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Traditional performance expectations and career advancement paths for academic physicians persist despite dramatic transformations in the academic workflow, workload, and workforce over the past twenty years. While the academic physician’s triple role as clinician, researcher, and educator has been lauded as the ideal by academic medical centers, current standards of excellence for promotion and tenure are based on outdated models. These models fail to reward collaboration and center around rigid career advancement plans that do little to accommodate the changing needs of individuals and organizations. Here, the authors describe an innovative, comprehensive, multi-pronged initiative at the Perelman School of Medicine at the University of Pennsylvania to initiate change in the culture of academic medicine and improve academic productivity, job satisfaction, and overall quality of life for junior faculty. As a key part of this intervention, task forces from each of the 13 participating departments/divisions met 5 times between September 2010 and January 2011 to produce recommendations for institutional change. The authors discuss how this initiative, using principles adopted from business transformation, generated themes and techniques that can potentially guide workforce environment innovation in academic health centers across the United States. Recommendations include embracing a promotion/tenure/evaluation system that supports and rewards tailored individual academic career plans; ensuring leadership, decision-making roles and recognition for junior faculty; deepening administrative and team supports for junior faculty; and solidifying and rewarding mentorship for junior faculty. By doing so, academic health centers can ensure the retention and commitment of faculty throughout all stages of their careers.

The tissue response to silicone gel breast implants typically includes an inflammatory infiltrate that consists of macrophages, foreign body-type giant cells, and a variable number of lymphocytes and plasma cells. The phenotype of the lymphocytic component was investigated with three-color flow cytometry. Lymphocytes were obtained by collecting fluid from the space between the implant and the fibrous capsule or by washing cells from the fibrous capsule at the time of implant removal with total capsulectomy. Eighty-nine percent of the implant-associated lymphocytes were T cells. Twenty-five percent of the CD3+ T cells coexpressed HLA-DR compared with only 7.9% of matched peripheral blood lymphocytes. Sixty-eight percent of the implant-associated T cells coexpressed CD4 and CD29, while only 3% of the T cells coexpressed CD4 and CD45RO. The expression of HLA-DR and the predominance of CD29+ CD4+ T cells indicate that there is immune activation with the potential for stimulating antigen-specific antibody production. The role of silicone gel breast implants in immune activation and its clinical significance require further investigation.

The work environment culture inhibits women's career success in academic medicine. The lack of clarity and consistency in the definition, measurement, and analysis of culture constrains current research on the topic. The authors addressed this gap by defining the construct of a culture conducive to women's academic success (CCWAS) and creating a measure (i.e., tool) to evaluate it.First, the authors conducted a review of published literature, held focus groups, and consulted with subject matter experts to develop a measure of academic workplace culture for women. Then they developed and pilot-tested the measure with a convenience sample of women assistant professors. After refining the measure, they administered it, along with additional scales for validation, to 133 women assistant professors at the University of Pennsylvania. Finally, they conducted statistical analyses to explore the measure's nature and validity.A CCWAS consists of four distinct, but related, dimensions: equal access, work-life balance, freedom from gender biases, and supportive leadership. The authors found evidence that women within departments/divisions agree on the supportiveness of their units but that substantial differences among units exist. The analyses provided strong evidence for the reliability and validity of their measure.This report contributes to a growing understanding of women's academic medicine careers and provides a measure that researchers can use to assess the supportiveness of the culture for women assistant professors and that leaders can use to evaluate the effectiveness of interventions designed to increase the supportiveness of the environment for women faculty.

High rates of attrition have been documented nationally in assistant professor faculty of U.S. medical schools. Our objective was to investigate the association of individual level risk factors, track of academic appointment, and use of institutional leave policies with departure in junior faculty of a research-intensive school of medicine.Participants included 901 faculty newly hired as assistant professors from July 1, 1999, through December 30, 2007, at the Perelman School of Medicine at the University of Pennsylvania. The faculty affairs database was used to determine demographics, hiring date, track of appointment, track changes, time to departure, and use of work-life policies for an extension of the probationary period for mandatory review, reduction in duties, and leave of absence.Over one quarter (26.7%) of faculty departed during follow-up. Faculty appointed on the clinician educator or research tracks were at increased risk of departure compared to the tenure track (hazard ratio [HR] 1.87, confidence interval, [CI] 1.28-2.71; HR 4.50, CI 2.91-6.96; respectively). Women appointed on the clinician educator track were at increased risk of departure compared to men (HR 1.46, CI 1.04-2.05). Faculty who took an extension of the probationary period were at decreased risk of departure (HR 0.36, CI 0.25-0.52).At this institution, junior faculty on the tenure track were least likely to depart before their mandatory review compared to faculty on the clinician educator or research tracks. Female assistant professors on the clinician educator track are of significant risk for departure. Taking advantage of the work-life policy for an extension of the probationary period protects against attrition.

Massive pulmonary embolism remains a clinical challenge where rapid diagnosis and appropriate therapy have a critical impact on patient outcome. This article reviews the pathophysiology, diagnosis, and therapeutic options involved in the management of pulmonary embolism. Clinical case discussions illustrate the principles that are described by the authors.

A steep escarpment edge, deep gorges and distinct knickzones in river profiles characterize the landscape on the Western Escarpment of the Andes between ~5°S and ~18°S (northern Peru to northern Chile). Strong north–south and east–west precipitation gradients are exploited in order to determine how climate affects denudation rates in three river basins spanning an otherwise relatively uniform geologic and geomorphologic setting. Late Miocene tectonics uplifted the Meseta/Altiplano plateau (~3000 m a.s.l.), which is underlain by a series of Tertiary volcanic-volcanoclastic rocks. Streams on this plateau remain graded to the Late Miocene base level. Below the rim of the Meseta, streams have responded to this ramp uplift by incising deeply into fractured Mesozoic rocks via a series of steep, headward retreating knickzones that grade to the present-day base level defined by the Pacific Ocean.\ud \ud It is found that the Tertiary units on the plateau function as cap-rocks, which aid in the parallel retreat of the sharp escarpment edge and upper knickzone tips. 10Be-derived catchment denudation rates of the Rio Piura (5°S), Rio Pisco (13°S) and Rio Lluta (18°S) average ~10 mm ky−1 on the Meseta/Altiplano, irrespective of precipitation rates; whereas, downstream of the escarpment edge, denudation rates range from 10 mm ky−1 to 250 mm ky−1 and correlate positively with precipitation rates, but show no strong correlation with hillslope angles or channel steepness. These relationships are explained by the presence of a cap-rock and climate-driven fluvial incision that steepens hillslopes to near-threshold conditions.\ud \ud Since escarpment retreat and the precipitation pattern were established at least in the Miocene, it is speculated that the present-day distribution of morphology and denudation rates has probably remained largely unchanged during the past several millions of years as the knickzones have propagated hea

A case of massive bilateral diaphragmatic rupture following a low impact motor vehicle accident is described. The patient experienced herniation of intraabdominal contents into the thoracic cavity, but suffered no additional injuries. Few cases of bilateral diaphragmatic rupture have been reported and no cases of acute bilateral rupture have been described as an isolated injury. Diaphragmatic rupture in general may be a difficult injury to recognize. Based on our review of recent cases of diaphragmatic rupture (1979-1990), most patients presenting acutely have additional trauma (89.9%) but only vague symptoms related to their diaphragmatic insult. A chest roentgenogram may be a useful diagnostic tool, although many patients with diaphragmatic rupture have only nonspecific findings. A nasogastric tube placed prior to chest roentgenogram may enable the physician to recognize the injury more readily. A high index of suspicion is required to recognize diaphragmatic rupture and should be maintained for all victims of motor vehicle accidents with abnormal but nondiagnostic chest roentgenograms.

Awards given to medical school faculty are one important mechanism for recognizing what is valued in academic medicine. There have been concerns expressed about the gender distribution of awards, and there is also a growing appreciation for the evolving accomplishments and talents that define academic excellence in the 21st century and that should be considered worthy of award recognition.Examine faculty awards at our institution for gender equity and evolving values.Recipient data were collected on awards from 1996 to 2007 inclusively at the University of Pennsylvania School of Medicine (SOM). Descriptions of each award also were collected. The female-to-male ratio of award recipients over the time span was reviewed for changes and trends. The title and text of each award announcement were reviewed to determine if the award represented a traditional or a newer concept of excellence in academic medicine.There were 21 annual awards given to a total of 59 clinical award recipients, 60 research award recipients, and 154 teaching award recipients. Women received 28% of research awards, 29% of teaching awards and 10% of clinical awards. Gender distribution of total awards was similar to that of SOM full-time faculty except in the clinical awards category. Only one award reflected a shift in the culture of individual achievement to one of collaboration and team performance.Examining both the recipients and content of awards is important to assure they reflect the current composition of diverse faculty and the evolving ideals of leadership and excellence in academic medicine.

There exists a growing consensus that career flexibility is critical to recruiting and retaining talented faculty, especially women faculty. This study was designed to determine both accessibility and content of work-life policies for faculty at leading medical schools in the United States.The sample includes the top ten medical schools in the United States published by U.S. News and World Report in August 2006. We followed a standardized protocol to collect seven work-life policies at each school: maternity leave, paternity leave, adoption leave, extension of the probationary period for family responsibilities, part-time faculty appointments, job sharing, and child care. A review of information provided on school websites was followed by e-mail or phone contact if needed. A rating system of 0-3 (low to high flexibility) developed by the authors was applied to these policies. Rating reflected flexibility and existing opinions in published literature.Policies were often difficult to access. Individual scores ranged from 7 to 15 out of a possible 21 points. Extension of the probationary period received the highest cumulative score across schools, and job sharing received the lowest cumulative score. For each policy, there were important differences among schools.Work-life policies showed considerable variation across schools. Policy information is difficult to access, often requiring multiple sources. Institutions that develop flexible work-life policies that are widely promoted, implemented, monitored, and reassessed are likely at an advantage in attracting and retaining faculty while advancing institutional excellence.

The incidence of pressure ulcers among elderly hospital patients is high (1) despite increased awareness of the clinical and economic impact of pressure ulcers (2,3). Although there have been numerous studies of intrinsic patient characteristics (such as immobility, nutritional status, and incontinence) in relation to pressure ulcer risk [e.g., (4)], little is known about the impact of extrinsic factors. We define extrinsic factors as procedures and events that may contribute to pressure ulcer risk because they involve periods of immobility-related pressure. Because health care providers influence these extrinsic factors, understanding their association with pressure ulcers may make it possible to reduce the risk of pressure ulcers by modifying provider behavior. The pathologic processes resulting in pressure ulcers may begin after a few hours of immobility-induced pressure on bony prominences (5,6). There is ample opportunity early in the hospital stay for periods of immobility that are long enough to increase elderly patients’ pressure ulcer risk. In the emergency department (ED), patients may lie on a stretcher for many hours awaiting tests, treatments, or transfer (7,8): Stretchers may lack adequate cushioning or be too narrow for regular repositioning (9). Lengthy surgical and radiologic procedures and the use of certain devices (e.g., restraints) can immobilize the patient. Similarly, medications that cause sedation can result in long periods of immobility (10-13). Because mobilization of patients depends partly on the availability of hospital staff, pressure ulcer risk may be higher on night and weekend shifts (14,15). In the intensive care unit (ICU), patients may be bedbound, unconscious, or otherwise immobilized for significant periods of time. The aim of the study was to determine whether the risk of pressure ulcers early in the hospital stay is associated with extrinsic factors such as longer stays in the ED, night or weekend admission, potentially immobilizing procedures and medications, and admission to an ICU.

Since its inception in the 1960s, the field of second language acquisition (SLA) has sought to document and explore how children and adults acquire a nonnative language. Researchers have investigated the linguistic, cognitive, social, contextual, psychological, and neurobiological characteristics of second language (L2) learning, processing, and use. Typical research questions include: What are the characteristics of learner interlanguage? How do individual differences, such as working memory capacity, impact the learning of an L2? How does the social context (such as stay-at-home vs. study abroad) influence the fluency, accuracy, and complexity of learner language? How do different types of motivation impact the learning process? How is the L2 processed in the learner’s mind and how is this affected by age of acquisition? To investigate these and many other questions, SLA researchers have at their disposal a large array of research designs. In this chapter, we will discuss various research designs, including quantitative, qualitative, and mixed methods traditions. We will also address current works in progress and examine recent topics of concern related to the conducting of research on L2 learning. Finally, we will conclude with future directions for SLA research.

Anterior uveitis is a relatively rare adverse drug reaction when the prescription rate of sulfonamides is considered. Current medications should be included in the differential diagnosis of patients who present with uveitis, because discontinuation of the offending agent is mandatory to resolution of the problem. Lack of recognition and failure to discontinue the medication will increase the patient's risk of ocular injury.

Pain and swelling at the first metatarsophalangeal joint can be caused by acute calcific periarthritis (ACP), an inflammatory condition resulting from deposition of hydroxyapatite crystals. A case is reported of a 23-year-old man in whom ACP was initially mistaken for gout, septic arthritis, and cellulitis. The diagnosis of ACP is based on the finding of inflammation around a joint along with radiographic evidence of periarticular soft tissue calcifications. Calcifications may disappear over time, as they did in this case. Failure to recognize this condition can lead to unnecessary testing and inappropriate treatment.

A simple method for preparing multitissue control blocks (MTCB) for immunohistochemistry is described. Parallel rectangular tissue sections are embedded in paraffin and sections cut from these blocks are mounted at one end of the glass slide. A section from the tissue to be stained is mounted at the other end of the same glass slide. The slide containing both the control and test sections is processed for immunohistochemistry, allowing both the tissue sample and the controls to be treated equally in all steps. The control blocks can be tailored to include different tissues or tissues fixed in different fixatives, according to the needs of the laboratory. In contrast to MTCBs that contain large numbers of sections, ours provides adequate tissue for each positive control and at the same time allows improved accuracy and diagnostic sensitivity. MTCBs can be used as general control blocks for the majority of routine immunohistochemical stains and for initial antibody screening. (The J Histotechnol 18:...

The purpose of this study was to evaluate the effect of a switch to a filmless image management system on the time required for technologists to produce radiographic images in the emergency department (ED) after controlling for exam difficulty and a variable workload. Time and motion data were collected on patients who had radiographic images taken while being treated in the emergency department over the 3½-year period from April 1997 to November 2000. Event times and demographic data were obtained from the radiology information system, from the hospital information system, from emergency department records, or by observation by research coordinators. Multiple least squares regression analysis identified several independent predictors of the time required for technologists to produce radiographic images. These variables included the level of technologist experience, the number of trauma-alert patient arrivals, and whether a filmless image management system was used (all P

To determine who reads plain film radiographs, how quickly radiologists' interpretations are available, how many initial readings require correction, and how satisfied emergency physicians (EPs) are with radiology in emergency departments (EDs) with emergency medicine (EM) residency programs.A questionnaire was sent to the chairs of all U.S. EM residencies, asking about EM radiology services.Of 120 sites surveyed, 97 (81%) responded. Respondents reported that, on weekday days, EM attendings or residents performed the radiograph interpretation used for clinical decision making at 66% of sites; on nights and weekends, EPs performed the clinically relevant readings at 79% of sites. Twenty-one percent of sites reported that no radiologist reviewed images before patients left the ED on nights and weekends. Only 39% of sites reported that all images were read within four hours on weekday days, and only 19% of sites reported readings within this time frame on nights and weekends. Median misinterpretation rates were reported as 1% on weekday days and 1.5% at other times. Overall, EPs were satisfied with their interactions with radiology at 63% of EDs.This study summarizes the perceptions of EPs regarding radiology services; the findings must be interpreted with caution, given the lack of external validation. Nevertheless, EPs report that many EM residency programs depend on EPs' interpretations of radiographs. Emergency physicians report that attending radiologists rarely read images on nights and weekends and that images are misread more frequently at these times. Although EPs were satisfied with many aspects of radiology, EPs expressed the most dissatisfaction with turnaround times and misreads.

The article discusses the revision of handbooks, noting that many handbooks could be more comprehensive, up-to-date, and affordable. Gaps in content, scholarly ossification, and overly high prices are noted. The concerns of readers including academic researchers, students, and teachers are addressed. The authors suggest that these concerns could be addressed through the reduction of handbook prices, the collaboration of senior scholars and junior scholars in authoring chapters, and the inclusion of authors from various parts of the world.

The purpose of this study was to determine if the interval between an examination being ordered by an Emergency Department physician and his or her review of the report and images could be shortened by notifying the physician that the results were available. Though some time shortening was shown, it was not clearly attributable to the notification process.

[Lowe RA, Abbuhl SB. Appropriate standards for "appropriateness" research. Ann Emerg Med. June 2001;37:629-632.]

Objective: After a pilot study suggested that African American patients enrolled in managed care organizations (MCOs) were more likely than whites to be denied authorization for emergency department (ED) care through gatekeeping, the authors sought to determine the association between ethnicity and denial of authorization in a second, larger study at another hospital. Methods: A retrospective cohort design was used, with adjustment for triage score, age, gender, day and time of arrival at the ED, and type of MCO. Results: African Americans were more likely to be denied authorization for ED visits by the gatekeepers representing their MCOs even after adjusting for confounders, with an odds ratio of 1.52 (95% CI = 1.18 to 1.94). Conclusions: African Americans were more likely than whites to be denied authorization for ED visits. The observational study design raises the possibility that incomplete control of confounding contributed to or accounted for the association between ethnicity and gatekeeping decisions. Nevertheless, the questions that these findings raise about equity of gatekeeping indicate a need for additional research in this area.

Reflective language teaching: from research to practice, by Thomas Farrell, London, Continuum, 2007, viii + 202 pp., US$150.00 (hardback), ISBN 978-0-826-49657-7, US$39.95 (paperback), ISBN 978-0-8...

A study of timings of different events from the scheduling of an Emergency Department (ED) examination to the final reporting of it and review by the ED physician showed some expected and unexpected findings. Both computed radiography (CR) on film and CR using PACS were studied. The move of daytime reading of ED radiographs out of the Radiology reading area in the ED to a reading room in Radiology lengthened the time from when the request was sent to the time when the images were reviewed by the ED physician (1.02 hours to 1.29 hours). Despite anecdotal reports of increased reading time at workstations, the radiologists' use of PACS for reading ED radiographs resulted in a slight improvement in the time between the examination completion and report dictation (0.43 hours to 0.3 hours). Recently, we have found that there may be a workload effect on this time and this is presently being analyzed. The time from the sending of the request for an examination to the first review of the images by the ED physician was shortened with implementation of a PACS workstation in the clinical area of the ED (1.35 hours to 0.92 hours). A surprising finding was the impact the change to PACS had on the time between sending the request and the technologist's completion of the requested examination. The time increased with PACS from 0.45 hours for film-based CR to 0.8 hours for PACS. Several studies are ongoing to determine the causes of this increase.

To evaluate a conventional radiology image management system, by investigating information accuracy, and information delivery. To discuss the customization of a picture archival and communication system (PACS), integrated radiology information system (RIS) and hospital information system (HIS) to a high volume emergency department (ED). Materials and Methods: Two data collection periods were completed. After the first data collection period, a change in work rules was implemented to improve the quality of data in the image headers. Data from the RIS, the ED information system, and the HIS as well as observed time motion data were collected for patients admitted to the ED. Data accuracy, patient waiting times, and radiology exam information delivery were compared. Results: The percentage of examinations scheduled in the RIS by the technologists increased from 0% (0 of 213) during the first period to 14% (44 of 317) during the second (p less than 0.001). The percentage of images missing identification numbers decreased from 36% (98 of 272) during the first data collection period to 10% (56 of 562) during the second period (p less than 0.001). Conclusions: Radiologic services in a high-volume ED, requiring rapid service, present important challenges to a PACS system. Strategies can be implemented to improve accuracy and completeness of the data in PACS image headers in such an environment.© (1998) COPYRIGHT SPIE--The International Society for Optical Engineering. Downloading of the abstract is permitted for personal use only.