Continuing medical education: a new vision of the professional development of physicians.

The authors describe their vision of what continuing medical education (CME) should become in the changing health care environment. They first discuss six types of literature (e.g., concerning learning and adult development principles, problem-based/practice-based learning, and other topics) that contribute to ways of thinking about and understanding CME. They then state their view that the Association of American Medical Colleges (AAMC) has made a commitment to helping CME be more effective in the professional development of physicians. In presenting their new vision of CME, the authors describe their interpretation of the nature and values of CME (e.g., optimal CME is highly self-directed; the selection and design of the most relevant CME is based on data from each physician's responsibilities and performance; etc.). They then present seven action steps, suggestions to begin them, and the institutions and organizations they believe should carry them out, and recommend that the AAMC play a major role in supporting activities to carry out these steps. (For example, one action step is the generation and application of new knowledge about how and why physicians learn, select best practices, and change their behaviors). Six core competencies for CME educators are defined. The authors conclude by stating that collaboration among the appropriate academic groups, professional associations, and health care institutions, with leadership from the AAMC, is essential to create the best learning systems for the professional development of physicians.

Internal mammary arteriography without selective cannulation using a new balloon occlusion catheter.

Internal mammary artery (IMA) angiography can be difficult and time-consuming. We evaluated a custom designed balloon-tipped catheter, a Berman catheter (Arrow International, Reading, PA) modified by creating an end-hole to allow passage of a wire through the central lumen, for imaging the IMA without selective cannulation. We compared ease of use, procedure time, and image quality of the new catheter with the standard selective catheter technique. Thirty-six patients with IMA grafts were randomly assigned to imaging with either the study catheter or a standard catheter. Image quality, graded from poor to excellent, time to catheter placement in the subclavian artery (TIME 1), time to initial IMA angiography (TIME 2), and the difference between these two (TIME 3) were recorded. TIME 3 defined the time required to find and seat the catheter at the IMA site. The image quality was good or excellent in all but one patient. This one patient, randomized to the standard catheter technique, had poor image quality with the selective catheter. However, exchange for the study catheter resulted in excellent image quality. There was no difference in TIME 1 (P = 0.57) or TIME 2 (P = 0.55) between the two techniques. There was a significant difference in TIME 3 (P = 0.05) favoring the study catheter. There were no complication using either technique and the total contrast volume used was not significantly different between the two techniques (P = 0.32). We conclude that a new catheter technique for imaging the IMA without selective cannulation is safe, fast, easy to use, and may offer particular advantage in patients whose internal mammary artery is difficult to access.

Signal-averaged ECG prior to and serially after thrombolytic therapy for acute myocardial infarction.

Signal averaging has been performed to evaluate late potentials following infarction and the administration of thrombolytic therapy. Most studies have recorded signal-averaged electrocardiograms (SAECGs) at least 12 hours after the onset of the infarction. In this study, SAECGs were recorded before thrombolytic therapy and serially over 7-10 days following infarction in 21 patients. The high frequency QRS duration was significantly shortened at 1 and 24 hours compared to presentation (96.8 +/- 11.3 ms and 93.4 +/- 8.0 ms vs 103.3 +/- 14.3 ms, respectively, P < 0.05) and there was an increase in the terminal voltage over time, significant at 1 hour and 3 days (57.3 +/- 29.1 microV and 58.6 +/- 44.7 microV vs 44.4 +/- 35.5 microV, respectively, P < 0.01). Five patients met criteria for ventricular late potentials on at least one SAECG. The prevalence of late potentials was higher in patients with Q wave infarctions, or with occluded infarct related arteries. These changes in myocardial activation may be related to ischemia and reperfusion, and may not correlate with the development of a fixed substrate for reentry.

Effects of exercise on signal-averaged electrocardiogram.

Signal averaging can be used to assess changes in myocardial activation under a variety of physiological conditions including stress. This study prospectively evaluated patients who underwent rest and exercise recording of signal-averaged electrocardiograms. The 163 patients were divided into three groups based on thallium results: normal (group I), reperfusion (group II), and fixed defect (group III). Patients in group I showed shortening of the high frequency duration (P = 0.02) and the duration of the low amplitude signal (P = 0.024) after exercise. In these patients the terminal root mean square amplitude (RMSA) also increased significantly (P = 0.005). However, patients who were in either group II or group III showed little change in signal averaging measurements after exercise. The amplitude of the QRS in V5 and the RMSA of the total QRS also increased in all groups following exercise, with a lesser increase in the patients with reperfusion by thallium imaging (group II). There was no change among groups in the incidence of ventricular late potentials with exercise. This suggests that patients with ischemia or infarction may not have the same response to an increase in sympathetic tone with exercise as patients without abnormalities of cardiac perfusion. The clinical implications of these findings may include demonstration that an area of slow conduction exists in these latter two groups of patients.

Assessment tools in psychiatry.

With the advent of managed care, administrators of mental health care will need to implement outcomes measurement systems that will provide information for cost control and quality improvement. These systems must take into account the changes occurring in the delivery of mental health care, such as the broad range of settings in which mental health care occurs, and allow for the measurement of outcomes over time. A useful system must also be flexible, allowing measures to tailor the system to individual needs. Two types of systems are currently being used. Simple systems measure general outcomes, such as patient satisfaction, at baseline and discharge. More complex systems are disorder-specific and can be used to compare different types of treatments or different groups of patients. The simple systems are less costly but are not as useful to quality improvement. The disorder-specific systems are more expensive, but the information gathered with these systems can be used in quality management. As implementation of these systems becomes more commonplace, challenges such as lack of standardization, patient reluctance to fill out forms, and the need for sensitive measurement instruments will need to be addressed.

Adverse effects of calcium binding contrast agents in diagnostic cardiac angiography. A comparison between formulations with and without calcium binding additives.

RATIONALE AND OBJECTIVES: The authors compared complications and hemodynamic and electrophysiologic effects of two formulations of diatrizoate, one with additives that bind calcium and one without, in diagnostic cardiac angiography. METHODS: Two hundred twenty-three consecutive low-risk patients alternately received Hypaque 76 (group 1, little calcium binding effect), and MD 76 (group 2, significant calcium binding). Electrocardiographic and hemodynamic changes related to coronary angiography and left ventriculography were measured, and complications requiring treatment were recorded. RESULTS: There were more complications in patients in group 2 than in group 1 (18 versus 8, P = 0.04). Arterial pressure fell more, the QT interval increased more, and the heart rate fell more in group 2 after coronary angiography. CONCLUSIONS: Formulations of diatrizoate that minimize calcium binding are advocated for cardiac angiography when using high osmolality contrast media. The more detrimental effects that calcium binding has on myocardial function and cardiac conduction may lead to the higher incidence of complications.

Perceived and actual risks of driving in patients with arrhythmia control devices.

BACKGROUND: We surveyed patient attitudes about driving and about driving restrictions for patients with automatic defibrillators and pacemakers, and we assessed risk of arrhythmias occurring during driving. METHODS: One hundred two patients responded to a questionnaire (57 patients with defibrillators and 45 patients with pacemakers) about driving habits and opinions on restriction of patients who have devices and want to drive. In addition, the literature was reviewed for approximate incidences of sudden death and syncopal or nonsyncopal device therapy to estimate risk while driving of having a defibrillator discharge. RESULTS: Thirty-two patients with defibrillators (56%) and 28 patients with pacemakers (62%) currently drove an average of 196 and 161 km/wk, respectively. Most patients felt that driving was a right and 75% felt that restriction imposed a hardship on them. Respondents felt that common sense, limited distances, or physician input should set driving limitations. A minority felt that no restrictions should be placed on these drivers or that they should not drive at all. The risks of sudden death and syncopal and nonsyncopal defibrillator discharge were estimated at 0.0009%, 0.0011%, and 0.0015% per kilometer driven, respectively, based on weekly kilometers and published occurrences of these phenomena. CONCLUSIONS: Patients perceive that driving is their right and that there is a low risk of an arrhythmic event behind the wheel. The estimated risk and published accounts of sudden death support this. However, concurrent medical problems and stresses imposed by driving may increase risk. The physician must make reasonable recommendations to ensure patient and public safety, keeping in mind both state and federal driving regulations and reporting requirements.

Performance on the internal medicine second-year residency in-training examination predicts the outcome of the ABIM certifying examination.

For 223 residents from eight teaching hospitals, the results of the second-year in-training examination and the first-sitting certifying examination of the American Board of Internal Medicine were highly correlated. The results of the in-training examination can serve residents as an important measure of their preparedness for certification and can be useful in identifying the need for more intensive self-study strategies during the subsequent one and a half years.

The in-training examination in internal medicine.

OBJECTIVE: The In-Training Examination in Internal Medicine (ITE-IM) has been offered to internal medicine trainees annually since 1988 as an instrument for self-assessment. This report outlines the manner in which the test is prepared, reviews the results of annual examinations, and analyzes trends during the past 6 years. DESIGN: Results of each examination were reviewed with regard to the demographic characteristics of persons taking the test, their previous medical training, and their present program affiliations. RESULTS: Then number of residents participating in the ITE-IM has increased steadily over the past 6 years. In 1993, more than 12,000 residents from more than 90% of internal medicine training programs in the United States participated in the examination; the percentage of international medical school graduates taking the examination increased from 27% in 1988 to 47% in 1993. Statistical analyses of each examination have shown it to be reliable, internally consistent, and discriminating. Over the past 6 years, graduates of U.S. medical schools have scored consistently higher than those of international medical schools and schools of osteopathic medicine on all annual examinations. However, in 1993, for residents at all levels of training, the differences in scores between graduates of U.S. medical schools and graduates of international medical schools narrowed substantially. From 1988 to 1993, there has been a trend toward lower scores by every cohort on each subsequent examination. The decreases in scores are most pronounced for graduates of U.S. medical school and those of schools of osteopathic medicine. The lower scores may be caused by either an increased level of difficulty in the examination or decreased knowledge among examinees. CONCLUSIONS: The ITE-IM is a useful instrument to assess the knowledge base of residents and program directors with a reliable evaluation of themselves and their programs in comparison to their national peer groups. It also provides objective data to monitor trends over time in residents' scores and relates them to the changing demographic characteristics of trainees and to innovations in the clinical curricula of internal medicine training programs.