Program report cards: evaluation across multiple residency programs at one institution.

The designated institution official (DIO) is responsible for monitoring all residency programs within an institution. Although program-evaluation tools have been developed for residency program directors to use, there are currently no such published evaluation tools for DIOs. This manuscript describes the development and implementation of a standardized, dimensional program report card for the more than 60 residency and fellowship programs at our institution. This report card measures the theoretical construct of residency program performance and is divided into four sections: (1) quality of candidates recruited, (2) the resident educational program, (3) graduate success, and (4) overall house officer satisfaction. Each section is measured by objective and subjective metrics that allow the DIO to record programmatic strengths and weaknesses. These results are confidentially shared with the residency program director and encourage a partnership between the DIO and the program director. It is difficult to provide concrete construct validity with this instrument. The process used to develop the report card seems valid. The authors recognize that this report card is a surrogate for each program's RRC's perception of quality. In the future, the authors hope to work closely with the Accreditation Council for Graduate Medical Education and/or the group on resident affairs of the Association of American Medical Colleges to set national benchmark criteria for acceptable residency program performance for each medical discipline. They hope that DIOs and program directors will be able to compare residency programs objectively and identify areas for improvement at a local and national level.

Primary hyperparathyroidism with a low-normal, atypical serum parathyroid hormone as shown by discordant immunoassay curves.

CONTEXT: In patients with primary hyperparathyroidism (PHP), one expects to find a serum PTH in the high or high-normal range. The presence of a low-normal PTH in PHP can be difficult to explain. OBJECTIVE: Our objective was to investigate the cause of a low-normal serum PTH in a patient with PHP. PATIENT: A 57-yr-old asymptomatic white female from the private practice of F.W.L. presented with an 8-yr history of a rising serum calcium from 10.5-11.6 mg/dl (2.63-2.88 mmol/liter) and a low-normal serum intact PTH of 29.2 pg/ml. After localization of a parathyroid adenoma by [(18)F]fluorodesoxyglucose positron emission tomography scanning, a 120-mg parathyroid adenoma was removed with the achievement of normocalcemia for the subsequent 2 yr. METHODS: Routine pre- and postoperative serum intact PTH assays were preformed at both the Quest Diagnostics regional laboratory in Pittsburgh, Pennsylvania, and at the Quest Diagnostics Nichols Institute in California. In addition, intact, biointact, and C-terminal assays were measured in undiluted, 1:2 diluted, and 1:4 diluted sera at the Nichols Institute. PTH gene sequence analysis was performed from DNA extracted both from the parathyroid adenoma and the patient's peripheral blood leukocytes. RESULTS: Dilution, with correction for the dilution factor, of the preoperative serum produced a progressive rise in the intact, biointact, and the C-terminal assays, whereas no dilution effect was seen in postoperative serum. No intragenic mutations in the pre-pro-PTH coding region were found in either the parathyroid adenoma or matched blood DNA samples. CONCLUSIONS: The discordant preoperative immunoassay curves with dilution could not be explained by the adenoma producing a mutated PTH. Furthermore, an autoantibody against the PTH produced by the adenoma is ruled out by the prompt loss of the dilution effect in the three PTH assays within 1 wk of the adenoma's excision. A posttranslational effect on the PTH molecule within the adenoma remains a possible explanation for the discordant immunoassay curves. Our report emphasizes that one cannot always rule out PHP because of a low-normal serum intact or biointact PTH. Repeated PTH measurements after serum dilution in suspected cases of PHP with low-normal PTH levels may be a useful method for detecting atypical forms of PTH.

Personal observations on the cultural evolution in academic surgery.

BACKGROUND: The changing environment in academic medical centers has had a major effect on the recruitment and the demographic characteristics of leadership positions in academic surgery. Categorization of "cultures" from the business model has been extrapolated into the academic surgical model. METHODS: The types of cultures in organizations according to Cameron and Quinnn at a school of management can be classified into four: clan culture, adhocracy culture, hierarchy, and market-driven culture. In addition, academic surgical chairmen were surveyed in 1981 and also 20 years later, 2001, by the author. This was done in an effort to determine whether there is a difference in the type of person being attracted to such positions and if there is demographic difference in academic chairmen over the two decades. RESULTS: The organizational profile of academic departments in 1980 is perceived to be more clan and adhocracy in type and less hierarchical and market driven. That has reversed itself dramatically two decades later with much of the energy of a department and structure based on hierarchy and the market. Also, in terms of the chairman, the mean age at the time of appointment in 1981 was 44 years and the mean age at time of appointment in 2001 was 49 years. In 1981 the years in grade was 9.4 years and in 201 it is 7.1 years. The new chairman is now older and will not serve as long as his/her predecessor. CONCLUSIONS: There clearly has been a cultural evolution in academic surgery over the past two decades. The chairman has different priorities than chairmen 20 years ago. The success of an academic department will depend upon the adaptation to this cultural evolution and the understanding of the chairman as to what the job really is.