1979 November-December Faculty Journal

FACULTY JOURNAL UNIVERSITY OF UTAH COLLEGE OF MEDICINE Vol. 2, No. 3 Nov.- Dec. 1979Faculty Retreat discussions focus on issues vital to college When the College's recent faculty retreat adjourned and the chalkdust had finally cleared, there may not have been a single mind changed on the three controversial topics on the agenda. But the evening and morning dis-cussions, which ended a mere 16 hours after they had begun, likely afforded more spleen- venting, more candor and more interdepartmental dialogue than • he Medical Center had seen since the jst marathon faculty meeting five years ago. The retreat, held at Snowbird Ski and Summer Resort, drew 58 invited faculty members representing 13 academic departments, who deliberated three critical issues facing the medical school. The status of the clinician- teacher, a proposed interdepartmental graduate training program in biomedical sciences and the possibility of the University Medical Center developing its own pre-paid health care delivery system were discussed in nuts- and- bolts workshops the afternoon and evening of Friday, September 7. Recommendations from the workshops were refined and voted upon by the body as a whole during a Saturday morning wrap- up session. " It's been my observation that our faculty communications are irregular at best and at worst, woefully inade-quate," Dean Lee told the group. Facility Journal was conceived to improve communication, and the retreat also is a means to that end." The Dean pledged to find avenues for implementing the most widely- endorsed recommenda-tions to come out of the retreat. Paul M. Ellwood, M. D., a Minne-sota health care expert, set the stage for a provocative workshop on alternative health care delivery systems with a key-note address outlining the emergence of pre- paid health plans. Dr. Ellwood, president of Inter- Study, a non- profit health policy re-search institute, told the faculty that the current crisis in health care has been 15 years in the making. " By providing people with more and more health insurance, we've shielded consumers from the cost of health care and pro-tected providers from concern about cost." The solution, he says, is to " some-how make the health marketplace act like other marketplaces, and one way to do that is to divide providers into groups that compete on price." Dr. Ellwood says competitive health care appears to be working in the Twin Cities, where seven health care delivery systems involve 3,000 doctors and 300,000 people. And the bandwagon is growing, with many major cities hopping on. Boston, for example, has two pre- paid health plans in operation and seven in formation and San Diego has five and nine in the works. " Even though pre- paid plans have been slower to develop in Salt Lake City than in other Western cities, they are going to develop fast," Dr. Ellwood predicts, " because of the nature of the business community, the conservative and independent character of the area, and close medical ties and rivalries." Dr. Ellwood believes that academic medical centers have " pretty much maximized the return they can get for fee- for- service practice," and that the first academic institutions to " go all out" with pre- paid health plans will be the most successful. He cited several ways in which the University of Utah could proceed in the face of a groundswell for pre- paid plans: 1. Ignore the movement and the growing competition for patients. 2. Try to serve as the tertiary care center for fledgling alternative health care delivery systems. 3. Form its own plan, as George Washington University has done. 4. Assist in the formation of a plan out in the community, do some teaching in the plan and solicit referrals. While there are several problems associated with launching a pre- paid plan ( primary care demands will go up tremendously, for example), Dr. Ell-wood sees many advantages. He envisions more and better re-search in the health sciences, because there will be a defined, stable study population; medical education will be improved; there will be a guaranteed caseload; and, finally, " it may be your only means of survival." " It is by no means certain that you can succeed at your own pre- paid plan," cautioned Dr. Ellwood. The margin for error in Utah is much nar-rower than elsewhere because of the state's already low hospitalization rate. Discussing the issue on Saturday, the faculty focused on differences in the University's downstairs clinics and the so- called private clinics upstairs. Outpatient service in the down-stairs area needs improving, summar-ized discussion leader Gerald Rothstein, M. D., who pointed out that the number of downstairs clinic visits has fallen, while business is booming upstairs. " The University's good clinics are characterized by committed staff who are actually seeing patients themselves and who control the pursestrings. " Going to a pre- paid health plan may become necessary or we may lose our base of primary care patients and we may have an empty hospital," Dr. Rothstein added. " We have a potential captive audience in the more than 10,000 employees on campus, to whom we would offer an alternative to Blue Cross and FHP." Earlier, Dean Lee had told the faculty he expected reservations about the alternative health care delivery pro-posal, because " to many of you it will be a totally new idea." The idea proved popular, howevefl* and the faculty enthusiastically endorsed the workshop recommendations that ( 1) the Dean appoint a patient care ad-ministrative committee to identify major problems in outpatient services and ( 2) a six- month study be under-taken to examine the feasibility of a health maintenance organization at University Medical Center. The proposed graduate training program in biomedical education proved to be the least controversial of the three topics discussed at the retreat. The program, which would replace existing graduate programs in the de-partments of biochemistry, pathology, physiology and cellular, viral and mo-lecular biology, would be divided into four disciplinary tracks: cell biology and immunology; developmental and neurobiology; genetics; and molecular biology and biochemistry. While participating departments would not grant degrees or have grad-uate courses of their own, they will re-tain responsibility for courses designed primarily for medical students arv1 undergraduates and will continue make faculty appointments. Dana Carroll, Ph. D., who spoke in favor of the program, says the time is ripe for an interdepartmental graduate program in the basic sciences. It would, he says, attract the best students and faculty and allow both groups greater flexibility, give the University greater clout with granting agencies which now favor an interdepartmental approach to problems and improve the quality of raduate education. " It also makes a very logical basic science base for an M. D./ Ph. D. pro-gram and should help us attract funds and students for such a program," said Dr. Carroll. The faculty voted near- unanimously to endorse the program, with three pro-visos: ( 1) The steering committees which oversee each track should be elected by faculty in their own track ( rather than from the department), ( 2) students should be represented at the track level and ( 3) admission to the program should be distributed approxi-mately equally among the tracks. Additionally, it was recommended that the Dean appoint a committee to draft a proposal to consider an M. D./ Ph. D. program. And that's where faculty consensus ended. The clinician- teacher ( CT) work-shop, a free- wheeling three and a half-hour session, was thrown into chaos after it voted to scrap the two- track no tenure proposal under discussion and start over. " We did have unanimity on two ^ . siips discussion leader Gerasim Tikoff told the rest of the faculty the next morning. " We agree that the clinician- teacher is both wanted and needed by the College, and that this group has not fared well with the tradi-tional PRT review mechanisms and if this continues, college programs will suffer." Proponents of a dual system point out that CTs who fail academic ad-vancement at what they consider to be an appropriate pace get discouraged and leave the faculty. " The present PRT guidelines in the College of Medi-cine are sufficiently restrictive to delay, and in the higher ranks even to exclude, promotion of CTs," they argue. But the two- track plan as presented was voted down because it could be construed as being second- class system, according to Dr. Tikoff, who said the workshop overwhelmingly endorsed the concept of a single citizenship. The group also concluded that tenure, whether or not it has any practical value, does have a lot of symbolic meaning and should be available to any faculty member. The spirited Saturday morning dis-cussion stretched into afternoon. Dialogue was provacative: " Would it not be possible to develop a young cadre of clinician- teachers not interested in tenure?" " Scholarship must increase the increment of knowledge." " There are several ways to con-tribute and pass along new knowledge - not just publishing." " If we go to a single track, then we ought to use the same financial guide-lines for everybody - clinician-teachers, researchers and administra-tors. " " I'm against the proposal but if we're going to do it, let's also look at the third- class citizen - the guy who's a researcher and publishes should be promoted with the same ease as clini-cian- teachers. " " We ought not to be too threatened by the possibility of change, which I think I've seen happening in these ses-sions. The multi- track system has worked elsewhere without creating a second- class system." " Our guidelines say that faculty need meet only two criteria for promo-tion ( except to the professor rank), but our PRT actions deny this." " If you develop a way to distinguish between a first- rate clinician and a third- rate clinician, you won't have any trouble getting University approval." When the discussion finally calmed the faculty adopted, by a vote of 22 to 15, a recommendation for a single faculty track, with no differences in tenure or titles. They also approved a proposal that consideration be given to a mecha-nism to modify guidelines for promo-tion, retention and tenure and the composition of the PRT committee to be more appropriate to the candidate being considered for promotion. It also was recommended that the college address the problem of those who have research ranks. The recommendations are now under study by department chairmen, many of whom plan to schedule further discussions of these issues at depart-ment meetings. It is hoped that a con-sensus will emerge that will lead to workable regulations for implementa-tion in the next fiscal year. Dr. Pryor's automated measures of key ECG wave features are now available commercially. Computerized ECG analysis gives physicians ' another level of confidence' in diagnoses Computer analysis of electrocar-diography will never replace the " read-ing" of the test by a cardiologist, but a pioneer in the field says the two together provide the best possible diagnostic in-terpretation. T. Allan Pryor, Ph. D., associate professor of biophysics and computing, was the first researcher in the world to publish a program for computerized interpretation of electrocardiograms in light of previous ECG's on that patient. " Each person is a little different so we can never replace the human judg-ment that goes into such an analysis," emphasizes Dr. Pryor, " but automated interpretation of ECG's adds another level of confidence. The physician and computer together make a better reader than either does alone." In recent studies, a board of review physicians agreed with the computerized ECG analysis up to 90 percent of the time. " That compares very favorably with the group's agreement with in-dividual cardiologists' diagnoses when the same review criteria is applied to the computer," notes Dr. Pryor. " We have broad experience in this area be-cause more than four million ECG's are computerized annually." Frank Yanowitz, M. D., assistant professor of cardiology and director of the LDS Hospital Exercise Lab, says the automated ECG system is a great time-saver. " The computer takes away the bur-den of reading tons of ECG's. It's very good in weeding out the normals and abnormals and is very useful in diag-nosing underlying heart disease," Dr. Yanowitz explains. " The computer may not tell cardiologists anything they don't know, but it can be very helpful to the surgeon or other non- cardio-logist." There are three processes of ECG interpretation: morphologic analysis, rhythm analysis and serial comparison. All three functions have been available at LDS Hospital for five years but are only now becoming commercially available as a package. Morphologic analysis measures the key features of the P, QRS and T waves of the electrocardiogram, according to Dr. Pryor. " This determines the electrical con-duction pathway through the heart," he explains. " Electrical depolarization and repolarization tell the cardiologist whether or not there have been previous myocardial infarctions and indicate the possible presence of hypertrophy ( en-largement of the atria and ventricles)." The automated measures of key wave features also can indicate other conduction abnormalities. The blockag' of electrical impulses can occur at man- jm locations which are recognizable in the morphologic analysis of the ECG. Is the activation of the atrium and ventricles occurring from abnormal foci? This question can be answered by rhythm analysis as the computer mea-sures the interrelationships of various electrical activities. Serial comparison detects changes in an individual's ECG that may occur over time by comparing a current ECG with previous ECG's. Dr. Pryor explains. " These very sensitive tests can indi-cate the slightest deterioration in a given patient's ECG," says Dr. Pryor. " These slight changes in wave patterns may not be considered abnormal in a single tracing but they may be diagnostic when compared against a previous reading." In addition to his work with diag-nostic ECG interpretation, Dr. Pryor is recognized for research involving con-tinuous rhythm detection in coronary care unit patients, development of pro-grams for on- line analysis of electro-cardiographic recordings during tread mill interpretation and the development* of computer systems for other modes of medical decision- making. He also serves on the Committee for Electrocardiography of the Ameri-can Heart Association, the group responsible for establishing standards for electrocardiography in the U. S. FACULTY JOURNAL UNIVERSITY OF UTAH COLLEGE OF MEDICINE Vol. 2, No. 3 Nov.- Dec. 1979 Application to mail at second- class rates pending at Salt Lake City. Published bi-monthly by the University of Utah Medical Center, Office of Development and Commu-nity Relations, 50 North Medical Drive, Salt Lake City, UT 84132, under the auspices of G. Richard Lee, M. D., Dean, College ot Medicine. Faculty journal is published exclusively for College of Medicine faculty and alumni. Article suggestions, guest commentaries and correspondence are welcomed. Articles may be reprinted with permis-sion. Copyright" 1979 by the University of Utah College ot Medicine. Photographs by Medical Illustration Ser-vice, University of Utah College of Medicine Editor: Anne Brillinger Con tributing Editors: Shery Harris, dj Tippen Medical geneticists trace sources of hemophilia ^ o mid- 19th century pioneer women Hemophilia, the crippling blood clotting disorder that affects one in every 2,500 males born in Utah each year, can now be traced to its source - the pioneer women who settled in the state in the mid- to late- 1800s. Robert M. Fineman, M. D., Ph. D., director of the Division of Medical Genetics and assistant professor in the University of Utah Medical Center's Department of Pediatrics, is tracking down carriers of the genetic disease with the cooperation of families attending University Medical Center's Mountain States Regional Hemophilia Center, run by Edward J. Hershgold, M. D., asso-ciate professor of family and communi-ty medicine and pathology. The U researchers are attempting to trace hemophilia back several genera-tions; in some cases, as many as six or seven generations. " Several factors are necessary to trace the origin of genetic diseases such as hemophilia and muscular dys-trophy," says Dr. Fineman. " We need arge, well- defined pedigrees, a mini- ^ Tnum of family migration and illegiti-macy, and a good, relatively inexpensive carrier detection test. Thanks to two much improved blood tests developed recently and the meticulous genealogic record- keeping of Utah families, we will have probably the most complete car-rier detection program ever." A grant from the Bureau of Com-munity Health Service, Department of Health, Education and Welfare, has enabled Dr. Hershgold to employ a technician to set up two extremely sensitive tests to detect factor VIII - the anti- hemophilic clotting factor. The tests require only a small amount of blood. One test measures the amount of factor VIII in the blood; the other test assays its biologic activity. In a normal person, both level and activity are usually about 100 percent of normal, says Dr. Fineman. Hemo-philia is characterized by the presence of an abnormal factor VIII, one that lacks coagulant activity. Thus, in hemo-philiac males, the level is normal, but the activity is very low ( less than a few percent). In carrier females, the level is normal, but the activity is only around 50 percent. Hemophilia is an x- linked recessive trait. Approximately 50 percent of daughters born to carrier females will Meticulous Utah pedigrees help Dr. Fineman trace hemophilia to its source women who settled the state more than a century ago. pioneer be carriers; while 50 percent of the sons of carrier females will be hemophiliacs. All daughters of hemophiliac males are carriers, but no sons of affected males inherit the disease. In the next year, eight or nine Utah males will be born with hemophilia. The social- psychological burden on patients and families is great, and so is the financial one. Medication alone, consisting of potent factor VIII prepara-tions which must be injected intra-venously, can cost up to $ 22,000 per hemophiliac per year - about $ 1.5 to 2 million annually for the 80- 90 known cases in Utah. In addition, there are physician, nurse, hospital and other costs. Many physicians say that of all known genetic diseases, hemophilia has one of the highest known mutation rates, with approximately one- third of the cases occurring in families with no prior history of the disease. Dr. Fine-man disputes this contention. " There are many cases in which pa-tients do not know their ancestors, and/ or their relatives, and thus their family history might erroneously show up negative," he says. " Carrier detec-tion is like peeling an onion. With each layer of the pedigree that is stripped away, more carriers and affected males will be discovered." Dr. Fineman and his colleagues have contacted about 13 families thus far from the Medical Center's hemo-philia clinic. The carrier detection pro-gram, which should take several years to complete, is a part of a statewide medical genetics program, with satellite clinics located throughout Utah. No patients or families, even those in geo-graphically isolated areas of the state, will have to travel more than 75 miles for counseling. " People have a right to know what chances they're taking when they have children," Dr. Fineman believes. " There are many reproductive options avail-able to women who are carriers. It is possible that with genetic counseling and the sophisticated carrier tests now available, hemophilia could become a preventable disease." The carrier detection program works in collaboration with the Medi-cal Center's hemophilia evaluation center. It is funded in part by the Na-tional Foundation- March of Dimes, the University of Utah, the Utah State Division of Health and the Department of Health, Education and Welfare. Nutritionist Sorenson: Is there a link between home canning and health? Effects of high- fiber diet on colon cancer investigated in statewide study More home canning paraphernalia is sold per capita in Utah than anywhere in America. The incidence of colon cancer in Utah is 30- 35 percent below the na-tional rate. Utah Mormons have a lower inci-dence of most cancers than non- Mormons who live in the state. Possible links among these diverse observations are under investigation in an ambitious three- year study on " Diet and Colon Cancer in Man: The Effects of Dietary Fiber," funded by an $ 883,793 grant from the Diet, Nutrition and Cancer Program of the National Cancer Institute. Principal investigator is Ann Soren-son, Ph. D., professor of family and community medicine in the College of Medicine. The research team includes food scientists from Utah State Univer-sity and interviewers from that school's extension division, biochemists from USU and the Wistar Institute in Phila-delphia, a clinical dietician, medical sociologist, nutritionist ( Dr. Sorenson) and epidemiologist ( Joseph L. Lyon, M. D., M. P. H., assistant professor of family and community medicine at the U). Drs. Sorenson and Lyon were co-investigators on a nearly- completed three- year $ 388,000 grant from the same agency. That study examined the diets of 900 Utahns ( 300 with colon cancer and 600 controls) and recorded the aggregate components of food nutrients ( carbohydrates, proteins, vitamins, fiber, etc.). Nutrition and diet may affect can-cer risk in one of two ways, according to Dr. Lyon. Either the foods and bever-ages themselves contain can