What did we learn about national organizational collaboration at the advisory committee level?

This article provides an overview of the typical roles and tasks of advisory groups in general, followed by a discussion of the roles and tasks the Interdisciplinary Generalist Curriculum (IGC) Project Advisory Committee was asked to assume and how these were fulfilled. It analyzes the lessons learned about advisory committees as a result of the IGC Project experience. Key elements of success in fulfilling advisory committee obligations include well-defined expectations, periodic evaluations, and clear communication between project leadership and the members of the advisory committee. In the spirit of lessons learned from the IGC Project, this critique identifies several philosophical and logistic issues that might be considered in the design and implementation of future projects, such as the need to choose committed, high-energy advisory committee members who are willing to perform many complex, time-consuming tasks.

What did we learn about the impact on community-based faculty? Recommendations for recruitment, retention, and rewards.

All ten schools participating in the Interdisciplinary Generalist Curriculum (IGC) Project were required to offer students significant generalist longitudinal preceptorship experiences during the first two years of medical school. Each school needed to recruit and then retain many new preceptors to meet the continued large demand. Effective recruitment was usually carried out by established community physicians and/or qualified staff coordinators. Retention of preceptors required establishing regular and succinct communications, quick response to problems, and flexible faculty development programs. For rewards, preceptors primarily requested acknowledgment and appreciation, along with tangible rewards such as decreased fees for continuing medical education and library or e-mail access. Preceptors continue to state that they teach because of the "joys of teaching" even in the current environment with increased demands for productivity. This article describes what has been learned about recruitment, retention, and rewards for community preceptors and how to maximize the positive impacts and minimize the negative impacts of teaching for community preceptors.

The Interdisciplinary Generalist Curriculum Project at the University of Vermont College of Medicine: The Vermont Generalist Curriculum (VGC) Experience.

The University of Vermont College of Medicine received its Vermont Generalist Curriculum (VGC) subcontract as one of the second-cycle Interdisciplinary Generalist Curriculum (IGC) Project schools from 1995 to 1998. The Vermont program was jointly codirected by the chairs of family practice and pediatrics and the program director for internal medicine on a rotating basis and was overseen by a multidisciplinary steering committee that included generalists, basic scientists, specialists, and students. This committee provided guidance and support in recruitment of preceptors, continuous assessment and improvement of the courses, development of a clinical correlation manual for students in clinical offices, and cooperation around a jointly sponsored annual primary care meeting that included a joint scientific program, a research forum, and a faculty development workshop. The VGC has provided a pilot for many innovative curricular changes that have served as models for the school-wide curriculum redesign process currently under way at VERMONT: While the funding for this project ended in 1998, the changes, innovations, and collaboration born out of the project are valuable enough for the dean's office to maintain the VGC's funding and its steering committee for the future.

Final report of the FOPE II Pediatric Workforce Workgroup.

From the inception of the Future of Pediatric Education II (FOPE II) Project, it was acknowledged that any discussion of pediatric education would need to encompass a review of the pediatric workforce. This report looks at the current trends in pediatric workforce and draws some conclusions regarding future growth and composition. In addition to looking at demographic trends, ranging from geography to gender, the report explores influences including managed care, telemedicine, and others. Models for determining workforce needs are described and scenarios and projections are discussed. Pediatrics 2000;106(suppl):1245-1255; pediatric workforce.

A case-study approach. Fellows' perceptions of a teaching course.

OBJECTIVE: To determine general and behavioral pediatric fellows' perceptions of a formal teaching course. DESIGN: Qualitative research design using a case-study approach. SETTING: Children's Hospital in Boston, Mass. PARTICIPANTS: All first-year general and behavioral pediatric fellows (n=5) taking the teaching course. INTERVENTION: A 12-week teaching course given to all participants. MEASUREMENTS/MAIN RESULTS: Data were collected using questionnaires completed by fellows; focused, open-ended interviews with fellows; and student ratings of fellows' teaching. Analysis revealed that after the course, the fellows perceived "teaching'' as an interactive, student-directed process; attained a greater awareness of the value of feedback; recognized new teaching opportunities; and changed their teaching strategies to reflect student-directed teaching. CONCLUSION: This formal course influenced fellows' approach to teaching.

The infant or young child with developmental delay.

The practitioner should attempt to identify the infant and young child with developmental delay as early as possible, so that appropriate services can be provided. Ongoing surveillance is required, rather than one-time screening. The practitioner should also serve as an advocate for children with developmental delay. He or she should ensure that appropriate services exist within the child's community and that they are readily accessible. This requires ongoing communication not only with the child and the family, but also with schools and community agencies.

Clinical determinants of the racial disparity in very low birth weight.

BACKGROUND: Although the risk of very low birth weight (less than 1500 g) is more than twice as high among blacks as among whites in the United States, the clinical conditions associated with this disparity remain poorly explored. METHODS AND RESULTS: We reviewed the medical records of over 98 percent of all infants weighing 500 to 1499 g who were born in Boston during the period 1980 through 1985 (687 infants), in St. Louis in 1985 and 1986 (397 infants), and in two health districts in Mississippi in 1984 and 1985 (215 infants). The medical records of the infants' mothers were also reviewed. These data were linked to birth-certificate files. During the study periods, there were 49,196 live births in Boston, 16,232 in St. Louis, and 16,332 in the Mississippi districts. The relative risk of very low birth weight among black infants as compared with white infants ranged from 2.3 to 3.2 in the three areas. The higher proportion of black infants with very low birth weights was related to an elevated risk in their mothers of major conditions associated with very low birth weight, primarily chorioamnionitis or premature rupture of the amniotic membrane (associated with 38.0 percent of the excess proportion of black infants with very low birth weights [95 percent confidence interval, 31.3 to 45.4 percent]); idiopathic preterm labor (20.9 percent of the excess [95 percent confidence interval, 16.0 to 26.4 percent]); hypertensive disorders (12.3 percent [95 percent confidence interval, 8.6 to 16.6]); and hemorrhage (9.8 percent [95 percent confidence interval, 5.5 to 13.5]). CONCLUSIONS: The higher proportion of black infants with very low birth weights is associated with a greater frequency of all major maternal conditions precipitating delivery among black women. Reductions in the disparity in birth weight between blacks and whites are not likely to result from any single clinical intervention but, rather, from comprehensive preventive strategies.

Learning by teaching. A resident-taught oral therapy program for acute diarrhea.

An educational program on oral rehydration therapy (ORT) for diarrhea was instituted in our residents' continuity clinics to evaluate the impact that residents teaching parents would have on the knowledge and practices of both groups. Sixty-one residents and 287 parents answered the initial written questionnaire before the teaching program began, and 48 residents and 147 parents completed a second questionnaire at the end of the program. Nineteen residents in two clinics were told to participate frequently in teaching the parents, while 29 residents in three other clinics were given no such instructions. The parents were divided into three groups: 58 received teaching and an instructional handout on the management of diarrhea; 73 received only the instructional handout; and 16 received neither intervention. The 19 "teaching" residents had a significantly improved overall score compared with the "nonteaching" residents (p < .03). No improvement was found in the scores of the 58 parents who received teaching compared with those of the 89 parents who received either a handout or no educational intervention. We conclude that active teaching of ORT may improve the knowledge and practices of residents, but that single teaching encounters, whether or not accompanied by written instructions, may have little impact on parents.

Infant mortality increase despite high access to tertiary care: an evolving relationship among infant mortality, health care, and socioeconomic change.

In this study, the determinants of an apparent increase in the infant mortality rate of an urban population with high access to tertiary neonatal care are reviewed. For a 4-year period (1980 to 1983), all infant deaths (n = 422) of the 32,329 births to residents of the City of Boston were analyzed through linked vital statistics data and a review of medical records. A significant increase in the infant mortality rate occurred in 1982 due to increases in three components of the infant mortality rate: the birth rate of very low birth weight infants (less than 1,500 g), the neonatal mortality rate of normal birth weight infants (greater than or equal to 2,500 g), and the mortality rate of infants dying during the postneonatal period (28 to 365 days). These increases were associated with inadequate levels of prenatal care. Although transient, the impact of the observed alterations in these infant mortality rate components was enhanced by a more long-standing phenomenon: the stabilization of mortality rates for low birth weight infants. This stabilization allowed the increases in other component rates to be expressed more fully than in previous years. In this report a mechanism is shown whereby fully regionalized neonatal care ultimately may confer to the infant mortality rate a heightened sensitivity to socioeconomic conditions and levels of adequate prenatal care.

Isolated thrombocytopenia after allogeneic bone marrow transplantation: existence of transient and chronic thrombocytopenic syndromes.

Isolated thrombocytopenia after bone marrow transplantation was investigated in 65 fully engrafted patients surviving at least 60 days posttransplant. Twenty-four patients (37%) developed this complication, which occurred most frequently in patients receiving pretransplant preparation with total body irradiation or busulfan. Two distinct thrombocytopenic syndromes were identified: (1) transient thrombocytopenia (nine patients), in which a normal platelet count (greater than 100,000/microL) was initially established by day +40 but then diminished to less than 10,000 to 45,000/microL on day +40 to +70, with subsequent resolution of the thrombocytopenia by day +90; (2) chronic thrombocytopenia (15 patients), in which a platelet count greater than 100,000/microL was not achieved at any time during the first four months posttransplant, despite the simultaneous presence of normal granulocyte and reticulocyte counts. Although the transient syndrome did not adversely affect prognosis, the chronic syndrome carried a high mortality (21% actuarial survival at 1,000 days posttransplant compared with 67% survival for all patients, P less than .01) and had a high association with both severe (grades 3 to 4) acute graft-versus-host disease (GVHD) and chronic GVHD. In three of nine patients with transient thrombocytopenia, a temporal association with trimethoprim-sulfamethoxazole administration was observed, whereas in all other patients, no drug association could be found. Bone marrow biopsies in those patients with drug-associated thrombocytopenia showed decreased numbers of megakaryocytes, whereas biopsies in the remainder of the transiently thrombocytopenic patients demonstrated adequate numbers of platelet precursors, suggesting peripheral platelet destruction or ineffective thrombopoiesis. Biopsies in the chronic thrombocytopenic patients included those with and without adequate numbers of platelet precursors, although the association with chronic GVHD was strongest in patients demonstrating normal numbers of megakaryocytes. We conclude that isolated thrombocytopenia represents a significant complication of bone marrow transplantation, particularly in patients receiving hematopoietic ablative preparatory regimens, and that it is the chronic, not the transient, thrombocytopenic syndrome that is associated with an adverse patient prognosis.

Primary cutaneous aspergillosis in a premature neonate.

A case of primary cutaneous aspergillosis in a 3-week-old premature infant is reported. The lesion, which presented as a solitary nodule surmounted by three pustules, occurred following the use of elasticized and cloth adhesive tape and was cured by surgical excision. Factors predisposing to this infection included maceration, antibiotic usage, and prematurity.