Charles J. Hatem

The academic health center coming of age: helping faculty become better teachers and agents of educational change.

There is a growing appreciation of the need for educational faculty development within medical education. The authors describe the establishment and subsequent expansion of one such fellowship in medical education that arose from the cooperative efforts of Harvard Medical School, Beth Israel Deaconess Medical Center, and Mount Auburn Hospital. Three resultant fellowships are outlined that share the common goals of enhancing the skills of the faculty as educators, providing an opportunity to conduct scholarly educational research, supporting the fellows as change agents, and fostering the creation of a supportive community dedicated to enhancing the field of medical education. Curricular structure and content are outlined as well as current approaches to curricular and programmatic evaluation. The fellowships have been well received and are widely perceived as transformative for the faculty, many of whom have assumed increased roles of organizational and educational leadership. Lastly, future directions for these fellowships are presented.

Strategies for creating a faculty fellowship in medical education: report of a 10-year experience.

The authors present 10 strategies, plus challenges and opportunities, that have informed three well-established, yearlong medical education fellowships (defined as single cohorts of medical teaching faculty who participate in extended faculty development activities) during the period 1998 to 2008. These strategies include (1) defining an operating philosophy, values, and goals, (2) establishing a curriculum that reflects the roles and responsibilities of fellows and faculty, (3) employing a basic approach to adult learning, (4) striving to achieve a balance between stated objectives and openness of discussion, (5) creating optimum learning opportunities for the fellows to acquire and practice skills delineated in the curriculum, (6) fostering interdisciplinary communication, team development, and the creation of a learning community, (7) developing mindfulness and critical self-reflection, (8) systematically reviewing each session, (9) evaluating fellowship outcomes, and (10) planning for the future. This in-depth look presents both curricular content and process, providing a useful starting point from which those who develop and conduct educational faculty development activities at medical schools and academic medical centers may fashion and implement a local curriculum.

Coronary artery blood flow in acute pulmonary embolism

Abstract The effect of acute pulmonary embolism upon left circumflex coronary blood flow was studied in 11 open-chest, anesthetized dogs. Pulmonary embolization, in the absence of shock, was associated with increased left circumflex coronary blood flow, hypoxemia and electrocardiographic changes compatible with myocardial ischemia. Mean flow in the left circumflex coronary artery increased an average of 45 per cent after pulmonary embolization. No support was found for the concept of pulmonocoronary reflex spasm. The increase of left coronary blood flow was reduced or eliminated when hypoxemia was corrected by the administration of oxygen.

Evaluating the interview in primary care medicine

Abstract Certain basic characteristics of primary care practice shape the content, form and techniqueof the medical interview. These characteristics force the interview to become more a joint discussion of a series of topics than an interrogation or inquisition; more negotiation and consensus seeking than authoritarian prescription and proscription; and more associational than rigidly structured. Information flows from physician to patient as well as vice versa, and includes the psychosocial aspects of being sick and being a patient. An instrument for evaluating routine doctor-patient interactions has been developed. It attempts totake account of these characteristics of primary care practice, and can be used with audio or video recordings of actual clinical encounters. It requires the rating of 19 items covering the form of the interview, the use of authority, technique of questioning, management of the patients emotions and information transmitted. It can be used in teaching, program planning and evaluation, and in medical care research.

A national survey of medical education fellowships.

Abstract Purpose: The purpose of our study was to determine the prevalence, focus, time commitment, graduation requirements and programme evaluation methods of medical education fellowships throughout the United States. Medical education fellowships are defined as a single cohort of medical teaching faculty who participate in an extended faculty development programme. Methods: A 26-item online questionnaire was distributed to all US medical schools (n=127) in 2005 and 2006. The questionnaire asked each school if it had a medical education fellowship and the characteristics of the fellowship programme. Results: Almost half (n=55) of the participating schools (n=120, response rate 94.5 %) reported having fellowships. Duration (10–584 hours) and length (<1 month–48 months) varied; most focused on teaching skills, scholarly dissemination and curriculum design, and required the completion of a scholarly project. A majority collected participant satisfaction; few used other programme evaluation strategies. Conclusions: The number of medical education fellowships increased rapidly during the 1990s and 2000s. Across the US, programmes are similar in participant characteristics and curricular focus but unique in completion requirements. Fellowships collect limited programme evaluation data, indicating a need for better outcome data. These results provide benchmark data for those implementing or revising existing medical education fellowships.

The human T-cell receptor β-chain repertoire: longitudinal fluctuations and assessment in MHC matched populations

The influence of the environment and of the major histocompatibility complex (MHC) in shaping the human T-cell receptor β-chain variable region (TCRBV) repertoire has not been systematically studied. Here, expression of TCRBV gene families was estimated by a sensitive polymerase chain reaction (PCR)-based method. Serial studies of peripheral blood, performed at 2-week intervals over a 3-month period, revealed that fluctuation in the expression of many TCRBV genes occurred in healthy individuals and in the absence of clinically evident infections. Fluctuation of TCRBV4, TCRBV5.2, TCRBV9, and TCRBV13.1 genes were present in all subjects. Additional TCRBV genes fluctuated in some but not in other individuals. Comparison of the TCRBV repertoire between these unrelated individuals indicated differences in the mean expression of TCRBV5.1, TCRBV9, TCRBV11, TCRBV15, TCRBV17, and TCRBV20 genes. For any TCRBV gene, intersubject differences were generally of a magnitude of twofold or less. Larger differences characterized the TCRBV repertoire of CD4 compared to CD8 cells. Some differences, for example over-representation of TCRBV2 and TCRBV5.1 on CD4, and TCRBV10, TCRBV14, and TCRBV16 on CD8 cells, were present in most subjects. Individuals homozygous for DR2- or DR3-bearing extended MHC haplotypes displayed similar individual variability of TCRBV expression. These data indicate that the circulating TCRBV repertoire in humans is both dynamic and diverse. Both environment and MHC effects contribute to the diversity of TCRBV expression.

Biased expression of T cell receptor genes characterizes activated T cells in multiple sclerosis cerebrospinal fluid

To better characterize the inflammatory response that occurs in the nervous system in multiple sclerosis (MS), T‐cell receptor (TCR) gene expression was quantified from cerebrospinal fluid (CSF) cells of 21 patients with active disease. Unstimulated CSF cells expressed each of 22 different TCR beta chain variable region (Vβ) gene families in proportion to their expression in simultaneously sampled peripheral blood. When CSF cells from individuals with MS were expanded by in vitro culture in T‐cell growth factor/interleukin 2 and 4‐containing medium (TCGF/IL2/IL4), restricted numbers of Vβ genes were expressed. In many subjects, expanded CSF cells expressed predominantly Vβ2. In contrast to CSF, expansion of corresponding peripheral blood mononuclear cells (PBMC) in TCGF/IL2/IL4 resulted in persistent expression of an Vβ gene families. Within individuals, different Vβ genes were overexpressed by PBMC compared with CSF cells. No effect of the HLA haplotype of the individual on CSF Vβ gene expression was observed. Expanded CSF cells retained their capacity to respond to mitogen stimulation, but the proliferative response to myelin basic protein (MBP) was not enhanced. Finally, freshly obtained CSF cells stimulated directly with MBP also expressed a limited number of Vβ genes, although these were generally different from patterns observed following stimulation with TCGF/IL2/IL4. Thus, restricted populations of T cells capable of responding to TCGF/IL2/IL4, presumably reflecting in vivo activated cells, are compartmentalized in the nervous system in MS.

Comparing ambulatory care practices of primary care and traditional medicine residents

Although special residency programs preparing internists for primary care have been in existence for a decade, little is known about whether these tracks have achieved their goals. As part of a multicenter evaluation of ambulatory care at four university hospitals, 1,040 patient care encounters were reviewed for 16 primary-care and 41 traditional medicine residents. Using a chart-based audit, the authors examined 16 discrete items of patient care to assess resident management in the following areas: screening for colorectal carcinoma, management of hypertension, benzodiazepine drug prescribing, and management of chronic lung disease. Their hypothesis that primary care residents would score higher than traditional medicine residents in the areas of screening, prevention, and prescribing of drugs was not supported. There was no association between type of training and performance of a task with the following exception: second-year primary care residents screened for colorectal carcinoma in 86% (126) of patients whose charts were audited, while second-year traditional medicine residents did so in 77% (160) (P<0.025). This difference was not maintained when the residents were reaudited 1 year later. Both groups of residents scored high in all areas with the following exceptions: documentation of the amount of sedative dispensed and immunization of susceptible patients against pneumococcus and influenza. The ambulatory practices of both groups of residents exceeded expectations, probably because of the wider influence of primary care training.

Multicenter evaluation of primary care internal medicine residency training. Are practice goals met

Over the past decade primary care internal medicine residencies, combining inpatient and outpatient training, were developed with two goals: 1) to provide more appropriate training for practice and 2) to increase the number of general internists.l2 Although recent studies report that graduates from these programs choose primary care careers,3 the quality of ambulatory patient care practiced by residents in these new programs has not been documented. This study reports an assessment of the quality of outpatient care provided by 26 2nd-year primary care residents in six university-affiliated training programs. Our goal was to assess the clinical ambulatory practice of residents currently in training. Using a chart-based audit, patient