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A national panel on medical education was appointed as a component of the AAMC's Mission-based Management Program and charged with developing a metrics system for measuring medical school faculty effort and contributions to a school's education mission. The panel first defined important variables to be considered in creating such a system: the education programs in which medical school faculty participate; the categories of education work that may be performed in each program (teaching, development of education products, administration and service, and scholarship in education); and the array of specific education activities that faculty could perform in each of these work areas. The panel based the system on a relative value scale, since this approach does not equate faculty performance solely to the time expended by a faculty member in pursuit of a specific activity. Also, a four-step process to create relative value units (RVUs) for education activities was developed. This process incorporates quantitative and qualitative measures of faculty activity and also can measure and value the distribution of faculty effort relative to a school's education mission. When adapted to the education mission and culture of an individual school, the proposed metrics system can provide critical information that will assist the school's leadership in evaluating and rewarding faculty performance in education and will support a mission-based management strategy in the school.

Rapidly evolving characteristics of our health care system are creating new and expanding opportunities for physician managers. Formal graduate degree training in management has become desirable to prepare the physician for these new professional responsibilities. The Schools of Medicine and Management at Northwestern University instituted a formal combined degree program eight years ago. Directed by a physician holding faculty appointments in both schools, the program offers an integrated five year curriculum. During the past eight years, 16 students have matriculated in the program without attrition. Eleven students have completed both degrees on schedule. The results of a comprehensive telephone survey of all U.S. and Canadian medical schools concerning dual degree programs are presented. The advantages and disadvantages of pursuing management training at various stages of a physician's career are discussed.

In 15 patients with acute myocardial infarction (group I) and in 14 patients undergoing routine cardiac catheterization (group II) cardiac output values obtained by multiplying the 1 minute sum of the systolic integral of aortic blood flow velocity by the average systolic diameter of the aortic root were compared with values obtained with the thermodilution and Fick methods, respetively. Patients in group I were studied under various hemodynamic conditions, whereas those in group II were studied in the baseline state conditions, whereas those in group II were studied in the baseline state only. In group I, the correlation between the two methods was excellent (r values ranged from 0.96 to 0.99) except in one severely anemic patient whose Doppler signals were noisy, but at heart rates exceeding 150 beats/min it was not as good. In group II, the correlatin between the two methods was r = 0.96 with a standard error of the estimate of 0.226 liter. The Doppler method is totally noninvasive and is useful for monitoring changes in cardiac output in patients with acute myocardial infarction.

The present study was performed to determine whether qualitative and quantitative differences are present in the regional vasomotor responses to the somatopressor reflex evoked by stimulation of muscle afferents. Studies were performed in vagotomized, chloralose-anesthetized dogs with the carotid baroreceptor reflex intact. Regional vasomotor responses were determined in the isolated, innervated, constant flow-perfused vascular beds of hindlimb muscle, hindpaw, kidney, gut (superior mesenteric), and heart (circumflex coronary). Somatic afferent fiber stimulation evoked a significant systemic pressor response (+ 42%) and increased heart rate (+ 30%). An initial vasoconstrictor response occurred in all vascular beds studied, with peak reflex responses as follows: muscle +41%, paw +6%, kidney + 17%, gut + 17%, and coronary + 8%. A late, reflex vasodilator effect occurred in the hindpaw and was caused by secondary carotid baroreflex inhibition of vasomotor tone. A late vasodilator component in the coronary bed appeared to be secondary to the inotropic and chronotropic effects of the somatopressor reflex, since coronary vasodilation was eliminated by constant rate pacing and beta-adrenergic blockade, and was unaffected by vagotomy. Primary venodilation occurred in the perfused lateral saphenous venous system. Additional experiments demonstrated that spontaneous blood flow to muscle and kidney were significantly increased during the somatopressor reflex despite the generalized vasoconstrictor response.

Three patients presented with severe congestive cardiomyopathy of unknown cause. All three had a profound depression of serum phosphorus levels resulting from the chronic ingestion of large quantities of a phosphorus-binding antacid. Results of physical examination and echocardiograms were consistent with cardiomegaly and severe myocardial dysfunction, and chest films showed enlargement of the cardiac silhouette with interstitial pulmonary edema. Serum phosphorus was restored to normal levels, and within 2 to 5 weeks the results of physical examination and echocardiogram of each patient returned to normal. We conclude that these patients had reversible hypophosphatemic cardiomyopathy and show the importance of inorganic phosphorus in myocardial metabolism and function. Serum phosphorus measurements should be a part of the routine evaluation of patients with congestive cardiomyopathy because, at least in some patients, hypophosphatemia appears to be a reversible cause of this disorder.

The People's Republic of China is in the process of developing a comprehensive system of health care for one-quarter of the world's population. A continually evolving system of medical education that presently operates on three levels for the education and training of (a) "barefoot" or worker doctors, (b) "assistant" doctors, midwives, and nurses, and (c) both traditional and Western-style physicians has been a key factor in the process. Three aspects of Chinese medical education are noteworthy for the contrast they provide to medical education in the United States. In the first place, Chinese students enter medical college and become committed to a medical career immediately upon completion of secondary school. Second, Chinese medical colleges are independent of their universities, and all education for the health professions is integrated under a single college. A common curriculum and faculty are used for a considerable portion of each educational program. Finally, the entire medical curriculum is five to six years in duration, and postgraduate education is not required for the practice of medicine in China; nor is it available to the majority of graduates.

Left ventricular structure, function, and the coronary circulation were studied in a subset of patients with mitral valve leaflet prolapse. This group of 26 patients (21 females, five males, with mean age of 46 years), had the syndrome identified as idiopathic mitral valve prolapse (IMVP), which was characterized by a systolic click-murmur, clinical symptoms that were highly variable in duration and intensity, angiographically-documented mitral prolapse, and no obvious associated systemic or cardiovascular disease. Mitral regurgitation was of moderate degree in four, mild in 14, and absent in eight. The left ventricular (LV) end-diastolic volume index was elevated in ten of 25 (40%), the LV mass index was elevated in six of 17 (35%), but the LV anterior wall thickness was increase in only one of 17. Three major patterns of ventricular contraction were identified: 1) normal in seven; 2) abnormal, usually an inferior deformity and/or anterior asynergy, in eight; and 3) hyperkinetic in 11. Normal resting left ventricular function, assessed as an ejection fraction greater than 55%, was present in 17 of 25 (68%). Selective coronary arteriography was essentially normal in all 25 patients studied. An ischemic ECG response was detected during only one of 12 maximal treadmill exercise tests and in none of ten atrial pacing stress tests (AP). Myocardial lactate extraction did not change significantly during AP in six patients. We conclude that cardiomyopathy does not appear to be a primary cause or an important associated component of the IMVP syndrome. Abnormalities of the coronary circulation or of myocardial metabolism were not demonstrated by available methods. A proposed pathophysiological mechanism to explain the clinical and angiographic findings in IMVP is discussed.

To determine whether hypertrophic cardiomyopathy is associated with a human leukocyte antigen (HLA) phenotype, we tissue-typed 70 unrelated afflicted patients and 86 of their asymptomatic family members (from nine separate kindreds). Forty-five per cent of the white patients had B-12 antigen as compared to 23 per cent in matched control subjects; 69 per cent of black patients had a B-5-complex antigen as compared to 33 per cent in matched controls. Patients with a B-12 or B-5-complex antigen were nonhypertensive and had family members with the disease. Patients without these antigens were severely hypertensive and had no affected family members. Linkage analysis of six families revealed a lod score of 7.7 for asymmetric septal hypertrophy and the HLA region of chromosome 6. We conclude that there is a heritable, nonhypertensive form of hypertrophic cardiomyopathy linked to the HLA loci on chromosome 6 and that a sporadic form is associated with severe, systemic hypertension.

To characterize an unusual, sex-linked recessive neuromuscular disease, we studied two families with 37 males who had involvement of distal leg and proximal arm muscle groups. Electromyography and muscle biopsy in five subjects showed features of both neuropathy and myopathy. Bradycardia and syncope in 15 involved subjects were associated with early death (before the age of 50 years). Electrocardiograms in 15 others showed a spectrum of atrial abnormalities that ranged from abnormal P waves to permanent atrial paralysis and from first-degree atrioventricular block to complete heart block. No patient exhibited clinical muscle disease without electrocardiographic atrial disease. Dilated, hypertrophied left ventricles with normal indexes of function were found in three cases with permanent atrial paralysis and chronic junctional bradycardia. Cardiomegaly and cardiac failure were not present in the other cases. We conclude that permanent ventricular pacing (instituted four patients) is indicated in many of these patients to prevent serious sequelae.

The effects of isotonic physical training and detraining on cardiac function were studied in young and adult male rats trained by graded treadmill running and compared with sedentary controls. Absolute left ventricular mass was not increased, and ventricular compliance was not altered by training. Ventricular function curves that plotted peak systolic pressure, maximum rate of rise of left ventricular pressure, cardiac output, coronary flow, or stroke work as a function of atrial filling height in the isolated perfused heart did not demonstrate a training effect in either age group. The cardiac response to hypoxia was also comparable in the trained and sedentary rats. The base-line heart rate of anesthetized rats, in which in situ cardiac function was studied, was lower in the trained rats (321 +/- 14 vs. 377 +/- 8, P less than 0.005). Resting hemodynamics and left ventricular function curves generated from pressure-flow data during volume infusion did not differentiate between the hearts of trained and sedentary rats. In conclusion, a moderate level of endurance training did not enhance cardiac contractility when this was assessed under nonexercise conditions in both the isolated perfused heart and intact in situ heart preparations.

Eleven patients with hypertrophic obstructive cardiomyopathy and eight patients with idiopathic congestive cardiomyopathy underwent extensive neuromuscular studies to determine if a skeletal myopathy is associated with uncomplicated primary cardiomyopathy. The clinical examination revealed peripheral neuropathies in six patients, but no evidence of muscle weakness or atrophy. Nerve conduction studies demonstrated a neuropathy in five of these six and in one other patient: three were in the hypertrophic group and three in the congestive group. Seven patients had abnormal electromyography, but none had characteristic myopathic changes. Of these seven patients, muscle biopsies showed denervation in two patients in the congestive group and type II atrophy in two patients in the hypertrophic group. We found no evidence of primary skeletal muscle involvement; however, neuropathic features and biopsy changes of denervation were present in both groups.

The effects of physical training and detraining on cardiac structure and myocardial mechanics were studied in young and adult male rats trained by graded treadmill running for 12 wk and compared with sedentary controls. Detraining was produced by training for 12 wk followed by 6 sedentary wk. A training effect was demonstrated by increased succinate dehydrogenase activity in skeletal muscle (trained 10.0 +/- 1.2 mumol . g-1 . min-1; sedentary 6.4 +/- 0.8 mumol . g-1 . min-1; P less than 0.05). Although heart weight-to-body weight ratios were increased in trained rats of both ages, left ventricular fiber diameters and myocardial RNA, DNA, and collagen content were unchanged by training. Active and passive mechanics (myocardial contractility and stiffness) were studied in left ventricular papillary muscles and did not differ significantly between groups, with the exception of depressed contractility observed in young trained rats [(e.g., papillary peak developed isometric tension at Lmax (length at peak tension)] was 2.64 +/- 0.24 g/mm2 in trained vs. 3.59 +/- 0.22 g/mm2 in sedentary (P less than 0.01). This difference was abolished by detraining. Papillary muscle contractile responses to calcium, norepinephrine, and hypoxia were not altered by training or detraining. In conclusion, moderate endurance training did not result in significant cardiac hypertrophy, altered myocardial stiffness, or consistent changes in myocardial contractility.

The medical school curriculum is dominated by efforts to teach the mass of facts that comprise an ever-expanding pool of biomedical knowledge. As a result, little time remains for learning the scientific method, how to evaluate medical information, and how to apply analytic processes for the prevention, diagnosis, and management of disease. A new component in the medical curriculum at Emory University School of Medicine, a course titled Analytic Medicine, is proposed as a first step toward correcting these deficiencies. Analytic Medicine is intended to provide the opportunity and the necessary skills, through a problem-oriented approach, for medical students to learn to reason scientifically and to utilize analytic processes, including computers, in making clinical decisions.

Adaptive cardiac responses to isotonic training were studied with echocardiographic measurement of cardiac dimensions and function in 20 endurance runners whose maximal aerobic capacity on the treadmill was 4.88 +/- 0.13 (mean standard error of mean) liters of oxygen/min. They were compared with 26 young sedentary control subjects whose capacity was 3.34 +/- 0.11 liters of oxygen/min (P less than 0.001). A modest degree of right and left ventricular chamber enlargement and left ventricular hypertrophy was observed in endurance runners (left ventricular mass index 140 +/- 6 g/m2 compared with 107 +/- 4 g/m2 in sedentary control subjects, (P less than 0.001). Resting heart rate was slower in endurance runners (51 +/- 2 versus 62 +/- 2 beats/min, P less than 0.001) and resting left ventricular function as evaluated with ejection fraction and maximal posterior wall shortening velocity and mean circumferential shortening velocity (VCF) was comparable or slightly depressed in endurance runners (0.98 +/- 0.03 versus 1.02 +/- 0.05 circumferences/sec [difference not significant]). This study suggests that isotonic training results in adaptive changes in ventricular volume and mass, slower heart rates that may be associated with more efficient pumping function (that is, increasing stroke volume) and insignificant alterations in resting ejection phase indexes of left ventricular function.

Pulsus alternans was induced in 11 anesthetized, open-chest dogs by rapid atrial pacing, and the left ventricular filling characteristics and length-tension-velocity relationship of alternating beats were compared. The end-diastolic circumferences (cire) of the strong beats were slightly, but significantly, increased over the weak beats (7.3 > 6.9 cm, P < 0.01), confirming that diastolic filling does alternate in pulsus alternans. This alternation in initial fiber length seemed to result from an alternation in the prior end-systolic length, rather than from an alternation in diastolic filling time or compliance. There was also no difference in end-diastolic tension as measured by an isometric strain gauge suggesting no difference in contractile element relaxation before weak and strong beats. THE CONTRACTILE STATE OF THE STRONG BEATS WAS CONSISTENTLY GREATER THAN THAT OF THE WEAK BEATS WHEN CONTRACTILITY WAS DEFINED IN TERMS OF: (a) V(max) (3.13 > 2.53 circ/sec, P < 0.01); and (b) the velocity of circumferential fiber shortening (0.84 > 0.39 circ/sec, P < 0.001) and developed tension (82.5 > 74 g/cm, P < 0.01) at isolength. The length-tension-velocity relationship of the left ventricle also varied between strong and weak beats when: (a) the maximum velocity of contractile element shortening at least common tension (1.68 > 1.28 circ/sec, P < 0.05); and (b) the velocity of circumferential fiber shortening (0.81 > 0.39 circ/sec, P < 0.001) at maximum developed tension were examined. Analysis of the length-tension-velocity characteristics of sequential beats at the onset of alternans in three dogs suggests that an alternation in contractility initiates alternans, with secondary alternations in ventricular filling. Cross-clamping of the aorta in three other dogs essentially eliminated the alternating changes in end-diastolic length and pressure, while the resultant isovolumic contractions continued to demonstrate clear evidence of pulsus alternans in the ventricular systolic pressure, suggesting the persistance of an alternating contractile state. The evidence suggests that an important mechanism in the production and propagation of pulsus alternans, as produced in the intact canine ventricle by rapid pacing, is a beat-to-beat alternation in contractile state with secondary alternations in ventricular filling.