The Oslerian Tradition and Changing Medical Education: A Reappraisal

Although only 21 of Sir William Osler''s 45 years in academic medicine were spent in US medical schools (1884 to 1905), he played a major role in shaping modern medical education in this country. The integration of scholarship with patient care, together with the science and art of medicine, was central to Osler''s teaching and writing throughout his career. A classic generalist and a charismatic clinical teacher, he taught by example and was as concerned with the ideals of medicine as with its science and knowledge.Many changes have reshaped the content, process and concerns of American medical education since Osler''s time. Subspecialization and balkanization of medical education and practice have become dominant. Many of the important issues in medicine today do not fit neatly into the domain of any of the established specialties or medical organizations. There is now an urgent need to promote generalist attitudes in medicine, and the Oslerian tradition has much to offer in approaching today''s problems in medical education and practice.     

Bone Marrow-Derived Stem Cell (BMDSC) Transplantation Improves Fertility in a Murine Model of Asherman's Syndrome

Asherman''s Syndrome is characterized by intrauterine adhesions or fibrosis resulting as a consequence of damage to the basal layer of endometrium and is associated with infertility due to loss of normal endometrium. We have previously shown that bone marrow derived stem cells (BMDSCs) engraft the endometrium in mice and humans and Ischemia/reperfusion injury of uterus promoted BMDSCs migration to the endometrium; however, the role of BMDSCs in Asherman''s syndrome has not been characterized. Here a murine model of Asherman''s syndrome was created by traumatizing the uterus. We evaluate stem cell recruitment and pregnancy after BMDSCs transplantation in a model of Asherman''s syndrome. In the Asheman''s syndrome model, after BMDSC transplant, the Y chromosome bearing CD45-cells represented less than 0.1% of total endometrial cells. Twice the number of Y+CD45- cells was identified in the damaged uterus compared to the uninjured controls. There was no significant difference between the damaged and undamaged uterine horns in mice that received injury to a single horn. In the BMDSC transplant group, 9 of the 10 mice conceived, while only 3 of 10 in the non-transplanted group conceived (Chi-Square p = 0.0225); all mice in an uninjured control group conceived. The time to conception and mean litter size were not different between groups. Taken together, BMDSCs are recruited to endometrium in response to injury. Fertility improves after BMDSC transplant in Asherman''s Syndrome mice, demonstrating a functional role for these cells in uterine repair. BMDSC transplantation is a potential novel treatment for Asherman''s Syndrome and may also be useful to prevent Asherman''s syndrome after uterine injury.     

Value of Routine Multiple Blood Tests in Patients Attending the General Practitioner

The paper describes the investigation of 296 patients selected at random from those attending the general practitioners'' surgery and studied by means of multiple biochemical and haematological tests. The tests that would not normally have been requested led to a new diagnosis of clinical significance in 16·9% of patients, in most instances requiring an alteration of the patient''s therapy. The effect of the profile tests on patient follow-up, referral of patients to hospital, and the need for subsequent investigations was studied by comparing the patients profiled with a control group of patients not having a blood profile. The place of such an investigation in general practice is considered.     

Grampian Health Board's joint drug formulary.

OBJECTIVE--To develop a model for creating a joint general practice-hospital formulary, using the example of ulcer healing drugs. DESIGN--A joint formulary development group produced draft guidelines based on an earlier hospital formulary, which were sent to interested local general practitioners for consultation. Revised guidelines were then drawn up and forwarded to the health board''s medicines committee for approval and distribution. SETTING--Grampian Health Board. SUBJECTS--Nine members of joint formulary development group plus local general practitioners who were invited to comment on a list of 11 ulcer healing drugs. MAIN OUTCOME MEASURE--Degree of coincidence of drugs selected by hospital doctors and general practitioners. RESULTS--The ulcer healing drugs selected by the panel of general practitioners and by hospital doctors were highly coincident. The cost of one day''s treatment with drugs varied considerably between hospital and general practice--for example, one drug cost 46p in hospital and 1 pounds in general practice and another cost 1.26 pounds in hospital and 1.01 pounds in general practice. Overall, six drugs cost more in hospital and five cost more in general practice. CONCLUSIONS--A joint formulary for use in hospitals and general practice in a health board can be devised fairly simply by consultation as virtually the same drugs are used in both types of practice. It should influence the health board''s expenditure on drugs and affect the choice of drugs when a patient is discharged from hospital or is referred to any hospital in the region.     

The role of computers in preventive medicine in a rural family practice.

Five family physicians in a group practice in rural Quebec have introduced a computer system to improve the delivery of preventive medicine. In addition to billing, the computer is used mainly to recall specific groups of patients for preventive measures, to prompt the physicians to carry out certain procedures at the patient''s next visit, to indicate which procedures are required for the family members and to generate reminder letters. The physicians are conducting a randomized controlled trial to evaluate the impact of computer-generated reminder letters on patient compliance and disease prevention among families in their practice.     

Sick Absence Certification. Analysis of one Group Practice in 1967

Certificates of inability or fitness to work were issued on 6,161 occasions in one year in one group practice. Half the episodes of illness lasted for seven days or less, and two thirds of the episodes ended on a Sunday. Clearly in most cases the doctor does no more than countersign the patient''s declaration of his fitness or not to work. Abolition of short-term medical certification would probably have little effect on absenteeism or the sums paid out as sick benefit.     

肝毛细线虫对雌性布氏田鼠繁殖参数的影响

2005年5月,在内蒙古锡林郭勒盟阿巴嘎旗北部,研究了肝毛细线虫(Capillaria hepatica)对典型草原区雌性布氏田鼠(Lasiopodomys brandtii)繁殖参数的影响。采用标准夹线法捕获鼠类,对捕获的鼠类进行常规生物学解剖,根据虫卵有无确定肝毛细线虫病感染情况,记录鼠类名称、体长、体重、胴体重、繁殖特征以及肝毛细线虫病感染情况。由于体重是划分鼠类年龄的常用指标之一,结合布氏田鼠的繁殖特征研究数据,采用25.1~55.0 g之间的雌性个体作为本研究分析样本,并将其分为25.1~35.0 g、35.1~45.0 g和45.1~55.0 g体重(年龄)组。采用卡方检验比较分析同一体重(年龄)组内,肝毛细线虫病感染情况与雌性布氏田鼠妊娠率的关系,T检验分析感染情况与胎仔数的关系。结果显示,在各个体重(年龄)组中,感染肝毛细线虫组布氏田鼠雌鼠妊娠率均略低于未感染组,但感染情况与妊娠情况无显著相关关系(P0.05);感染肝毛细线虫布氏田鼠胎仔数低于未感染布氏田鼠,感染情况与胎仔数有显著相关关系(P0.05)。结果表明,肝毛细线虫病对布氏田鼠妊娠率无明显影响,但对布氏田鼠胎仔数有明显的负面影响。     

The teacher, the physician and the person: how faculty's teaching performance influences their role modelling

Objective

Previous studies identified different typologies of role models (as teacher/supervisor, physician and person) and explored which of faculty''s characteristics could distinguish good role models. The aim of this study was to explore how and to which extent clinical faculty''s teaching performance influences residents'' evaluations of faculty''s different role modelling statuses, especially across different specialties.

Methods

In a prospective multicenter multispecialty study of faculty''s teaching performance, we used web-based questionnaires to gather empirical data from residents. The main outcome measures were the different typologies of role modelling. The predictors were faculty''s overall teaching performance and faculty''s teaching performance on specific domains of teaching. The data were analyzed using multilevel regression equations.

Results

In total 219 (69% response rate) residents filled out 2111 questionnaires about 423 (96% response rate) faculty. Faculty''s overall teaching performance influenced all role model typologies (OR: from 8.0 to 166.2). For the specific domains of teaching, overall, all three role model typologies were strongly associated with “professional attitude towards residents” (OR: 3.28 for teacher/supervisor, 2.72 for physician and 7.20 for the person role). Further, the teacher/supervisor role was strongly associated with “feedback” and “learning climate” (OR: 3.23 and 2.70). However, the associations of the specific domains of teaching with faculty''s role modelling varied widely across specialties.

Conclusion

This study suggests that faculty can substantially enhance their role modelling by improving their teaching performance. The amount of influence that the specific domains of teaching have on role modelling differs across specialties.     

Rural background and clinical rural rotations during medical training: effect on practice location

BACKGROUND: Providing health care services in rural communities in Canada remains a challenge. What affects a family medicine resident''s decision concerning practice location? Does the resident''s background or exposure to rural practice during clinical rotations affect that decision? METHODS: Cross-sectional mail survey of 159 physicians who graduated from the Family Medicine Program at Queen''s University, Kingston, Ont., between 1977 and 1991. The outcome variables of interest were the size of community in which the graduate chose to practise on completion of training (rural [population less than 10,000] v. nonrural [population 10,000 or more]) and the size of community of practice when the survey was conducted (1993). The predictor or independent variables were age, sex, number of years in practice, exposure to rural practice during undergraduate and residency training, and size of hometown. RESULTS: Physicians who were raised in rural communities were 2.3 times more likely than those from nonrural communities to choose to practise in a rural community immediately after graduation (95% confidence interval 1.43-3.69, p = 0.001). They were also 2.5 times more likely to still be in rural practice at the time of the survey (95% confidence interval 1.53-4.01, p = 0.001). There was no association between exposure to rural practice during undergraduate or residency training and choosing to practise in a rural community. INTERPRETATION: Physicians who have roots in rural Canada are more likely to practise in rural Canada than those without such a background.     

Decreased tuftsin concentrations in patients who have undergone splenectomy.

Serum tuftsin concentrations were measured, using a radioimmunoassay developed in Israel, in normal subjects and in patients who had undergone splenectomy. Concentrations in those who had undergone traumatic and elective splenectomy were much lower. The tuftsin concentration in 38 patients with Hodgkin''s disease who had undergone splenectomy during staging laparotomy was not significantly different from the mean concentration in other patients who had had elective splenectomy. In four patients who underwent splenectomy for non-malignant haematological disorders measurements made before and after operation showed that tuftsin concentrations fell significantly in the days after operation. The increased susceptibility to overwhelming infections of patients with Hodgkin''s disease and others who have undergone splenectomy may be related to the low tuftsin concentrations. As pre-splenectomy tuftsin concentrations in patients with Hodgkin''s disease were normal, the practice of performing staging laparotomy and splenectomy in patients with Hodgkin''s disease should perhaps be reconsidered.     

In-vitro Inhibition of Leucocyte Migration in Crohn's Disease by a Sarcoid Spleen Suspension

A Kveim suspension has been shown to inhibit the migration of leucocytes in vitro from 12 out of 18 patients with Crohn''s disease but to have no comparable effect on leucocytes from patients with ulcerative colitis or from a group of patients with other diseases. These findings provide further evidence of cross-reactivity or of a possible aetiological link between Crohn''s disease and sarcoidosis and suggest a further immunological distinction between Crohn''s disease and ulcerative colitis.     

Nurse Practitioner and Physician's Assistant Clinics in Rural California: Part I: Issues

The primary health care needs of at least 26 rural California communities are being served by nurse practitioners (NP''s) or physician''s assistants (PA''s). All of these have physician supervision and support. NP''s and PA''s have proved to be acceptable and effective. With 230 rural areas in California identified as having unmet health care needs, this type of service is likely to increase and should be supported.NP/PA clinics serve total populations or concentrate on Indians, Chicanos or the poor. Many barriers have been overcome, especially over the past four years, to allow these clinics to flourish and increase in number. The availability of nurse practitioners and physician''s assistants has increased due to support to schools and to school policies. Clinic funding has greatly improved; federal funds for general rural clinics, Indians, migrants, family planning and maternalchild health have been greatly supplemented by California state funds. Beginning in 1978, rural NP and PA services can be reimbursed by Medicare and Medi-Cal (California''s Medicaid program).Since 1975 state laws have defined PA and NP roles broadly, and these roles are more precisely defined at the local level. Although nurse practitioners and physician''s assistants generally cannot prescribe or dispense drugs (a major problem in many clinics), demonstration legislation allows special pilot projects to do both. As remaining funding and legal problems are corrected, NP''s and PA''s will serve an even greater role in rural areas.     

消费者视角下用户评论对公众再生水消费意愿的影响机制——来自眼动实验的证据

再生水回用是解决水资源紧缺的有效途径,对缓解区域水资源紧缺和促进环境保护有重要的意义。公众作为再生水的直接使用者,其对再生水的态度是再生水回用项目实施的关键环节。再生水作为一种再生资源产品,价格是消费者使用再生水必须支付的货币成本,用户评论是消费者了解再生水,评估再生水质量的最直接途径。为了更加清晰的辨明价格、用户评论对公众再生水使用意愿的影响机制,以消费者为视角,模拟再生水购买场景,以刺激-机体-反应模型为理论框架,采用3(实验分组：高价格、中价格和低价格)×2(评论分类：质量评论和环境评论)的眼动追踪实验,探究公众再生水购买决策过程中的行为机理,并进一步分析不同价格下公众再生水使用行为的差异。研究结果表明：(1)公众再生水使用意愿在中价格组最高,低价格组次之,高价格组最低。(2)公众决策过程中,不论是再生水质量评价,还是环境评价,均偏向于注视消极评论内容。在低价格组中,公众对评论内容的关注程度最高,高价格组最低,中价格组中,公众更关心再生水对环境的影响。(3)消费过程中,公众对评论内容的关注会影响消费情绪从而影响再生水使用意愿。(4)再生水价格在公众消费决策过程中发挥重要的调节作用...     

Acupuncture in Nevada

Nevada''s Senate Bill 448 was signed into law by Governor Mike O''Callaghan on 20 April 1973. The law permits the practice of Chinese medicine, including acupuncture, by practitioners who do not have to be physicians. The state legislature rapidly approved it with only two dissenters, one of them a physician.Similar legislation may be considered in other states this year.     

"Don't let others design your future", new CMA president tells physicians. Interview by Nancy Robb.

Dr. Judith Kazimirski of Nova Scotia becomes the CMA''s 126th president during the association''s annual meeting in Sydney, NS, this month. She says her priority for the next year is to help the CMA play a lead role as the debate intensifies about the future of health and health care in Canada. "The time is right for a very public debate about what people want their system to be, what problems they''re having, and how reform is moving ahead," she says, "and physicians have a critical leadership role to play."     

Can primary prevention or selective screening for melanoma be more precisely targeted through general practice? A prospective study to validate a self administered risk score.

OBJECTIVES: To establish whether a questionnaire incorporating MacKie''s risk factor flow chart can identify patients at high risk for melanoma so that they can be targeted for primary and secondary prevention. To validate the risk score derived from the questionnaire and test the feasibility of self completion by comparing patients'' self reported skin characteristics with a skin examination performed by an experienced general practitioner. DESIGN: Prospective questionnaire survey followed by a comparative study. SETTING: 16 randomly selected group practices in a health district in Cheshire, United Kingdom. SUBJECTS: Questionnaire survey--3105 consecutive patients aged 16 years and over attending for a primary care consultation; comparative study--a self selected subsample of 388 of the 3,105 patients. MAIN OUTCOME MEASURES: MacKie risk group for melanoma. Comparison of high risk skin characteristics reported by patients and those noted during a skin examination by a doctor (kappa statistic). RESULTS: 4.3% of patients (87% women) were in the highest risk group and 4.4% (79% men) were in the second highest risk group, as defined by the MacKie score. Agreement between patients'' self appraisal of skin characteristics and clinical skin examinations was reflected in kappa values of 0.67 for freckles, 0.60 for moles, and 0.43 for atypical naevi. CONCLUSION: This questionnaire helped to identify a group at high risk for melanoma. Furthermore, good agreement was found when the patient''s risk scores were compared with results of the clinical skin examination. This risk score is potentially useful in targeting primary and secondary prevention of melanoma through general practice.     

Sex role ideology among physicians.

Physicians have been accused by some feminist writers of having traditional views on sex roles that make them part of society''s oppressive power structure and therefore responsible in part for the high incidence of psychologic problems and drug dependency among women. To assess whether physicians'' attitudes towards women are indeed polarized in a traditional fashion, a sex role ideology questionnaire was given to all practising physicians belonging to the Manitoba Medical Association. Overall the physicians were found to be more feminist than male college students and a group of women with traditional beliefs. Psychiatrists, who had the highest adjusted group mean score on a sex role ideology scale (high indicating feminist beliefs), were found to be significantly more feminist than family practitioners, surgeons, and obstetricians and gynecologists, although not more so than internists, radiologists, pediatricians and anesthesiologists. These findings do not support the assumption that physicians have traditional views that reflect those of society. However, the significant differences between specialties emphasize the need for educating physicians and medical students in the behaviour of women.     

Managed-care plans. Their future under national health insurance.

The nation''s health maintenance organizations, preferred-provider organizations, independent practice associations, and similar managed-care efforts are not well positioned to take a leadership role in a nationwide universal access or national health insurance plan. They--with the possible exception of some large staff and group health maintenance organizations--have been unable to show uniformly that they can contain costs, provide better access or higher quality of care, and achieve greater patient satisfaction than fee-for-service endeavors. As the United States pursues universal access as a step toward national health insurance, the managed-care plans will continue to increase their numbers of subscribers. They will not, however, be able to enroll large numbers of the young, low-income employees and their dependents who account for most of the 63 million people uninsured sometime during each year. Under national health insurance, there might be an option for some health maintenance organizations to negotiate capitated payments. The vast majority of the nation''s physicians, however, will reluctantly embrace a centrally managed fee-for-service approach rather than a salary or capitated reimbursement method, leaving only a trace of the competitive managed-care plan theme in a future, primarily monolithic, national health care system.     

Assistants to Primary Physicians in California

The mid-level practitioner movement is no longer experimental; nurse practitioners and physician''s assistants in California have proved to fill a necessary and viable professional role in the delivery of primary health care. The physician''s assistant law (AB2109) and the Experimental Manpower Act (AB1503) have facilitated the training and functioning of these new health care professionals; more comprehensive laws are still needed to permit optimal utilization. National agencies for approval of teaching programs and testing of individual graduates will play an increasing role in the accreditation and certification procedures. Professional role difficulties, issues of sex and questions of delegation of responsibility are being resolved and it is hoped that a more equitable and patient-oriented system is evolving.     

The Effect of an Individualized Practice-Based CME Program on Physician Performance and Patient Outcomes

The Professional Competence Assurance Program (PROCAP) is an individualized educational program that examines physicians'' performance in ambulatory practice. It uses medical record review to identify deficiencies in the care process that guides development of the educational intervention. Medical care is reassessed one year later. This program was used with 51 private practitioners to assess the care of 1,229 hypertensive patients. The educational program included a computer printout comparing one physician''s performance with that of peers, readings targeted to management problems, and a conference call or group seminar with an expert stressing issues relevant to each physician''s performance. Postintervention assessment showed that physicians prescribed beta-blockers (P<.01) and vasodilators (P<.01) more often. Improvement (P<.05) occurred in the control of diastolic blood pressure (≤90 mm of mercury) and in several other criteria. These results show that well-designed, individualized continuing medical education addressing specific deficiencies can change physicians'' performance and patients'' intermediate outcome.