Mixed cryoglobulinemia in chronic hepatitis C infection. A clinicopathologic analysis of 10 cases and review of recent literature.

We present 10 cases of mixed cryoglobulinemia in patients infected with hepatitis C, including pertinent clinical, serologic, and pathological data. The findings attributable to MC appear to be similar in patients who are HCV-infected as in those with unknown HCV status. The prevalence of MC in HCV-infected patients appears to be lower in our region (13%) than in southern Europe (50-90%) although some of this difference is due to our requirement that patients included in our study have a cryocrit of at least 5%. In our patients, cryoglobulins were shown to be deposited in skin and kidney, but not in liver. The mechanisms by which HCV and MC are related remain uncertain. Although we and others have evidence for enrichment of HCV RNA in the cryoprecipitates of some patients, this was not always the case, and it is not yet clear that this finding is of fundamental pathogenic importance. Finally, it appears that some patients with HCV and MC may have a beneficial clinical response of vasculitic symptoms to therapy with alpha-interferon, as well as to glucocorticoids or other immunosuppressants. In our group, no predictors were apparent to distinguish responders from nonresponders before treatment. Similarly, the duration of response remains to be determined.

The effect of Public Law 94--484 on pathology residency programs.

The Health Professions Educational Assistance Act of 1976 (Public Law 94--484) will affect graduate medical programs. The author surveyed directors of medical education in one major metropolitan area to study what the effects might be. With regard to pathology residency programs there are a number of important influences. For example, there will be fewer foreign medical graduates available to study in United States pathology programs. However, those who do come may be of higher quality. Also, owing to financial incentives to increase primary care, medical schools and hospitals may show less interest in the development of speciality programs such as pathology. The changing environment poses challenges to pathology directors to maintain or improve their programs.

A second look at consequences for medical education of problem solving in science and medicine.

This article reports that most freshman and senior medical students in one medical school were not able to solve a written problem case, concerning back pain, that required the examinee to recognize that foot drop was a key physical finding. The students' responses were not influenced by the fact that half of the examinations listed the foot drop finding first and the other half listed it seventh in a list of eight physical findings. The authors conclude that the outcome of this sample problem hints at a fault in medical education: the failure of medical students to learn the skill of formulating overall hypotheses and subhypotheses before choosing treatment options.

Marital adjustment among housestaff and new attorneys.

Previous reports have suggested that physicians' marriages may be adversely affected by the stresses of the profession. Some social scientists, however, question the view that demanding careers are the primary cause of poor marital adjustment and suggest instead that such careers may actually invigorate a marriage. This study, involving 116 housestaff physicians, 106 new attorneys, and the spouses of both groups, identified the factors that significantly affected their marital adjustments. No difference in marital adjustments was found between housestaff and attorneys or between the two spouse groups. In general, the spouses had higher marital adjustment scores than did the professionals, and the women professionals had higher scores than did the men professionals. The two most important factors associated with adjustment were the perceived level of emotional support received from one's spouse for one's career and the level of such support given to one's spouse for his or her career. The results suggest that housestaff and new attorneys are as satisfied with their marriages as are the other populations in which the same marital inventory has been used.

A review of constructivism: understanding and using a relatively new theory.

The purpose of this review paper is to familiarize family medicine educators with a relatively new educational theory, "constructivism." This theory is derived from the philosophical proposition that reality is constructed by the individual. According to the more traditional theory of "objectivism," knowledge exists in the world external to personal experience. Constructivist theory postulates that personal experience cannot be separated from knowledge. In analyzing the literature, the author found that constructivism can be viewed at the cognitive (individual) and social (community) levels. Cognitive constructivism maintains that individuals develop their own models of reality using personal experience and research-based data. Two key elements of cognitive constructivism with implications for family medicine educators are promoting student independence and active learning. Social constructivism maintains that individuals use their membership in a community to continually refine and shape their models of reality. By communicating with each other (for physicians, in the "conversation of medicine"), we test our constructs. Two key elements of social constructivism with implications for application by family medicine educators are promoting collaboration and peer teaching.

Learning and teaching styles: implications for teachers of family medicine.

BACKGROUND: Much attention has been given to learning and teaching "styles" in adult education and in medical education. Since style refers to assumptions and beliefs about how adults learn, it affects what teachers do to facilitate learning. A synthesis of two models views the educational process as a cycle: "experience," followed by "reflection," "abstraction," and "experimentation." Four styles of learning or teaching are possible by combining experience with observation, observation with abstraction, abstraction with experimentation, and experimentation with experience. Students and residents could use this information to negotiate with faculty to best meet their educational needs, and faculty could use this information to tailor their teaching strategies to best suit each encounter.

The pattern of publishing previously rejected articles in selected journals.

Although it is important to medical school faculty that they publish articles, little has been done to study the process of submitting manuscripts to journals. Specifically, the authors of this study surveyed authors in nine journals read by family medicine teachers to see if their published articles previously had been rejected by other journals. Based on 517 responses from 541 authors (96% response rate), the authors learned that the New England Journal of Medicine had the highest "not previously rejected" rate of 98% and the Journal of the American Medical Association had the lowest rate of 68%. Overall, 11% of the articles published in the eight other journals in the study previously had been rejected by NEJM. It might be interesting for an author whose manuscript is rejected to know the rates of rejection and publication of various journals.

Resource materials for faculty development.

BACKGROUND AND METHODS: Practical, well-designed, state-of-the-art resources are needed to help medical faculty enhance their skills as educators, researchers, administrators, and academics. Books, audio and video programs, CD-ROM-based programs, and interactive programs created for use on the Internet are needed for independent study, for peer learning, and for activities that are facilitated by faculty developers. The more pressure there is on faculty time, the more desirable becomes the availability of resources that can be used privately, flexibly, and in multiple locations (including home). In this paper, we 1) describe the strategies we used in identifying resources, 2) briefly describe some recently developed resources, 3) make observations about existing resources, and (4) make recommendations for the kinds of resources that need to be created and some criteria to consider when selecting and creating resources. The task of finding existing resources proved to be quite difficult, so as an outgrowth of the research done for this article, we created a Web site (http:@www.uchsc.edu/CIS) that provides a continually updated, annotated list of resources for faculty in the health professions and links to other sites with relevant information.

Where, how, and from whom do family practice residents learn? A multisite analysis.

This paper presents the results of a multisite study of 2,481 teacher-learner events reported by family practice residents in four separate training programs. Teacher-learner events were characterized by the location, activity, and teacher involved. Distinct patterns of teacher-learner interaction emerged across each of the three years of training. Hospital based direct patient care under the supervision of a non-family practice specialist was the most frequent type of educational experience in each of the three years. In contrast, family practice faculty influence throughout each of the three years is minimal. Learning in the outpatient setting with another specialist matched, or in some cases, exceeded that with a family physician. This study raises several important issues regarding the type and appropriate nature of educational influences on family practice physicians. Of greatest concern is the adequacy of role modeling and direct teaching by family practice specialists of family practice residents.

Creative medical teaching. Commitment to becoming the best.

The limits of exciting and fruitful medical teaching exist only in the mind of the teacher. Whether the instructor is in a classroom lecturing, in a small group experience, or in a clinical setting, teaching can be made both interesting and informative if the educator is willing to plan the encounter so that both teacher and student may come away feeling fulfilled.

Back to the bedside. Teaching on nursing rounds.

1. Teaching at the bedside provides the means for nursing students to begin their professional contacts with patients. 2. Teaching at the bedside should begin with selecting patients who illustrate specific problems and obtaining their consent. 3. Connoisseurship in clinical teaching means knowing and appreciating what is clinically significant at the bedside. 4. After teaching at the bedside, it is important to debrief students.

Academic tenure and collective bargaining in American dental schools.

In thier survey of organizational structures in American dental schools, Dilts and Fields reported that the organization and administration of dental schools are of importance in the operation and attainment of educational goals. If one institutional goal is to provide faculty with attractive working conditions, then academic tenure and collective bargaining are important. In this respect, dental schools run true to higher education form. Having great variability, tenure systems were reported to be universal in dental schools. On the other hand, collective bargaining was found to be a new phenomenon on trial. The experience of dental schools with academic tenure and the trial of collective bargaining are of some interest to all college educators. Dilts and Fields concluded that "Although dental education is traditional in nature, resisting changes as do other phases of higher education, the results indicate that dental education is dynamic and is responding to internal as well as external needs." Dental educators may wish to follow these tenure and union issues to help determine successful policies for the conditions of dental faculty employment.

Faculty evaluation as a means of faculty development.

Although there is little evidence that evaluation actually helps improve teaching, some conditions increase the likelihood of evaluation leading to improvement, including a combination of student ratings with educational consultation, comparison of student ratings to self-ratings, feedback early enough to provide time for improvement, and linkage of faculty development to the promotion-retention-tenure process. These conditions were built into a family practice faculty development program. The faculty development program was carried out in steps analogous to a medical model with which faculty already were familiar. An educational consultant took an instructor's teaching "history" and conducted a "physical examination" of his teaching. The evaluator collected "laboratory" data regarding the instructor's teaching and made a "diagnosis." He provided "treatment" in terms of educational consultation and "assessed" the changes in the instructor's teaching. A repetition of the data collection and consultative process demonstrated improvement in clinical teaching, particularly with regard to the skill of leading a collaborative group discussion during resident teaching rounds.