Mental health, job satisfaction, and intention to relocate. Opinions of physicians in rural British Columbia.

OBJECTIVE: To determine the prevalence of depression and burnout among family physicians working in British Columbia's Northern and Isolation Allowance communities. Current level of satisfaction with work and intention to move were also investigated. DESIGN: Cross-sectional, mailed survey. SETTING: Family practices in rural communities eligible for British Columbia's Northern and Isolation Allowance. PARTICIPANTS: A random sample of family physicians practising in rural BC communities. Initial response rate was 66% (131/198 surveys returned); excluding physicians on leave and in temporary situations and those who received duplicate mailings gave a corrected response rate of 92% (131/142 surveys returned). MAIN OUTCOME MEASURES: Demographics; self-reported depression and burnout; Beck Depression Inventory and Maslach Burnout Inventory scores; job satisfaction; and intention to leave. RESULTS: Self-reported depression rate was 29%; the Beck Depression Inventory indicated 31% of physicians suffered from mild to severe depression. About 13% of physicians reported taking antidepressants in the past 5 years. Self-reported burnout rate was 55%; the Maslach Burnout Inventory showed that 80% of physicians suffered from moderate-to-severe emotional exhaustion, 61% suffered from moderate-to-severe depersonalization, and 44% had moderate-to-low feelings of personal accomplishment. Depression scores correlated with emotional exhaustion scores. More than half the respondents were considering relocation. CONCLUSION: Physicians working in these communities suffer from high levels of depression and very high levels of burnout and are dissatisfied with their current jobs. More than half are considering relocating. Intention to move is strongly associated with poor mental health.

Opportunities and issues for medical group practices.

For the second consecutive year, McManis Associates, a health care management consulting firm and subsidiary of MMI Companies Inc., held, in conjunction with the 1996 MGMA/AMA joint legislation conference, an executive forum for leaders of medical group practices for a discussion of some of the key trends and issues they are facing today. The forum included five group practice executives from a variety of organization types and situations, and was structured to encourage them to engage in a candid exchange about their own opinions and experiences. Discussion was facilitated by Gerald L. McManis, president of McManis Associates, Louis Pavia Jr., executive vice president, and F. Kenneth Ackerman Jr., FACMPE, principal associate. This article provides a summary of the forum proceedings, as well as some commentary by the authors, based on their experience in working with medical group practices around the country.

Integration: opportunities and issues for medical group practices.

McManis Associates, a health care management consulting firm, recently gathered several medical group practice leaders for an informal discussion of integration and other key trends affecting medical groups. The goal of this "Forum for Medical Group Practice Leaders" was to elicit candid discussion among a small group of executives (who are in key positions in medical group practices), identify some of the key strategic issues they are facing and encourage them to share their opinions and experiences. The forum participants come from diverse backgrounds, a wide range of geographic locations and many different types of professional settings, including a single specialty medical group; independent, physician-owned multispecialty groups; an integrated medical center with its own hospital; the physician component of a large, integrated, multi-hospital system; and the leadership of the Medical Group Management Association (MGMA). The discussion was facilitated by Gerald L. McManis, president of McManis Associates, Inc., Louis Pavia Jr., senior vice president, and F. Kenneth Ackerman Jr., FACMPE, principal associate with the management consulting firm. This article provides a summary of the forum's proceedings, and the executive views and opinions of some of the key issues and challenges facing medical group practices today, including integration initiatives, governance, access to capital, critical success factors for group practices, as well as trends and projections for the future.

Resistance of malignant trophoblast cells to both the anti-proliferative and anti-invasive effects of transforming growth factor-beta.

Human placental trophoblast invasion of the uterus is a highly controlled event. We had shown that transforming growth factor-beta (TGF-beta) produced in the pregnant uterus controls invasiveness and reduces proliferation of first trimester placental trophoblasts in vitro. The anti-invasive effect of TGF-beta was due, at least in part, to induction of tissue inhibitor of metalloproteinases (TIMP)-1. In the present study we compared the effects of TGF-beta on proliferation ([3H]-TdR incorporation) and invasiveness (3-day Matrigel invasion assay) of JAR and JEG-3 choriocarcinoma cells vs normal first trimester human trophoblast cells. Transcripts of type IV collagenases (72- and 92-kDa enzymes, i.e., gelatinases A and B) and their inhibitors (TIMP-1 and TIMP-2) in these cells were measured by Northern analysis, and secretion of gelatinases and plasminogen activators (PAs) was evaluated by gel zymography. The results revealed that: (a) TGF-beta inhibited invasiveness and proliferation of normal trophoblast but not JAR and JEG-3 choriocarcinoma cells; (b) gelatinase A mRNA, expressed by the normal trophoblast and JAR cells, was upregulated in the presence of TGF-beta; (c) gelatinase B mRNA was not detected in the total RNA preparations of treated or untreated normal trophoblast or choriocarcinoma cells; (d) TGF-beta significantly upregulated the levels of TIMP-1 mRNA in the normal trophoblasts, but this transcript was very low in treated as well as untreated choriocarcinoma cells; TGF-beta also upregulated the 3.5-kb TIMP-2 message in the normal trophoblast; (e) gelatin zymography revealed a distinct band of approximately 68-kDa (gelatinase A) in the conditioned media of normal trophoblast and JAR cells; however, TGF-beta did not change the level of secretion of this gelatinase; and (f) the normal trophoblast also exhibited significant PA secretion (casein zymography) which was reduced in the presence of TGF-beta. PA secretion by the malignant trophoblast cells was low and unaffected by TGF-beta. These findings suggest that choriocarcinoma cells may become refractory to the mechanisms which control normal trophoblast proliferation and invasiveness. Concurrent resistance to antiproliferative and anti-invasive molecules such as TGF-beta may be highly relevant to tumor progression.

cDNA sequence and alternative mRNA splicing of surfactant-associated protein C (SP-C) in rabbit lung.

An 784 base pair (bp) copy DNA (cDNA) for the low molecular weight hydrophobic surfactant-associated protein C (SP-C) has been isolated from a lambda gt11 cDNA library constructed from fetal rabbit lung mRNA. The cDNA, which coded for a 193 amino-acid proprotein with 6 bp 5' and 193 bp 3' untranslated segments, possesses considerable nucleic acid and predicted amino-acid homology with previously reported SP-C cDNAs. The predicted amino-acid sequence of the 35 amino-acid mature polypeptide shares 94-97% identity with human, rat and mouse SP-C and is 88-91% homologous to the mature proteins from bovine, porcine and canine lung. The last 12 amino acids of mature SP-C are highly hydrophobic and invariant. Alignment of the rabbit and human nucleic acid sequences required introduction of a 27 bp gap in the rabbit sequence at a site corresponding to the exon-intron junction of the 5th exon of the human genomic sequence. Since previous studies have identified differential splicing at the 5' and 3' ends of the human 5th exon, we investigated the potential existence of alternative splicing of rabbit SP-C mRNA. Reverse transcription (RT) of total RNA followed by polymerase chain reaction (PCR) was used to establish the relative abundance of alternative splicing products from fetal and adult lung and from rabbit kidney, placenta and liver. The relative abundance of the 250, 280 and 350 bp bands observed was the same in lung and other tissues. PCR amplification of genomic rabbit DNA indicated that the 350 bp fragment corresponds to the unspliced nascent transcript. The lack of developmental or tissue-specific abundance patterns implies the absence of secondary influences on SP-C mRNA polymorphism. Indeed, free energy of formation calculations predicted the presence of hairpin structures favouring formation of the more abundant 250 bp form. These observations plus the absence of any effect of alternative splicing on SP-C protein structure led us to conclude a physiological role is unlikely.

Levels of surfactant-associated protein messenger ribonucleic acids in rabbit lung during perinatal development and after hormonal treatment.

The levels of messenger RNAs for the surfactant-associated proteins, SP-A, SP-B, and SP-C, have been examined in the developing rabbit lung in vivo. Northern blot analysis detected SP-C mRNA by day 22 of gestation (term 31 days) and SP-A mRNA and SP-B mRNA on day 26, while solution hybridization assays detected all three mRNAs on day 22 of gestation. Both techniques revealed that the mRNA levels increased rapidly during the last quarter of gestation. The mRNA levels determined by solution hybridization were highly correlated during development, with average molar ratios of 1.0:1.1:2.1 for SP-A, SP-B, and SP-C, respectively. We also examined the effect of accelerating fetal pulmonary maturation by maternal administration of either 17 beta-estradiol or betamethasone (9 alpha-fluoro-16 beta-methylprednisolone) on day 26 of gestation. These treatments increased SP-A mRNA levels 8- to 12-fold, resulting in levels 3- to 4-fold greater than in the adult. SP-B mRNA levels increased by approximately 2-fold to near adult levels, while SP-C mRNA was lowered somewhat by 17 beta-estradiol and significantly to less than half by betamethasone. No differences in the levels of surfactant apoprotein mRNAs or in choline incorporation into total or disaturated phosphatidylcholine were noted between male and female fetuses. These observations are consistent with the accepted view that the genes for the surfactant-associated proteins are independently regulated. However, the various factors affecting these mRNAs result in a coordination of mRNA levels during normal perinatal development.