Paul F. Griner

Use of the Laboratory in a Teaching Hospital: Implications for Patient Care, Education, and Hospital Costs

Abstract Laboratory studies contribute significantly to the cost of hospitalization. Arguments for the liberal use of laboratory tests are countered by concern over costs and the need for young phy...

Veno-Occlusive Disease of the Liver After Chemotherapy of Acute Leukemia: Report of Two Cases

Two adult male patients with acute leukemia developed a fatal Budd-Chiari-like illness while receiving 6-thioguanine. Both had previously received cytosine arabinoside. Antemortem and postmortem specimens of liver showed changes characteristic of toxic veno-occlusive disease. Similar findings have been described after ingestion of certain plant alkaloids and after treatment with arsphenamine, urethane, and ionizing radiation to the liver. We are unaware of any published reports of veno-occlusive disease of the liver after treatment with either 6-thioguanine or cytosine arabinoside. Although 6-thioguanine was most likely responsible for this syndrome, it is not possible to eliminate cytosine arabinoside as the causative agent. Since both drugs are occasionally used for benign conditions, physicians should be aware of this possible complication.

Diagnostic uses of the activated partial thromboplastin time and prothrombin time

The activated partial thromboplastin time (APTT) and prothrombin time (PT) have three principal uses. In screening for coagulation disorders (or increased risk of postoperative hemorrhage), the tests add no information to the preoperative care of patients without clinical findings indicative of increased bleeding risk. Furthermore, the prevalence of asymptomatic congenital coagulopathies is so low that false-positive test results greatly outnumber true-positive results. Thus, clinicians may use clinical assessment to screen and should reserve coagulation tests to investigate patients with abnormal findings. In evaluating abnormal bleeding, these tests are sufficiently sensitive that if both are negative, further investigation of the coagulation system is obviated. If one or both tests are positive, the pattern of results directs further attention to limited segments of the coagulation sequence. In monitoring anticoagulation therapy, the APTT and PT tests appear to contribute to the safety and effectiveness of heparin and warfarin therapies, respectively.

Treatment of Acute Pulmonary Edema: Conventional or Intensive Care?

Abstract The experience of adult patients admitted to a general hospital with the diagnosis of acute pulmonary edema was determined for the year before and the year after the opening of an intensiv...

Distribution of Research Awards from the National Institutes of Health among Medical Schools

BACKGROUND Previous studies have demonstrated that a small number of the 125 medical schools in the United States receive a disproportionately large share of the research awards granted by the National Institutes of Health (NIH). We assessed whether the distribution of NIH research awards to medical schools changed between 1986 and 1997. METHODS We used NIH data to rank medical schools in each year from 1986 to 1997 according to the number of awards each school received (as a measure of each schools activity in research, also referred to as research intensity). The proportion of awards received by schools ranked 1 to 10, 11 to 30, 31 to 50, and 51 or lower in research activity was then calculated, and changes over time were examined. We also examined changes in the distribution of awards and changes in award amounts according to the type of department, the type of academic degree held by the principal investigator, and the awarding institute. RESULTS Between 1986 and 1997, the proportion of research awards granted by the NIH to the 10 most research intensive medical schools increased slightly (from 24.6 percent of all awards to 27.1 percent), whereas the 75 least research intensive medical schools (those ranked 51 or lower) received proportionately fewer awards (declining from 24.3 percent to 21.8 percent). The increased proportion of awards to top-10 schools consisted primarily of increases in awards to clinical departments, awards to physicians, and awards from highly competitive NIH institutes. Basic-science departments received a smaller proportion of awards than clinical departments, both in 1986 and in 1997. CONCLUSIONS Research funded by the NIH is becoming more concentrated in the medical schools that are most active in research.

Extracorporeal Hemolysis of Blood in a Microwave Blood Warmer

Abstract Marked hemoglobinemia and hemoglobinuria developed in a 13-year-old girl during an operative repair for scoliosis. Residual blood from 1 of 5 U of whole blood, preheated in a microwave blood warmer and administered during the procedure, was found to be hemolyzed. The blood warmer was studied in an effort to reproduce extracorporeal hemolysis. Faulty placement of the blood container in the heating unit was found to produce improper heating through nonrotation of the container. No change in plasma hemoglobin or red-cell filterability was found when normally heated samples were compared with unheated control samples. Improperly heated blood revealed a marked increase in plasma hemoglobin (maximum, 949 mg per 100 ml) and a reduction in filterability of residual cells (maximum, 19 per cent). Morphologic changes (e.g., budding) were identified in improperly but not properly heated red cells. These studies indicate the production of extracorporeal hemolysis and reduced viability of a population of nonhe...

Medical Intensive Care in the Teaching Hospital: Costs Versus Benefits: The Need for an Assessment

Abstract In the teaching hospital, improved patient care, education, and research are anticipated outcomes of intensive care units. Finite resources dictate the examination of these benefits in rel...

Chloral Hydrate and Warfarin Interaction: Clinical Significance?

Abstract Chloral hydrate has been cited among the sedatives and hypnotics capable of altering the anticoagulant response to coumarin drugs. The clinical significance of any interaction between chlo...

New Bottles for Vintage Wines: The Changing Management of the Medical School Faculty.

Medical schools are being challenged to develop innovative mechanisms of faculty governance and management that enlist faculty in meeting the demands of a competitive marketplace. The authors describe some of these mechanisms in this article, which is the result of case studies made in 1997 of ten schools. Measures to increase the accountability of faculty to the strategic directions of the school include having appointment letters that specify explicitly the roles and responsibilities of the faculty member, conducting annual performance reviews based upon more objective criteria, tying salary to performance, lengthening the pre-tenure probation period, instituting post-tenure review, and redefining the salary guarantees of tenured faculty. Equally important is balancing these policies with initiatives to strengthen the accountability of schools to their faculty. Improved methods of communication between administrators and faculty and more efficient processes to enable faculty to participate in decision making are appearing. Formal approaches to mentoring and faculty development are being implemented. Recognition and reward programs are being strengthened. Alternatives to tenure are being developed in recognition of the need for increasingly diverse roles of faculty and to ensure job security. The reengineering of the processes that will lead to shared vision and accountability will require massive cultural change. The realization of these goals is likely to depend on the skill of medical school managers and the ability and willingness of faculty members to work collaboratively and creatively in designing new methods to accomplish old missions. Next months AAMC Paper will explore changes in the structure and management of medical schools and their owned or closely affiliated facilities to improve the efficiency of achieving their core missions.

The Effects of a Changing Environment on Relationships between Medical Schools and Their Parent Universities

Medical schools differ from other university graduate schools in that community settings, hospitals, and ambulatory care facilities are required for medical education, and most of these settings are either owned by or closely affiliated with the university. Thus, the extraordinary changes in recent years in the organization, delivery, and financing of health care have required the attention not only of the leadership of academic medical centers (i.e., medical schools and their owned or closely affiliated teaching hospitals) but also of the administrators and boards of their parent universities. Many university-wide structures and policies that previously served the medical school well in accomplishing these missions may now be viewed as inflexible by the faculty and administration of the school. Conversely, the historically distant governance and administrative oversight of the medical school has become a concern for some at the university, given the huge budgets of the school, its faculty practice, and its affiliated hospital(s). From information derived mainly from annual visits to 14 medical schools from 1996 through June 2000, the authors review the issues between medical schools and their parent universities and the strategies being used to resolve them. These strategies include changes in the governance, organization, and management of the medical school, such as unified authority for health affairs, reengineered administrative systems, and increased autonomy in decision making. The authors conclude that these strategies appear to be working on behalf of not only the medical school but, in some instances, the university at large. They also comment on possible negative implications of the greater separation of the medical school from its parent university.