The evolution of a Department of Internal Medicine under an integrated clinical enterprise model: the University of Kentucky experience.

The impact on the Department of Internal Medicine of the emergence of the University of Kentucky Healthcare Enterprise as an integrated clinical model has been enormous. In fiscal year 2004, the department was financially insolvent and on the verge of implementing plans to decrease faculty from 127 to 65. Since that time, the department has changed dramatically with a corresponding improvement in its clinical, academic, and financial activity. The department has grown to 175 faculty, with a healthy financial outlook and a shared vision with the clinical enterprise. Departmental clinical growth has been accompanied by growth in extramural research funding. The clinical growth of the department, in turn, supported the growth of the integrated clinical enterprise overall.The purpose of this article is to present a case history of the impact of transition to an integrated clinical enterprise financial model on the clinical, research, and educational functions of a department of internal medicine, and the opportunities and lessons learned from this transition. The implementation of an enterprise model allowed revival and expansion of the clinical programs of the department. This expansion did not occur at the expense of the research and educational missions of the department but, rather, was associated with improved performance in these areas. The processes which were established during the conversion to the enterprise model, which involve strategic planning, monitoring of plan implementation, recalibration of objectives, financial transparency, and accountability of leadership and faculty, may better prepare the institution to face the challenges of the rapidly changing economic environment.

Abraham Flexner of Kentucky, his report, Medical Education in the United States and Canada, and the historical questions raised by the report.

One hundred years ago, the time was right and the need was critical for medical education reform. Medical education had become a commercial enterprise with proprietary schools of variable quality, lectures delivered in crowded classrooms, and often no laboratory instruction or patient contact. Progress in science, technology, and the quality of medical care, along with political will and philanthropic support, contributed to the circumstances under which Abraham Flexner produced his report. Flexner was dismayed by the quality of many of the medical schools he visited in preparing the report. Many of the recommendations in Medical Education in the United States and Canada are still relevant, especially those concerning the physician as a practitioner whose purpose is more societal and preventive than individual and curative. Flexner helped establish standards for prerequisite education, framed medical school admission criteria, aided in the design of a curriculum introduced by the basic and followed by the clinical sciences, stipulated the resources necessary for medical education, and emphasized medical school affiliation with both a university and a strong clinical system. He proposed integration of basic and clinical sciences leading to contextual learning, active rather than passive learning, and the importance of philanthropy. Flexner's report poses several questions for the historian: How were his views on African American medical education shaped by his post-Civil War upbringing in Louisville? Was the report original or derivative? Why did it have such a large impact? This article describes Flexner's early life and the report's methodology and considers several of the historical questions.

The applicant pool: the genesis of the physician pipeline.

As medical schools across the nation consider the recent call made by the Association of American Medical Colleges to increase numbers of medical school students by 30% by 2015, it is important to explore the characteristics of the applicant pool. Understanding the make-up of the pool of recent applicants to the University of Kentucky College of Medicine can assist us in defining areas where the pool could be expanded in the future. Reviewing data from 2002-2006, we will examine the Kentucky county of origin of our applicants and matriculants. We will describe demographic characteristics of our applicants and matriculants with regard to gender, race and ethnicity, and international backgrounds. We will also look at factors that may discourage or dissuade prospective applicants from seeking admission to medical school including undergraduate grades, denial of the initial application to medical school, and cost considerations.

Reinforcing the necessary and obvious: doctors should be nice.

Numbers of articles have recently appeared in the lay press regarding the need for physicians to improve their rapport with patients, enhance their caring behaviors, and demonstrate actions that could be described as nice. Nice physicians are patient-centered, demonstrating skills that enable them to understand the patient's perspective, share information, and develop a partnership with patients. In fact, various medical associations have called for students, residents, and practicing physicians to demonstrate professional behaviors that might be indicative of nice, such as honesty, respectfulness, compassion, integrity, sensitivity, responsiveness, and altruism. Unfortunately, however, nice behaviors are not always modeled in academic medical centers. Medical staff members may, on occasion, demonstrate lack of patience, insensitivity, or rudeness that suggests that the coarseness of society has crept too much into our profession. Can the culture of an institution be moved toward embracing nice behaviors? We believe that a culture of nice can be nurtured in our setting by expecting civility, and exhibiting it in all interactions; reinforcing the message of being nice in all forms of verbal and written communication; recognizing Master Clinicians distinguished by their manner and their quality of care; developing methods to measure and reward physicians based on the way they "doctor;" devising innovative ways to integrate training on how to be nice into the educational curricula for both medical students and residents; and recruiting students, residents, faculty, and staff who are most likely to fit into our institutional environment and contribute to our mission in a positive manner.

A community-driven obesity prevention and intervention in an elementary school.

UNLABELLED: In partnership with community agencies and organizations, University of Kentucky College of Medicine (UKCOM) launched an after-school program focusing on creating healthy, active lifestyles for students at a Lexington elementary school. Chosen for the underserved population of children it cares for, the school exhibits all of the national risk factors for obesity: low-income families (57% of annual household incomes less than $10,000); minority population (80% of the children African-American or Hispanic); and located in an unsafe neighborhood for outdoor physical activity. These demographics resulted in a school population that had body mass index (BMI) demographics of 48.8% overweight (BMI >85%), including 30.7% obese (BMI >95%), in contrast with the national average of 16% obese. METHODS: Targeting the school's children with a BMI >85th percentile, an after-school program was created. The students met twice a week for 90-minute sessions of fun physical activities, proper nutritional information, as well as small group sessions with pediatric psychiatry residents focusing on good choices and proper motivations in life. Universal school interventions were also instituted in an attempt to reach the entire school population. RESULTS: Initial findings after the first year of the program indicated a slowing in the average rate of weight gain by the targeted population. While the results, compared to accessible data in a school population with similar demographics, did not reach statistical significance, the trends were in the desired direction. A statistically significant difference (p=0.027) was observed in mean BMI percentile for the universal school population versus the comparison school. CONCLUSION: School-based prevention and intervention conducted by a coalition of community agencies and organizations is a promising and cost-effective approach to curtailing childhood obesity.

Lessons from industry: one school's transformation toward "lean" curricular governance.

As medical education grapples with organizational calls for centralized curricular oversight, programs may be compelled to respond by establishing highly vertical, stacked governance structures. Although these models offer discrete advantages over the horizontal, compartmentalized structures they are designed to replace, they pose new challenges to ensuring curricular quality and the educational innovations that drive the curricula. The authors describe a hybrid quality-assurance (QA) governance structure introduced in 2003 at the University of Kentucky College of Medicine (UKCOM) that ensures centralized curricular oversight of the educational product while allowing individualized creative control over the educational process. Based on a Lean production model, this approach draws on industry experiences that strategically separate institutional accountability (management) for a quality curriculum from the decision-making processes required to ensure it (production). In so doing, the authors acknowledge general similarities and key differences between overseeing the manufacture of a complex product versus the education of a physician-emphasizing the structured, sequential, and measurable nature of each process. Further, the authors briefly trace the emergence of quality approaches in manufacturing and discuss the philosophical changes that accompany transition to an institutional governance system that relies on vigorous, robust performance measures to offer continuous feedback on curricular quality.

Gastric function in children with cystic fibrosis: effect of diet on gastric lipase levels and fat digestion.

The effect of diet, usual (44 +/- 4% energy as fat), high-fat (49 +/- 4% energy as fat), and moderate-fat (33 +/- 2% energy as fat), on gastric function (lipase and pepsin activities, pH, emptying rate) and intragastric digestion of fat were assessed in six children with cystic fibrosis. Fasting and postprandial activity of digestive enzymes, gastric pH, and gastric volume measured before, during, and after 120 min of feeding did not differ significantly as a function of fat intake. Postprandial gastric lipase output (units per kilogram of body weight) during usual, moderate-fat, and high-fat diets was close to or higher than (38.8 +/- 7.2, 44.9 +/- 8.6, and 54.8 +/- 5.5 U/kg per 20 min) gastric lipase output of premature infants (22.5 +/- 6.4 to 28.3 +/- 6.6 U/kg per 20 min) or of healthy adults (5.4 +/- 0.4 U/kg per 15 min) fed a high-fat diet. Postprandial pepsin output was higher (4749 +/- 797, 6117 +/- 925, and 5444 +/- 819 U/kg per 20 min) than in premature infants (597 +/- 77 to 743 +/- 97 U/kg per 20 min) or healthy adults (781 +/- 56 U/kg per 15 min). Eighty minutes after feeding gastric lipolysis reached 20 to 36%. This study shows that gastric lipase activity is high in cystic fibrosis patients maintained on diets providing 32% to 49% energy as fat, and that gastric lipase level did not increase over the ranges of dietary fat intake tested.

Lactose digestion in pregnant African-Americans.

OBJECTIVE: This paper reports on the status of lactose digestion during early and late pregnancy and at 8 weeks postpartum in an African-American population. The hypothesis is that lactose digestion and milk tolerance do not change throughout pregnancy and do not differ from those of non-pregnant African-American women. DESIGN AND SUBJECTS: This longitudinal study determined lactose digestion after ingesting 240 ml of 1% fat milk containing 12 g of lactose at: (1) early pregnancy, prior to 16 weeks (n=148); (2) late pregnancy, 30-35 weeks (n=77); and (3) 8 weeks postpartum (n=93). One hundred and one comparably matched non-pregnant African-American women served as controls. RESULTS: Prevalence of lactose digestion, as measured by breath hydrogen, was 80.2% in the control women, 66.2% in early pregnancy, 68.8% in late pregnancy and 75.3% postpartum. The prevalence of women reporting symptoms was approximately 20% regardless of lactose absorption status. However, the control women reported significantly more symptoms than did the pregnant women. CONCLUSIONS: This study indicates that there is no significant change in lactose digestion during pregnancy. The prevalence of lactose intolerance for the pregnant African-American women studied is similar to that for non-pregnant African-American women and similar to previous prevalence reports in adult African-Americans. There was no change in the tolerance of lactose noted during pregnancy in these women. There were, however, fewer symptoms reported by the lactose-maldigesting pregnant women.

Autistic disorder and gastrointestinal disease.

Autistic disorder is a pervasive developmental disorder manifested in the first 3 years of life by dysfunction in social interaction and communication. Many efforts have been made to explore the biologic basis of this disorder, but the etiology remains unknown. Recent publications describing upper gastrointestinal abnormalities and ileocolitis have focused attention on gastrointestinal function and morphology in these children. High prevalence of histologic abnormalities in the esophagus, stomach, small intestine and colon, and dysfunction of liver conjugation capacity and intestinal permeability were reported. Three surveys conducted in the United States described high prevalence of gastrointestinal symptoms in children with autistic disorder. Treatment of the digestive problems may have positive effects on their behavior.

Autism and gastrointestinal symptoms.

Autism is a collection of behavioral symptoms characterized by dysfunction in social interaction and communication in affected children. It is typically associated with restrictive, repetitive, and stereotypic behavior and manifests within the first 3 years of life. The cause of this disorder is not known. Over the past decade, a significant upswing in research has occurred to examine the biologic basis of autism. Recent clinical studies have revealed a high prevalence of gastrointestinal symptoms, inflammation, and dysfunction in children with autism. Mild to moderate degrees of inflammation were found in both the upper and lower intestinal tract. In addition, decreased sulfation capacity of the liver, pathologic intestinal permeability, increased secretory response to intravenous secretin injection, and decreased digestive enzyme activities were reported in many children with autism. Treatment of digestive problems appears to have positive effects on autistic behavior. These new observations represent only a piece of the unsolved autism "puzzle" and should stimulate more research into the brain-gut connection.