Institutional change: embracing the initiative to train more generalists.

Dartmouth Medical School was one of 16 U.S. medical schools that received a Generalist Physician Initiative (GPI) grant from The Robert Wood Johnson Foundation in 1994. This article describes institutional change at the school, noting that while the context in which the GPI was launched was receptive, the grant enabled Dartmouth to accelerate institutional changes already under way. Perhaps even more important is that Dartmouth used an approach to change that worked, and although the specific actions may not generalize to other schools, the authors hope the principles will. Key among these principles were capitalizing on a sense of urgency for change, creating and empowering a guiding coalition, developing and communicating the vision, generating short-term wins, consolidating gains, and anchoring new approaches to the existing institutional culture. Changes at Dartmouth are described in the areas of admission and recruitment, undergraduate and graduate medical education, and supporting community practice. The authors also describe shortcomings in developing the program, such as maintaining the guiding coalition in the face of the changing health care system and clinical pressures, developing a vision and strategy in areas managed by the state, and engagement of a broad-based group.

Sustaining the development of primary care in academic medicine. Working Group on Sustaining the Development of Academic Primary Care. Association of American Medical Colleges.

This article is the report of the Working Group on Sustaining the Development of Academic Primary Care, one of the six subgroups of the Advisory Panel on the Mission and Organization of Medical Schools (APMOMS) sponsored by the Association of American Medical Colleges (AAMC). To begin, the group draws a distinction between primary care and generalism. Primary care is a core domain of health care and, in the context of emerging integrated systems, will increasingly be a multidisciplinary shared function. Non-subspecialized physicians, or "generalists," are a key element in the provision of primary care, but do not act alone. Core competencies for primary care are central to the education of all physicians. Therefore, irrespective of workforce goals for generalist physicians, primary care should have a strong, central position in the medical school so that graduates can receive a sound general medical education and can be prepared for any specialty and for lifelong learning in an evolving health care system. For primary care to achieve that position, medical schools must integrate primary care into their missions, strategic plans, operation, organization, academic administrative structures, curriculum development, faculty development (both school- and community-based), resource development, alliances with appropriate clinical services networks, financial policy, and evaluation and educational monitoring systems. The group briefly describes the elements of those changes and also proposes ways that the AAMC and medical school leaders could promote the central role of primary care in medical schools.

Tapping the power of information: an orientation for academic medical centers.

In September 1994 the Association of American Medical Colleges' (AAMC's) Advisory Panel on the Mission and Organization of Medical Schools (APMOMS) established a working group to address both the long-term and the immediate implications of the expanding capacity of and need for information technology (IT) within academic medical centers (i.e., medical schools and teaching hospitals). Over a two-year period, group members assessed the utilization of IT through surveys of current practices and interactions with acknowledge leaders in the field. They also had discussions with deans and other institutional leaders. The group developed the consensus that proper use of currently available IT is crucial to virtually every aspect of academic medicine's clinical, educational, and research missions. Moreover, current IT technology will be further enhanced by the powerful new applications that are nearing deployment. All group members agreed that IT must become a core competency of academic and medical centers (AMCs), the profession, and individual physicians and scientists to ensure the survival of AMCs in the current highly competitive environments. The authors outline their arguments for the development of strong information systems within AMCs and present basic characteristics of systems that show promise for successful implementation. The y review some of the major institutional obstacles that have hindered the planing and implementation of IT. They conclude with a list of practical institution strategies for success in planning and implementing IT systems, and suggestions for how the AAMC can help members achieve success in these activities.

Educating tomorrow's doctors: the thing that really matters is that we care.

The unique purpose of medical schools is to select and educate competent, caring physicians capable of meeting society's expectations for health care. The author discusses this purpose first in the context of liberal education, which provides a broad perspective essential in the education of doctors and other professionals. Such an education can be achieved partly by how medical students are selected and by effectively uniting it with professional learning. The most important goal of liberal education is to promote intellectual wholeness as a lifelong pursuit of physicians. Second, the author reviews medical curricula, which have been slowly evolving away from a focus on providing instruction and toward one of producing learning. This new approach is a more rational one, and can be seen in some schools' reductions of lectures and increases in team teaching and problem-based learning, and earlier exposure of students to patients, especially in ambulatory care settings. An important role of medical educators is to provide enough free time for students to learn, and to pay attention to the "informal curriculum," where the unwritten ethical codes of medicine are revealed. The author then turns to issues of professionalism, especially that elusive part that goes beyond expertise. He emphasizes that the training of tomorrow's doctors is ultimately a public goal, and that medical schools must help restore public trust in doctors by selecting and nurturing professionals who see medicine in a broad social context. He reiterates that a liberally educated doctor is most likely to have such an outlook, and concludes by urging medical educators to remember that there is no substitute for a doctor's competence, caring, and professionalism expressed in the context of a liberally educated mind. And that the most important thing that educators can do as they bend to their task is to care.

Fulfilling the social contract between medical schools and the public.

To gain a better understanding of the effects of medical schools related to transformations in medical practice, science, and public expectations, the Association of American Medical Colleges (AAMC) established the Advisory Panel on the Mission and Organization of Medical Schools (APMOMS) in 1994. Recognizing the privileges academic medicine enjoys as well as the power of and the strain on its special relationship with the American public, APMOMS formed the Working Group on Fulfilling the Social Contract. That group focused on the question: What are the roles and responsibilities involved in the social contract between medical schools and various interested communities and constituencies? This article reports the working group's findings. The group describes the historical and philosophical reasons supporting the concept of a social contract and asserts that medical schools have individual and collective social contracts with various subsets of the public, referred to as "stakeholders." Obligations derive implicitly from the generous public funding and other benefits medical school receive. Schools' primary obligation is to improve the nation's health. This obligation is carried out most directly by educating the next generation of physicians and biomedical scientists in a manner that instills appropriate professional attitudes, values, and skills. Group members identified 27 core stakeholders (e.g., government, patients, local residents, etc.) and outlined the expectations those stakeholders have of medical schools and the expectations medical schools have of those stakeholders. The group conducted a survey to test how leaders at medical schools responded to the notion of a social contract, to gather data on school leaders' perceptions of what groups they considered their schools' most important stakeholders, and to determine how likely it was that the schools' and the stakeholders expectations of each other were being met. Responses from 69 deans suggested that the survey provoked thinking about the broad issue of the social contract and stakeholders. Leaders on the same campuses disagreed about what groups were the most important stakeholders. Similarly, the responses revealed a lack of national consensus about the most important stakeholders, although certain groups were consistently included in the responses. The group concludes that medical school leaders should examine their assumptions and perspectives about their institutions' stakeholders and consider the interests of the stakeholders in activities such as strategic planning, policymaking, and program development.

Preserving medical schools' academic mission in a competitive marketplace.

To gain a better understanding of the effects on medical schools of transformations in medical practice, science, and public expectations, the AAMC in 1994 formed the Advisory Panel on the Mission and Organization of Medical Schools and appointed six working groups to address relevant issues. This article is a report of the findings of the Working Group on Preserving Medical Schools' Academic Mission in a Competitive Marketplace, which was charged with exploring how medical schools could acquire and/or preserve an adequate patient base for teaching, research, and income generation in a competitive marketplace. The other groups' reports will appear in future issues of Academic Medicine. To understand the diversity of approaches that schools have taken to achieve this goal and to preserve their missions, the group interviewed representatives of nine medical schools, selected to represent a cross section of U.S. medical schools. The interviews took place on four occasions between June 1995 and March 1996. The information and comments shared by participants helped the working group gain insight into the fundamental issues it had been charged to address, including those of new delivery structures, what value schools offer to delivery structures, how education and research can be incorporated and supported financially, possible new pressures on relationships between medical schools and teaching hospitals, changes in faculty physicians' employment relationships and terms, and the role of the medical school in graduate medical education. In collecting and analyzing the data, the working group focused on the distinction between protecting an institution's existing enterprise and preserving an institution's core mission. This article gives a detailed overview of the information and comments each school presented, organized under the appropriate question. The working group's conclusions and commentaries on the findings follow. An appendix presents more detailed summaries of the schools' presentations, organised as case studies. The picture that emerges is complex. The working group concluded that medical schools will take a variety of approaches to define and preserve their missions. Most, but not all, medical schools will be able to secure the patient bases necessary to fulfill their missions even in a competitive marketplace. However, the nature of many of the schools is likely to change, and it is not clear whether the core missions of education and research will continue at their present levels at all schools.

Resource use and cost of initial coronary revascularization. Coronary angioplasty versus coronary bypass surgery.

Although there is intense interest in the cost-saving potential of therapeutic alternatives, most studies have analyzed hospital charges rather than actual economic costs. To analyze cost differences rigorously, we studied 115 patients undergoing initial elective angioplasty (percutaneous transluminal coronary angioplasty, PTCA) and 274 patients undergoing initial elective surgery (coronary artery bypass graft surgery, CABG). Detailed resource consumption profiles were constructed and used to estimate the cost savings from switching a patient from CABG to PTCA. Four cost-accounting methods were used in the analysis; each method made different assumptions about the costs that would vary and the costs that would be fixed according to the number of procedures performed. The variable costs in the four methods were the 1) cost of supplies, 2) cost of personnel and supplies, 3) average direct costs, and 4) average direct costs plus allocated hospital overhead. The mean hospital charges for CABG patients were $19,644 versus $9,556 for PTCA patients (p less than 0.0001). The estimated cost difference between CABG and PTCA was substantially less than the $10,088 difference in charges, however, with net savings of 19%, 46%, 53%, and 78% of charges using cost-accounting methods 1-4, respectively. Thus, although the initial hospital charges for PTCA are significantly less than for CABG, the actual economic cost savings may be significantly overestimated by the use of hospital charge data.

Effect of daily charge feedback on inpatient charges and physician knowledge and behavior.

Concurrent charge feedback has gained widespread acceptance as a method of minimizing hospitals' losses under the Medicare prospective payment system despite the fact that its effect on patient outcomes, physician behavior, or charges has not been studied in depth. In a controlled trial on two medical wards in an academic medical center, the effect of daily charge feedback on charges was studied. Sixty-eight house staff and 16 teaching attending physicians participated during a 35-week period, taking care of 1057 eligible patients. No significant differences in charges were seen when all patients were included. Since 45% of patients had planned protocol admissions (diagnostic workups or protocol treatment) on which the house staff had little change to impact, a subgroup analysis was performed, excluding these patients. In the remaining patients, a highly significant reduction in mean total charges (17%), length of stay (18%), room charges (18%), and diagnostic testing (20%) was found. In-hospital mortality and preventable readmission within 30 days were similar on the two wards. It was concluded that charge feedback alone is effective in a teaching hospital for decreasing charges.

Career choices of 135 cardiology trainees at Duke University Medical Center from 1970 to 1984.

Alarm has been expressed at recently presented evidence showing that diminishing numbers of physicians are entering academic careers. The experience of the cardiology training program at a university medical center between 1970 and 1984 was reviewed to determine the career paths chosen by its trainees. During the study period, 135 physicians received training. Between 1970 and 1978 the percentage of trainees making academic medicine their initial career choice fluctuated considerably. Beginning in 1978, the percentage entering academic medicine steadily increased; in the most recent class, 8 of 9 trainees accepted academic faculty positions. Among 72 former trainees who joined an academic faculty after finishing training, approximately 7% per year left academic medicine for clinical practice. The median length of an academic career was 10 years. Individual institutions may be able to reverse the national trend of trainees making clinical practice their initial career choice. However, physicians who leave academic medicine for clinical practice may continue to deplete faculty ranks.

Effects of physical conditioning on left ventricular ejection fraction in patients with coronary artery disease.

To address the hypothesis that physical conditioning may improve left ventricular function in patients with coronary artery disease, we performed first-pass radionuclide ventriculography in 53 patients at rest and during upright bicycle exercise before and after 6 to 12 months of exercise training. The peak bicycle workload achieved before the onset of fatigue, dyspnea, or angina increased by an average of 22% (p = .0001) after training, and mean heart rate at a workload equal to the pretraining maximum workload was decreased by 10 beats/min after training (p = .0002). Of 21 subjects with angina or exertional ST segment depression before training, 15 (71%) were able to exercise to the same workload without these manifestations of ischemia after training. Whereas neither mean resting left ventricular ejection fraction (LVEF) nor LVEF at peak exertion was significantly altered, mean LVEF at the pretraining maximum workload was increased from 0.50 to 0.54 (p = .002) after training. There was a significant correlation between the magnitude of training bradycardia and the increment in LVEF at the pretraining maximum workload (p = .009). We conclude that the relative bradycardia at comparable exercise workloads produced by exercise conditioning is associated with improvements in left ventricular performance as assessed by the LVEF. This observation is compatible with the hypothesis that training bradycardia in conditioned subjects with ischemic heart disease is associated with lower myocardial oxygen demand and lesser degrees of ischemia at comparable workloads. However, training effects on ventricular afterload or on ischemia contractile performance of the heart cannot be excluded.

Late fractionated potentials and continuous electrical activity caused by electrode motion.

Late fractionated potentials, recorded during cardiac mapping to find the source of a ventricular arrhythmia, have been ascribed particular localizing value. Re-entry is assumed when these highly amplified and filtered recordings span diastole during tachycardia. The purpose of this study was to see if such potentials can occur artifactually. A saline soaked 7 X 2 X 3 cm sponge was sewn to the epicardium of the right ventricle in five non-infarcted, open-chest dogs. Two bipolar button electrodes, one with 1 mm and one with 1 cm interelectrode spacing, were attached to the outer surface of the sponge and a bipolar wire hook electrode was placed just under the outer surface of the sponge. Thus all three electrodes were 3 cm from the nearest myocardium yet still subjected to cardiac motion. The electrodes were recorded at gains of 4,000-40,000 and filtered to pass 50-300 hertz. One to three rapid deflections were recorded during the QRS from all electrodes. In seven of the the 15 electrode recordings, two or three additional deflections, 1100-200 microV in amplitude, occurred after the QRS. These late potentials were fractionated and recurred reproducibly from cycle to cycle. In two cases, these late fractionated potentials could be made to span diastole by rapid pacing to simulate tachycardia. Clamping the sponge to sliminate motion between the sponge and electrode caused this late activity to disappear. Thus, in highly amplified and filtered recordings, electrode motion can cause artifacts resembling late fractionated potentials and continuous electrode activity.

Disopyramide: six years' experience.

Since its approval by the FDA six years ago, oral disopyramide has earned a recognized role in the treatment of ventricular arrhythmias. During this time, clinical experience has refined our knowledge of this agent, allowing revision of dosing guidelines and better selection of patients. This review explores the recent therapeutic experience with disopyramide.

Localization of septal pacing sites in the dog heart by epicardial mapping.

To examine whether different septal pacing sites could be distinguished by their epicardial activation patterns, six to eight stimulating electrodes were placed throughout the septum in seven open chest dogs. Unipolar electrograms were obtained from 52 epicardial electrodes during pacing from each stimulating electrode and isochronous epicardial maps were constructed. The location of each stimulating electrode was found by dissection, and its distance from the overlying epicardium was measured. To allow comparison among epicardial maps, the septum was conceptually subdivided into nine regions to which stimulating electrodes were assigned. Epicardial activation patterns from the same region were similar and these patterns allowed the region containing a stimulating electrode to be identified in many cases. Three other variables were found to have additional localizing value. There were: 1) the time from the stimulus to epicardial breakthrough, 2) the duration of epicardial activation, and 3) the area of epicardium activated in the first 5 ms after epicardial breakthrough. For those stimulating electrodes that could not be localized by their epicardial activation patterns, the distance of the stimulating electrode beneath the epicardium was well fit from these three variables by multiple regression (correlation coefficient [r] = 0.97). Thus, using all the previous factors, localization of septal pacing sites was possible in the noninfarcted dog heart by epicardial mapping.

Physiological and psychological variables predict compliance to prescribed exercise therapy in patients recovering from myocardial infarction.

Previous research has documented high rates of noncompliance to prescribed medical therapy in patients recovering from myocardial infarction (MI). This study was undertaken to determine if patients who subsequently drop out of a structured cardiac rehabilitation program could be prospectively distinguished from those who remain in the program based upon their initial baseline characteristics. Thirty-five consecutive patients with recent MIs underwent comprehensive physical and psychological assessments at entry into the program, and were followed for a period of 1 year. The 14 patients who dropped out of the program could be distinguished from the compliers on the basis of their reduced left ejection fraction assessed by first pass radionuclide angiography at rest and during peak exercise. In addition, their psychological profiles assessed by the MMPI indicated the dropouts were more depressed, hypochondriacal, anxious, and introverted and had lower ego strength than those who remained in the program. Statistical analysis further indicated that psychological variables were associated with noncompliance independently of physical status. These findings suggest that MI patients who are unlikely to adhere to this form of medical therapy may be prospectively identified based upon their initial physical and psychological characteristics.