example, 1 Competition for resources from new priorities: The chronic and complex health needs of an increasing and often influential aging population and the expansion of rural programmes may not always cater for the needs of children. 2 Shorter postgraduate entry programmes: These intensify the competition between paediatric and other specialities for resources and scheduled time within the undergraduate programme. 3 Increased student numbers: These put pressure on the duration and the quality of paediatric clinical placements. 4 Changes in the delivery of paediatric services: The increasing provision of paediatric services by emergency departments, short-stay facilities and after-hours primary care providers using different models of care may challenge the provision of an appropriate paediatric learning environment. Children now make up less than 10% of GP workload in Australia, despite there being more children in Australia than ever before, and there are genuine concerns about the ability to maintain clinical and teaching expertise within this forum.10 Children with chronic illness are seen even less in the community.11 The ability to maintain teaching standards outside
Journal of Paediatrics and Child Health 50 (2014) 949–951 © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
R Pinnock et al.
of specialist paediatricians is increasingly problematic. Conversely, the increasing subspecialisation in children’s hospitals can result in limiting exposure to the more common childhood conditions and more difficulty in focussing on the key curricula agenda described. 5 Pressures to increase health service efficiency: The drive for efficiency and cost containment in the health service further compromises both the quantity and the quality of teaching in clinical environments that are primarily designed for service. 6 The informatics and technology revolution: The management of rapidly increasing access to educational, health and research information specifically relevant to children and their families necessitates the provision of appropriate resources for simulated patient encounters which allow practice in a safe environment.
Conclusion In conclusion, the exposure of medical students to infants, children and adolescents, and the development of an understanding of key concepts best taught through these patient populations, are critical to the students’ ability to develop a skill set useful in any future field of medicine. The teaching of paediatrics thus must be a core element of all medical curricula, with relevance far beyond the treatment of sick children
Dedicated paediatric teaching
References 1 Pearn J. Paediatrics: the etymology of a name. Arch. Dis. Child. 2011; 96: 759–63. 2 Remmel E. The benefits of a long childhood. Book review: why youth is not wasted on the young: immaturity in human development, Bjorklund David F., Blackwell Publishing, 2007. Am. Sci. 2008; 96: 250. 3 Forrest CB, Riley AW. Childhood origins of adult health: a basis for life course policy. Health Affair. 2004; 23: 155–64. 4 Foege WH. Adverse childhood experiences: a public health perspective. Am. J. Prev. Med. 1998; 14: 354–5. 5 Kuh D, Ben-Shlomo Y, Lynch J, Hallqvist J, Power C. Life course epidemiology. J. Epidemiol. Community Health 2003; 57: 778–83. 6 Barker DJP. In utero programming of chronic disease. Clin. Sci. 1998; 95: 115–28. 7 Saxena S, Jane-Llopis E, Hosman C. Prevention of mental health and behavioural disorders. World Psychiatry 2006; 5: 5–14. 8 Aber JL, Bennett NG. The effects of poverty on child health and development. Annu. Rev. Public Health 1997; 18: 463–83. 9 Forsyth K, Rotem A. Meeting the needs of medical students training in paediatrics and child health. J. Paediatr. Child Health 1999; 35: 11–13. 10 Freed GL, Sewell J, Spike N, Moran L, Brooks P. Changes in the demography of Australia and therefore general practice patient populations. Aust. Fam. Physician 2012; 41: 715–19. 11 Freed GL, Spike NA, Sewell JR et al. Changes in longer consultations for children in general practice. J. Paediatr. Child Health 2013; 49: 325–9.
Journal of Paediatrics and Child Health 50 (2014) 949–951 © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
951
Copyright of Journal of Paediatrics & Child Health is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
doi:10.1111/jpc.12775
VIEWPOINT
Dedicated paediatric teaching remains critical to the undergraduate medical curriculum Ralph Pinnock,1* Paul Monagle,2 Jennifer Couper,3 Ian Wright,4 Innes Asher,5 Peter Jones,6 Peter van Asperen,7 Joerg Mattes8 on behalf of the Paediatric Professorial Heads Committee of Australia and New Zealand† 1
Child and Adolescent Health, James Cook University, Townsville, 6Bond University, Gold Coast, Queensland, 2Paediatrics, University of Melbourne, Melbourne, Victoria, 3Paediatrics, University of Adelaide, Adelaide, South Australia, 4Paediatrics and Child Health, University of Wollongong, Wollongong, 7Paediatrics and Child Health, University of Newcastle, Newcastle, and 8Paediatrics, University of Sydney, Sydney, New South Wales, Australia and 5Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
Paediatrics, the branch of medicine responsible for the health and medical care of infants, children and adolescents from birth to young adulthood, is a relatively recent speciality with its origins in the mid-19th century.1 Unlike many other areas of practice, the population it serves is unable to advocate for itself. This often results in paediatrics being overlooked in planning services and education. One should note that a long protected childhood is unique to our species and essential for human mental and physical health.2 Dedicated paediatric teaching in the undergraduate/ postgraduate medical curriculum is essential, irrespective of the intended area of practice for the doctors in training. The reasons for this are as follows.
Correspondence: Associate Professor Ralph Pinnock, Department of Women’s and Children’s Health, Dunedin School of Medicine, PO Box 56, Dunedin 9054, New Zealand. Fax: +64 3 4709066; email: ralph.pinnock@ otago.ac.nz *Current address: Department of Women’s and Children’s Health, Dunedin School of Medicine, Dunedin, New Zealand. † Paediatric Professorial Heads Committee of Australia and New Zealand: Prof Paul Monagle, University of Melbourne, Melbourne, Victoria; Chair. Prof Innes Asher, University of Auckland, New Zealand; Prof Sean Beggs, University of Tasmania, Australia; Assoc Prof Mark Coulthard, University of Queensland, Queensland; Prof Jennifer Couper, University of Adelaide, Adelaide, Australia; Prof Anne Cunningham, University of Western Sydney, Sydney, New South Wales; Prof Andrew Day, University of Otago, Christchurch, New Zealand; Prof Dawn Elder, University of Otago, Wellington, New Zealand; Prof Syed Fasihullah, Griffith University, Brisbane, Australia; Prof Kevin Forsyth, Flinders University, Adelaide, South Australia; Prof Nick Freezer, Monash University, Melbourne, Victoria; Prof Adam Jaffe, University of New South Wales, Sydney, Australia; Prof Peter Jones, Bond University, Gold Coast, Australia; Prof Peter Le Souef, University of Western Australia; Prof Jeorg Mattes, Newcastle University Australia; Prof Fleming Nielsen, University of Notre Dame, Australia; Assoc Prof Ralph Pinnock, James Cook University, Townsville, Australia; Prof Graham Reynolds, Australian National University, Canberra, Australian Capital Territory; Prof Barry Taylor, University of Otago, Dunedin, New Zealand; Prof Peter van Asperen, University of Sydney, Sydney, Australia; Prof John Whitehall, University of Western Sydney, Sydney, New South Wales; Prof Ian Wright, University of Wollongong, Australia. Conflict of interest: We declare no conflicts of interest. Accepted for publication 8 June 2014.
Normal and Abnormal Growth and Development and Holistic Care Knowledge of normal growth and development in children including the limits of normal variation is essential in recognising abnormalities in growth and development that require further investigation and management. Because this growth and development occur within a family construct, paediatric medicine is the most obvious example for students when considering the holistic environment in which medical care is trying to be delivered.
The Spectrum of Disease Paediatrics includes a wide spectrum of diseases and developmental disorders, many of which are unique to childhood. It differs from other specialities in that the manifestations of the same disease will differ at different ages. The clinical skills required to assess a newborn, a 6-month-old infant, a 6-yearold child and a sixteen-year-old adolescent differ considerably. The spectrum of disease has changed from a focus on infections and under-nutrition to include disorders in development, behaviour and over-nutrition. Paediatrics, more than any other speciality, provides students with the opportunity to apply their knowledge of advances in genetics, metabolism, systems biology and immunology. Paediatrics also provides the most training and exposure to disability and its impact on the family. These important lessons are relevant to medicine throughout the patient’s life.
The Origins of Adult Diseases Preventative care, in the form of vaccination policy and practice, has dramatically modified the health of the world, and infancy and childhood are the ideal window for intervention. However, commencing prevention during childhood is relevant for more than just infectious disease. Many serious physical and mental disorders of adulthood have modifiable precursors in childhood.3,4 Studies to identify the risk and the protective processes of chronic diseases of adulthood will come from life course epidemiology which examines how biological programming in utero and later lifestyle factors interact to produce the
Journal of Paediatrics and Child Health 50 (2014) 949–951 © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians).
949
Dedicated paediatric teaching
R Pinnock et al.
non-communicable disease epidemics of adulthood particularly diabetes, hypertension and cardiovascular disease.5 Indeed, the first signs of the metabolic syndrome and vascular disease, and their risk factors, can be detected and treated in childhood. Any effective intervention on life-long smoking, diet and exercise habits must start in childhood, as is also the case for sun exposure and other cancer risk factors. Further, survivors of childhood cancer, cardiac disease and other major illnesses are now constituting new and large populations entering the adult health care system. More recently, the study of fetal programming has provided evidence that the major chronic diseases of adulthood have their origins in a compromised intrauterine environment.6 There is a large body of evidence suggesting that good health in pregnancy and the first 3 years of life are critical for later health during adult life.
Life Cycle Concept Identifying risk and resilience factors must start in childhood. There is substantial evidence that a good start in the early preschool years promotes resilience and mental health in later childhood and adolescence.7 The current increase in mental health problems across all age groups will best be modified by interventions in early life. Similarly, when prescribing therapeutics, considering side-effects of treatments that have a lifetime in which to manifest themselves is peculiar to paediatrics. This again highlights the importance of understanding health in the context of the whole life cycle.5
Disproportionate Impact of Social Disadvantage In no other area of practice are the social determinants of health as apparent as in paediatrics. The improvement in childhood mortality and morbidity rates over time, the increased rates in the socially and economically disadvantaged within a country, and the differences in rates between developed and developing countries all attest to the critical influence of social and economic factors on child health. Children, and especially young children, are more likely to live in poverty than any other age group.8
Critical Thinking and Process Skills Paediatrics requires some unique physical and cognitive clinical skills. Many students learn their history-taking and examination skills in a particular pattern, with a defined start and end point to their system. The ability to take a history from a parent, older children and at times from teachers and others; the skill of communicating with individuals at different stages of cognitive and emotional development from newborns to adolescents; the necessity to perform physical examinations in non-co-operative or just constantly moving toddlers; understanding of the fears common at different ages; and the awareness of the different risks and apprehension of investigations at different ages forces students to have a complexity of thinking that can only enhance their diagnostic and reasoning skills, whatever field of medicine they intend to eventually practice within. 950
In summary, in addition to providing access to the knowledge and skills to manage sick children, a paediatric rotation also provides students with opportunities to understand • What is normal and what is abnormal growth and development • The origins of and the potential to prevent chronic and debilitating adult diseases • The importance of the life cycle in health and disease • The relevance of the explosion of knowledge in the basic sciences • How the family is integral to patient management • The social determinants of disease in both a local and global context • The rationale behind the systems of history taking and examination, and how to critically determine the salient features in each case. To realise these advantages, the paediatric curriculum must be designed with these outcomes in mind. Hence, the educational concepts for paediatrics and child health outlined 14 years ago in a statement from this group remain relevant.9 The curriculum should include emphasis on: • Normal growth, development and behaviour • Disease recognition and management • The child in the family and society • Population health and health policy • Childhood origins of adult disease • Indigenous child health Many curricula merely pay lip service to this final important aspect of child health that should be taught following collaboration with indigenous colleagues. Formal assessment is required.9 We envisage a dedicated paediatric curriculum as providing the opportunity for the doctor of the future to learn much more than the diseases of childhood. However, there are currently many challenges to paediatric teaching within medical curricula. Some of these are unique to paediatrics, while other issues are generic to all aspects of medical teaching. For example, 1 Competition for resources from new priorities: The chronic and complex health needs of an increasing and often influential aging population and the expansion of rural programmes may not always cater for the needs of children. 2 Shorter postgraduate entry programmes: These intensify the competition between paediatric and other specialities for resources and scheduled time within the undergraduate programme. 3 Increased student numbers: These put pressure on the duration and the quality of paediatric clinical placements. 4 Changes in the delivery of paediatric services: The increasing provision of paediatric services by emergency departments, short-stay facilities and after-hours primary care providers using different models of care may challenge the provision of an appropriate paediatric learning environment. Children now make up less than 10% of GP workload in Australia, despite there being more children in Australia than ever before, and there are genuine concerns about the ability to maintain clinical and teaching expertise within this forum.10 Children with chronic illness are seen even less in the community.11 The ability to maintain teaching standards outside
Journal of Paediatrics and Child Health 50 (2014) 949–951 © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
R Pinnock et al.
of specialist paediatricians is increasingly problematic. Conversely, the increasing subspecialisation in children’s hospitals can result in limiting exposure to the more common childhood conditions and more difficulty in focussing on the key curricula agenda described. 5 Pressures to increase health service efficiency: The drive for efficiency and cost containment in the health service further compromises both the quantity and the quality of teaching in clinical environments that are primarily designed for service. 6 The informatics and technology revolution: The management of rapidly increasing access to educational, health and research information specifically relevant to children and their families necessitates the provision of appropriate resources for simulated patient encounters which allow practice in a safe environment.
Conclusion In conclusion, the exposure of medical students to infants, children and adolescents, and the development of an understanding of key concepts best taught through these patient populations, are critical to the students’ ability to develop a skill set useful in any future field of medicine. The teaching of paediatrics thus must be a core element of all medical curricula, with relevance far beyond the treatment of sick children
Dedicated paediatric teaching
References 1 Pearn J. Paediatrics: the etymology of a name. Arch. Dis. Child. 2011; 96: 759–63. 2 Remmel E. The benefits of a long childhood. Book review: why youth is not wasted on the young: immaturity in human development, Bjorklund David F., Blackwell Publishing, 2007. Am. Sci. 2008; 96: 250. 3 Forrest CB, Riley AW. Childhood origins of adult health: a basis for life course policy. Health Affair. 2004; 23: 155–64. 4 Foege WH. Adverse childhood experiences: a public health perspective. Am. J. Prev. Med. 1998; 14: 354–5. 5 Kuh D, Ben-Shlomo Y, Lynch J, Hallqvist J, Power C. Life course epidemiology. J. Epidemiol. Community Health 2003; 57: 778–83. 6 Barker DJP. In utero programming of chronic disease. Clin. Sci. 1998; 95: 115–28. 7 Saxena S, Jane-Llopis E, Hosman C. Prevention of mental health and behavioural disorders. World Psychiatry 2006; 5: 5–14. 8 Aber JL, Bennett NG. The effects of poverty on child health and development. Annu. Rev. Public Health 1997; 18: 463–83. 9 Forsyth K, Rotem A. Meeting the needs of medical students training in paediatrics and child health. J. Paediatr. Child Health 1999; 35: 11–13. 10 Freed GL, Sewell J, Spike N, Moran L, Brooks P. Changes in the demography of Australia and therefore general practice patient populations. Aust. Fam. Physician 2012; 41: 715–19. 11 Freed GL, Spike NA, Sewell JR et al. Changes in longer consultations for children in general practice. J. Paediatr. Child Health 2013; 49: 325–9.
Journal of Paediatrics and Child Health 50 (2014) 949–951 © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
951
Copyright of Journal of Paediatrics & Child Health is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
