The missions of medical schools: the pursuit of health in the service of society.

Mission statements and role documents of medical schools in the United Kingdom, United States, Canada and Australia have been examined on their Internet Web sites and categorised in purpose, content and presentation. The format and content are highly variable, but there is a common vision of three integral roles, namely, education, advancement of knowledge and service to society. Other frequent themes include tradition and historical perspective, service for designated communities, and benchmarking to accreditation standards. Differences in content reflect variable interpretation of the notion of "mission", and local or national characteristics such as institutional affiliations, the types, levels and organisation of medical education, relationships with health systems, and extent of multi-professional education. Outcomes data and measures of medical school performance referenced to the institution's stated missions are rarely encountered. Mission documents placed on the Internet are in the public domain. These Web sites and documents and linked information constitute a valuable new resource for international exchange of approaches and ideas in medical education and generally in academic medicine. Routine inclusion of outcome or performance data could help to demonstrate the community roles and social accountability of medical schools This paper proposes that partial standardisation of these Web documents could enhance their value both internally and for external readers. A generic descriptive statement template is offered.

Assessment of physician performance in Alberta: the physician achievement review.

The College of Physicians and Surgeons of Alberta, in collaboration with the Universities of Calgary and Alberta, has developed a program to routinely assess the performance of physicians, intended primarily for quality improvement in medical practice. The Physician Achievement Review (PAR) provides a multidimensional view of performance through structured feedback to physicians. The program will also provide a new mechanism for identifying physicians for whom more detailed assessment of practice performance or medical competence may be needed. Questionnaires were created to assess an array of performance attributes, and then appropriate assessors were designated--the physician himself or herself (self-evaluation), patients, medical peers, consultants and referring physicians, and non-physician coworkers. A pilot study with 308 physician volunteers was used to evaluate the psychometric and statistical properties of the questionnaires and to develop operating policies. The pilot surveys showed good statistical validity and technical reliability of the PAR questionnaires. For only 28 (9.1%) of the physicians were the PAR results more than one standard deviation from the peer group means for 3 or more of the 5 major domains of assessment (self, patients, peers, consultants and coworkers). In post-survey feedback, two-thirds of the physicians indicated that they were considering or had implemented changes to their medical practice on the basis of their PAR data. The estimated operating cost of the PAR program is approximately $200 per physician. In February 1999, on the basis of the operating experience and the results of the pilot survey, the College of Physicians and Surgeons of Alberta implemented this innovative program, in which all Alberta physicians will be required to participate every 5 years.

Seasonal onset of systemic-onset juvenile rheumatoid arthritis.

OBJECTIVE: This study was undertaken to investigate the recent finding of a seasonal difference in the onset of systemic-onset juvenile rheumatoid arthritis (SoJRA). We hypothesized that a seasonal onset pattern might implicate on infectious agent as a cause of SoJRA. METHODS: The date of onset was collected from the records of all patients with SoJRA from 1980 to 1992 at presentation to pediatric rheumatology clinics across Canada. The onset pattern of SoJRA was then compared with incidence data on viral infections obtained for the same period. RESULTS: Across Canada the onset of SoJRA was constant across the seasons. However, in the Prairie region there was a statistically significant seasonal pattern, with peaks in autumn and early spring. We could find no evidence that viral incidence correlated with disease incidence either throughout Canada or in the Prairie region. CONCLUSIONS: If a seasonal infectious agent causes SoJRA, then it is likely only one of several causes and may act only in certain regions. Future studies should be carried out in those areas where SoJRA does have a seasonal onset pattern.

Hospital grand rounds in family medicine. Content and educational structure.

OBJECTIVE: To investigate hospital grand rounds in family medicine, to examine their content and organization, and to recommend improved educational structures for these ubiquitous continuing medical education events. DATA SELECTION: Retrospective analysis of titles and content of 358 family medicine grand rounds offered in the department of family medicine of a large urban hospital from mid-1983 to the end of 1994. FINDINGS: Only 10% of family medicine grand rounds were presented by family physicians. Most grand rounds were in the form of specialists exhibiting their own interests in a lecture format. Analysis of grand rounds titles showed no consistent pattern of topics but an emphasis on practical aspects of medical care. Patient-based presentations were uncommon, as were grand rounds with more than one speaker. CONCLUSIONS: The content and mix of topics appeared appropriate, but in the absence of a curricular structure, or evaluation of learning gain, it is difficult to assess the value of grand rounds.

Juvenile dermatomyositis in a child infected with human parvovirus B19.

We report a case of juvenile dermatomyositis in which clinical onset occurred soon after infection with human parvovirus B19. To the best of our knowledge an association between juvenile dermatomyositis and human parvovirus B19 has not been previously reported. Parvovirus infection has been associated with several autoimmune diseases, and the findings in the case we describe raise the possibility that parvovirus may induce juvenile dermatomyositis, although we could not demonstrate a causal relationship.

Grand rounds: a paradox in medical education.

OBJECTIVES: To assess perceptions of the importance and educational purpose of hospital grand rounds among physicians with administrative responsibilities, and to examine organizational aspects of grand rounds as educational events. DESIGN: Descriptive survey by mailed nonanonymous questionnaire. SETTING: All hospitals of more than 100 beds in Calgary. PARTICIPANTS: A total of 150 residency program directors and directors of departments and divisions in hospitals with differing teaching functions. RESULTS: A total of 120 questionnaires (80%) were returned, and the responses of 107 physicians were analysed. Each year in Calgary formal grand rounds activities occupy auditoriums and seminar rooms for more than 2000 hours. Most respondents considered grand rounds to be the main hospital-based continuing medical education activity in their discipline. Aspects of grand rounds considered to be important were updates in research, diagnosis and management, and only one third of the respondents felt that actual patient problems should always be the focus of discussion. The organization and planning of grand rounds revealed a paradox: despite the perceived educational importance, only 13% of rounds were based on a curricular structure, and 16% were based on needs assessments. The grand rounds topic was most often the choice of the presenter. CONCLUSIONS: The quantity of time devoted to grand rounds suggests importance in the routine workings of hospital departments. Grand rounds are used as a showcase for excellence in medical care or recent medical advances. It is paradoxical, therefore, that little interest appears to be shown in educational structure such as curriculum or evaluation of learning. Professional interaction is an inherent objective of traditional grand rounds. Further evaluation of the purpose and educational efficacy of traditional grand rounds is suggested.

Sequence, expression and characterization of HPRTMoose Jaw: a point mutation resulting in cooperativity and decreased substrate affinities.

We have sequenced and studied the expressed protein of an HPRT mutation characterized by 5-12% residual erythrocyte activity, for which affected males exhibit hyperuricemia, arthritis and renal disease but are without severe neurological involvement. The HPRTMoose Jaw mutation is due to a single C to G transversion at nucleotide 582 relative to initiation of translation corresponding to substitution of aspartate 194 by glutamate. The mutant and wild type proteins were expressed and purified using the bacterial expression vector, pMAL-c2. The Km for hypoxanthine was increased 12-fold from 0.94 +/- 0.26 to 11.5 +/- 1.3 microM for control and mutant respectively. The apparent Km for PP-ribose-P was increased 44-fold from 6.8 +/- 0.6 to 295 +/- 7 microM for control and mutant respectively. Although the kcat of the mutant protein was equivalent to wild type, the catalytic efficiency, kcat/Km, of the purified mutant protein was only 6 and 3% of wild type with hypoxanthine and PP-ribose-P respectively. The mutant protein also exhibited positive cooperativity with PP-ribose-P, having a Hill coefficient of 2.3. The decreased substrate affinities and PP-ribose-P associated cooperativity of HPRTMoose Jaw provide additional evidence for the influence of carboxy-terminal residues of HPRT in specific catalytic functions.

Early introduction to medical problem-solving.

This is a descriptive report of a course unit designed to introduce concepts of medical problem-solving during the first month of an undergraduate MD curriculum. The unit is also used to provide an introduction to the dynamics of cooperative small group learning. The value of the unit was endorsed by the subjective opinions of faculty tutors and students, who recognized the relevance of the unit to the clinical practice of doctors. An end-of-course examination demonstrated that some novice medical problem-solvers have difficulty with recursive hypothesis testing and tend to use linear strategies. This type of learning experience has the potential to identify students who may have subsequent difficulty in clinical reasoning tasks in the curriculum. Medical problem-solving itself is the primary focus of problem-based learning in the unit. Experience with this unit suggests that concepts of medical problem-solving can be introduced into the curriculum at a very early stage, without a prerequisite for substantial knowledge of medical sciences.

The arthropathy of hereditary arthroophthalmopathy (Stickler syndrome).

Hereditary arthroophthalmopathy (Stickler syndrome) is an autosomal dominant syndrome characterized by musculoskeletal, ophthalmic and dysmorphic facial features. A family is described illustrating diverse expressions of Stickler syndrome, including abnormalities not directly attributable to mutation of the type II procollagen gene. A review of the literature demonstrates a range of articular problems, several of which are not specific to Stickler syndrome, and might be encountered in either adult or pediatric rheumatology practice. Stickler syndrome may be underrecognized by rheumatologists, particularly if the significance of nonarticular clinical features or a positive family history are not appreciated.

Spondyloepiphyseal dysplasia tarda simulating juvenile arthritis: clinical and molecular genetic observations.

A sibship is reported in which two of three children developed a symmetrical polyarthropathy associated with a mild spondyloepiphyseal dysplasia. Although the physical findings resembled juvenile arthritis, laboratory investigations for inflammatory disease were entirely negative. Molecular studies in members of this family showed that none of them had any structural rearrangements or other major abnormality of the type II procollagen gene (COL2A1). The laboratory findings in this family with "pseudo-rheumatoid arthritis" do not exclude the possibility of a minor mutation of the type II procollagen gene or a defect in the processing of articular cartilage collagens.

The clinical genetics of lupus.

Genetic aspects of lupus are reviewed, including recognition of genetic and clinical heterogeneity, genetic factors in the aetiology and heritability of disease, reproductive implications and genetic counselling of patients. Despite a large literature on the genetic epidemiology and immunogenetics of lupus, it remains difficult to apply the results of laboratory findings to the circumstances of individual patients. Generally, lupus is not transmitted as a simple Mendelian trait, and genetic counselling is based on the multifactorial model of disease aetiology with interaction of multiple genetic and environmental factors. Further studies are needed to clarify the heritability of lupus and improve the data for recurrence risk prediction in lupus families.

Disseminated zygomycosis associated with systemic lupus erythematosus.

We describe a 36-year-old patient who had systemic lupus erythematosus (SLE) and died of disseminated zygomycosis. There was rapid progression of his SLE, leading to suspicion of superimposed infectious disease, but the actual cause of his multiorgan failure was not recognized until after death. The manner in which systemic fungal infection may mimic SLE is discussed.

Breast arteritis in polymyalgia rheumatica.

A 79-year-old woman with the clinical presentation of polymyalgia rheumatica (PMR) also had breast cancer. Histopathologic evidence of arteritis was found in mastectomy tissue and in a temporal artery, neither of which had produced symptoms before surgery. Previously reported cases are reviewed in the context that breast vasculitis may be more common than in generally recognized in patients with PMR.