Who is a generalist? An analysis of whether physicians trained as generalists practice as generalists.

Accurate data on the number of generalist physicians are needed to monitor the physician workforce and to plan for future requirements in the changing health care system. This study assessed the relationship between two frequently used definitions of a generalist physician: completion of graduate medical education (GME) in only a generalist discipline and physician's self-report of practicing as a generalist. Data for 4,808 physician graduates from six Pennsylvania medical schools from 1986 to 1991 were analyzed using information from the GME tracking census of the Association of American Medical Colleges and the Physician Masterfile of the American Medical Association. Of 1,291 physicians trained in a generalist discipline, 1,205 (93%) reported practicing as generalists. Conversely, of the 3,517 not trained in a generalist discipline, 3,358 (95%) were not practicing as generalists. These results indicate GME training is a valid predictor of self-reported practice and provide baseline data to monitor future changes.

Fundamental concepts of problem-based learning for the new facilitator.

Problem-based learning (PBL) is a powerful small group learning tool that should be part of the armamentarium of every serious educator. Classic PBL uses ill-structured problems to simulate the conditions that occur in the real environment. Students play an active role and use an iterative process of seeking new information based on identified learning issues, restructuring the information in light of the new knowledge, gathering additional information, and so forth. Faculty play a facilitatory role, not a traditional instructional role, by posing metacognitive questions to students. These questions serve to assist in organizing, generalizing, and evaluating knowledge; to probe for supporting evidence; to explore faulty reasoning; to stimulate discussion of attitudes; and to develop self-directed learning and self-assessment skills. Professional librarians play significant roles in the PBL environment extending from traditional service provider to resource person to educator. Students and faculty usually find the learning experience productive and enjoyable.

Developing curricula to promote preventive medicine skills. The Teaching Immunization for Medical Education (TIME) Project. TIME Development Committee.

CONTEXT: Vaccines are underused in the United States, resulting in needless morbidity. Many experts have concluded that clinician education is critical to increasing the nation's vaccination rates. OBJECTIVE: To develop and evaluate case-based curricular materials on immunizations that promote preventive medicine skills. DESIGN: Before-and-after trial of an educational intervention. SETTING AND PARTICIPANTS: Medical schools and primary care residency programs from 20 institutions across the United States participated in the Teaching Immunization for Medical Education (TIME) project. INTERVENTION: A multidisciplinary team developed learning objectives, abstracted clinical cases, and created case-based modules that use contextual learning and small-group interaction to solve clinical and public health problems. The case-based methods are multistation clinical teaching scenarios (MCTS) and problem-based learning (PBL). MAIN OUTCOME MEASURES: Knowledge gained by learners from pretest to posttest and the overall ratings of the sessions by learners and facilitators based on evaluation questionnaires. RESULTS: Pretest and posttest results were obtained on a total of 1122 learners for all modules combined. For the MCTS method, mean scores increased from the 10-item pretest to the posttest by 3.1 items for measles, 3.8 for influenza, 1.8 for hepatitis B, 3.9 for pertussis, 1.9 for adult vaccination, 1.9 for childhood vaccination, and 2.6 for Haemophilus influenzae type b (P<.01 for each). For the PBL method, mean scores increased by 3.4 items for measles, 3.3 for influenza, 2.6 for hepatitis B, and 2.5 for pertussis (P<.01 for each). Most learners (MCTS, 98%; PBL, 89%) and most facilitators (MCTS, 97%; PBL, 100%) rated the sessions overall as very good or good. CONCLUSIONS: Use of TIME modules increases knowledge about immunizations, an essential step to improving vaccination practices of future clinicians. Given the realities of decreased faculty time and budgets, educators face major challenges in developing case-based curricula that prepare learners for the 21st century. Nationally tested libraries of cases such as the TIME modules address this dilemma.

Development and multicenter evaluation of Multistation Clinical Teaching Scenarios on immunization: the ATPM-CDC Teaching Immunization for Medical Education (TIME) Project.

INTRODUCTION: The objective of this project was to develop and evaluate case-based immunization education materials that use a new teaching method called Multistation Clinical Teaching Scenarios (MCTS) for use in medical school clerkships and primary care residencies. METHODS: A multidisciplinary team developed objectives, abstracted clinical cases, and created MCTS modules, which use contextual learning, problem solving, and small-group interaction. RESULTS: Mean scores increased from the 10-item pretest to the posttest by 3.2 (95% confidence interval [CI] of 2.8 to 3.6) items for measles, 3.8 (CI = 3.4 to 4.1) for influenza, and 1.8 (CI = 1.4 to 2.1) for hepatitis B (P < .01 for each). To evaluate the materials, we administered questionnaires and conducted focus groups. Most (99%) of the students and residents rated the materials highly, as did most (89%) facilitators. CONCLUSIONS: This new method has been widely tested, increases content mastery, and is well received.

Interrater concordance for faculty grading of student performances in a problem-based learning course.

PURPOSE: To determine whether it is possible for faculty to arrive at consistent, non-idiosyncratic grades in a problem-based learning (PBL) course. METHOD: Integrated Case Studies and Medical Decision Making (ICS) is the final course of the second year at the University of Pittsburgh School of Medicine. In ICS, 16 groups of nine students work in a PBL format over seven weeks. Each group is led by three faculty facilitators who, at the end of the course, independently give each student ratings for overall performance in the course and for each of seven performance categories. In 1993-94 and 1994-95, concordance in grades among the facilitators was determined by computing the intraclass correlation coefficients [ICC (3,1)] for the overall scores, the seven performance category scores, and all eight scores in aggregate. An ICC (3,1) of > or = .1 was considered indicative of statistically significant interrater concordance. An ICC (3,1) of > or = .7 was considered indicative of concordance of practical significance. RESULTS: Because the facilitators occasionally did not rate every student in every performance category, complete information was not available for all 32 groups. Statistically significant concordance was achieved in the aggregate scores in 100% of 23 groups, and in the overall scores in 90% of 18 groups. In six of the seven performance categories, concordance was achieved in at least 75% of the groups (n = 16-20). Practically significant concordance was achieved in the aggregate scores in 83% of 23 groups. CONCLUSION: The study results show that, given specific criteria by which to judge students' performances, it is possible to arrive at consistent, non-idiosyncratic grades for students in PBL courses.

Information management of a medical school educational program: a state-of-the-art application.

Quality in the design and management of a medical school education program depends on the ability to access and analyze relevant information in a timely fashion. The components of medical-education information system should support learning and instruction as well as the administrative and research responsibilities of the program. A system capable of meeting these needs requires core, operational, and strategic components. This article discusses a conceptual schema of the medical school environment and reports the results of 3 1/2 years' experience developing core, operational, and strategic components as the University of Pittsburgh School of Medicine. The value of a simple conceptual schema as a design and development instrument was confirmed. Limitations of the system are discussed along with potential solutions.

Integrated case studies and medical decision making: a novel, computer-assisted bridge from the basic sciences to the clinics.

This article describes a novel course that was designed to bridge the gap between the basic science years and clinical experiences in medical school by using information science and computer technology as major components of problem-based learning (PBL) sessions. The course, Integrated Case Studies and Medical Decision Making, was first given to second-year students at the University of Pittsburgh School of Medicine in the spring of 1994. It consists of 13 PBL exercises, each of which explores a clinical case. The cases, including images and gated access to information, are housed on a computer. Using one of 16 networked terminals in specially designed small-group rooms, groups of nine students progress through the cases with a faculty facilitator. The responses of students and faculty to the initial year of the course were favorable. In comparison with traditional PBL sessions, enhanced quality of and access to images and accountability for accessing case information in sequential fashion were cited as major strengths of the course. Juxtaposition of basic science and clinical material and utility in reviewing for the United States Medical Licensing Examination were also cited as strengths. The diversity of the basic science material involved in completing the cases drew overwhelming enthusiasm from students and facilitators alike. In conclusion, the course successfully employs computer and information science technology, which will be of increasing importance to future physicians. The course also serves as an effective bridge to the clinical years of medical school and as a study adjunct for the USMLE.

The undergraduate medical curriculum: centralized versus departmentalized.

The authors describe the advantages and disadvantages of central governance of the undergraduate medical curriculum as contrasted with traditional departmental approaches, based upon their school's experience with a new centrally governed curriculum during the preceding four years. Central governance has more advantages, but also more costs, compared with traditional departmental approaches. Central governance does what it was intended to do: it provides rational and integrative mechanisms for ensuring a broad general education in medicine focusing on the doctor-patient relationship. It also provides an effective mechanism for dealing with "turf" and time issues in the curriculum while allowing for and encouraging changes and providing mechanisms for evaluating those changes. However, as the allocation of resources and rewards remains more departmentally than centrally based, a major challenge of central governance has been to help faculty resolve a "conflict of loyalty" (the sense of serving two masters) between school and department, particularly in the evaluation and reward of teaching. On balance, central governance provides a powerful means of introducing broad-based reforms into all elements of the undergraduate medical curriculum, but it requires ongoing collaboration with faculty and chairs to assist them in negotiating competing pressures and priorities as they strive to become excellent teachers.

Using POSTDOC to recognize biomedical concepts in medical school curricular documents.

Recognition of the biomedical concepts in a document is prerequisite to further processing of the document: medical educators examine curricular documents to discover the coverage of certain topics, detect unwanted redundancies, integrate new content, and delete old content; and clinicians are concerned with terms in patient medical records for purposes ranging from creation of an electronic medical record to identification of medical literature relevant to a particular case. POSTDOC (POSTprocessor of DOCuments) is a computer application that (1) accepts as input a free-text, ASCII-formatted document and uses the Unified Medical Language System (UMLS) Metathesaurus to recognize relevant main concept terms; (2) provides term co-occurrence data and thus is able to identify potentially increasing correlations among concepts within the document; and (3) retrieves references from MEDLINE files based on user identification of relevant subjects. This paper describes a formative evaluation of POSTDOC's ability to recognize UMLS Metathesaurus biomedical concepts in medical school lecture outlines. The "precision" and "recall" varied over a wide range and were deemed not yet acceptable for automated creation of a database of concepts from curricular documents. However, results were good enough to warrant further study and continued system development.

Using the UMLS to represent medical curriculum content.

Recent innovations in medical education have highlighted the need for faculty involved with the curriculum to carefully examine curricular content with goals of detecting omissions and unwanted redundancies of subject matter, adding and integrating new content, and deleting old content. A number of medical schools have attempted to deal with these issues by developing a database of curricular content information, most often using faculty- or student-selected keywords to represent each unit of instruction. However, several problems have been identified with this method, and achieving the goals mentioned above remains a formidable task. This paper outlines an alternative method that uses the resources of the UMLS to characterize a medical concept by the semantic types of its co-occurring terms. This approach can facilitate achievement of the aforementioned goals.

Paraplegia after a routine lumbar laminectomy: report of a rare complication and successful management.

Arachnoid cysts of the spinal canal are relatively common lesions that may be either intra- or extradural. These cysts are usually asymptomatic but may produce symptoms by compressing the spinal cord or nerve roots. We report a case in which an intradural thoracic arachnoid cyst became symptomatic after a routine decompressive lumbar laminectomy for spinal stenosis. Myelography revealed no abnormality, although magnetic resonance imaging and computed tomography after myelography demonstrated a mass within the posterior aspect of the thoracic spinal canal associated with anterior displacement and compression of the spinal cord. A change in the flow dynamics of the cerebrospinal fluid probably allowed the development of spinal cord compression due to one of the following: expansion of the cyst, decreased cerebrospinal fluid buffer between the cord and the cyst, or epidural venous engorgement. A concomitant and more cephalad lesion such as an arachnoid cyst should be considered when myelopathic complications arise after lumbar surgery. Magnetic resonance imaging and computed tomography after myelography are useful to demonstrate the additional pathological processes.

Pure word deafness: a possible explanation of transient deteriorations after extracranial-intracranial bypass grafting.

Pure word deafness is a rare behavioral disorder in which the comprehension of spoken language is grossly disturbed, but the abilities to speak, read, write, and process nonverbal auditory stimuli remain intact. This disorder is caused by superior temporal gyrus lesions in the dominant hemisphere that isolate Wernicke's area from incoming auditory information. This involved area is supplied by cortical middle and posterior temporal end-artery branches of the middle cerebral artery. Among approximately 100 extracranial-intracranial bypass procedures performed at our institution in the past 5 years, three patients developed the syndrome of pure word deafness. A cortical or posterior temporal branch of the middle cerebral artery was utilized as the recipient artery in each instance. In all cases, the deficit was transient, delayed (i.e. the patient did not awaken from anesthesia with the deficit), and unrelated to the preoperative deficit. The syndrome of pure word deafness may be more common after bypass than is currently recognized. Localized arterial spasm, dysautoregulation secondary to operative manipulation, or focal brain swelling may be operative mechanisms in the development of this and other delayed, reversible deficits related to bypass surgery.

Percutaneous discectomy: an anatomical study.

Percutaneous discectomy is a viable alternative in the treatment of herniated intervertebral discs of the lumbar spine. Anatomical analysis of the retroperitoneal surgical path utilizing computed tomography suggests that the risk of vascular injury is negligible at the L-4, L-5 level, but substantial at the L-5, S-1 level. In addition, one-third of patients otherwise suitable for percutaneous discectomy have segments of bowel obstructing the surgical path. Obtaining an abdominal computed tomographic scan with the patient in the surgical position seems to be a valuable screening technique in the evaluation of candidates for this procedure.