Faculty--agents of change.

In medical schools and residencies, the faculty in all settings and through all facets of the curriculum influence learners' skills, attitudes, and behaviors. Mentorship and role modeling are powerful forces in shaping a professional. To positively affect the number of students seeking to enter the generalist specialties, the faculty community will need reevaluation, expansion, and professional development. This paper discusses some of the hurdles for institutional leaders and offers pragmatic suggestions for beginning the process of retooling the faculty. A matrix is presented to describe the multifaceted faculty required for educating the generalist.

The matrix of ambulatory education.

Ambulatory education has become an essential part of all internal medicine residencies. To develop excellent ambulatory education programs, we must thoroughly understand the opportunities available in such a setting, and the leaders in internal medicine must be willing to experiment with nontraditional locations and rotational formats. An "ambulatory matrix" can be constructed by program directors to help define the educational opportunities available in their institutions and to map the possibilities for educational rotations outside of the hospital wards.

A new contact neodymium:YAG laser for cyclophotocoagulation.

A newly developed compact (40 kg), self-contained contact Neodymium:YAG laser produces high-peak, high-energy (800 mJ/pulse), short (1.0 millisecond) pulses with 1 to 3 pulses/exposure. Energy is delivered via a 320-microns cleaved quartz fiber optic probe. Cyclophotocoagulation was performed in five eyes of three medium-sized Dutch-pigmented rabbits. The eyes received exposures of 1 to 3 pulses/exposure. Energy delivered ranged from 100 to 800 mJ/pulse. Histopathology revealed ciliary body disruption and hemorrhage with no damage to overlying sclera. When used for transscleral cyclodiathermy in the rabbit, the laser created significant ciliary body disruption with minimal scleral injury.

Subconjunctival THC: YAG laser limbal sclerostomy Ab externo in the rabbit.

A chromium-sensitized, and thulium and holmium-doped YAG laser (THC:YAG laser) was used to create bilateral limbal sclerostomies in six Dutch pigmented rabbits. The laser is a long-pulsed (300 microseconds) [corrected], compact, self-contained, solid-state laser operating in the near infrared (2.1 microns). A 1-mm conjunctival stab incision was made 12 mm away from the sclerostomy site to allow entry of a specially designed 26-gauge (480 microns) optic probe that delivers energy at right angles to the long axis of the fiber. Probe insertion minimally disturbed the conjunctiva. Pulse energies of 60 to 150 mJ were used with a repetition rate of 5 pulses/s. Energy levels ranging from 1.35 to 6.6 J produced full-thickness sclerostomies. Histopathology showed a sharply defined perforating limbal wound at all energy levels. The overlying conjunctiva was intact, with swelling of the adjacent cornea. A peripheral iridectomy was intentionally created with the laser through the peripheral limbus, resulting in a sharply defined perforating tract through the iris/ciliary body. This technique may simplify filtering sclerostomy surgery, without anterior chamber instrumentation and with minimal conjunctival trauma.

Two combined residency programs in internal medicine and pediatrics.

Combined residency training in internal medicine and pediatrics is becoming a popular postgraduate program among graduating medical students. The number of such programs has increased rapidly but with little interchange of ideas and without the benefit of a national data base. In this paper, the authors review the experience of two combined programs. Initially established because of the desire to provide broad-based training in primary care, the programs now offer a curriculum that prepares residents for primary care or education in the subspecialties. The difficulty for residents of achieving competence in two disciplines is compounded by a lack of faculty role models. The two programs offer special advantages to the residents and the departments involved. The career outcomes of program graduates have varied from primary care or subspecialty practice in one or both disciplines to faculty positions in teaching institutions. Whether the program remains successful will depend on the ability of its graduates to offer special talents to academic and clinical practice settings and on the availability of funding.

Use of private offices in education of residents in internal medicine.

Of the 440 accredited residency programs in internal medicine, 129 assign residents to private offices. From this group, 29 program directors with 47 resident-preceptor teams matched to the same offices submitted a complete set of questionnaires for analysis. The results provide information concerning the selection process for this assignment, its design and development, the nature of the educational activities, and evaluation and financing. The results suggest that the private office may be an effective learning experience for medical residents and an underused educational resource. A particular strength of the experience may be the frequent and effective resident-preceptor interactions, which seem to focus mostly on problem identification and clinical decision making.