1978 December Faculty Journal

Vol.1 No.1 December 1978FACULTY JOURNAL University of Utah Medical Center Biophysics Department Chairman Dr. Homer Warner is in forefront of the effort to merge diagnostic medicine with computer technology. Vol.1 No.1 December 1978 Medical computers: tool or crutch? For the first time, there will soon be a definitive book on the medical use of computers. Authored by Homer R. Warner, M.D., Ph.D., Medical Decision-Making in the Computer Age will be released next summer by Academic Press. Dr. Warner, Chairman and Professor in the Department of Medical Biophysics and Computing, completed the text while on sabbatical leave. The rate of accumulation of new knowledge is so rapid, according to Dr. Warner, that physicians become frustrated in attempting to keep abreast. "This forces specialization and limits the ability of the doctor to handle multiple organ system problems. As the age of the population advances, there will be a greater tendency to find multiple chronic illnesses in a single patient." Although Dr. Warner does not dispute the need for specialization, he argues that the ability of an individual physician to recall specific information is limited. "The problem of drug interactions is an important example. Several physicians could be treating different problems with interacting drugs and the computer is the logical way to detect the problem." As an example, an aminoglycoside might be prescribed as an antibiotic. The drug can accumulate in toxic levels if the kidneys are not functioning properly and excreting the aminoglycoside. The computer is programmed to see if serum creatinine levels are monitored at least every three days. If not, the physician is prompted by the system to check. Dr. Warner argues that while American medicine is the best in the world, there is a problem of distribution of medical information. "The library is not an adequate source of information because you can't keep running there." A medical computer system is working well at LDS Hospital, according to the Biophysics Chairman. The system offers diagnostic suggestions, pulmonary and blood gas interpretations, history taking and other services. "It's an excellent system because it outlines any deviations from normal medical practices when they occur not retrospectively. It is the way quality control should work. The use of computers helps keep the physician out of trouble." What about the issue of relying on technology too much? Dr. Warner has a quick answer: "The machine is not telling you what to do. The system is based on physicians with expertise in certain areas introducing their logic. If you disagree, don't blame the machine. Talk to the expert!" It is difficult to prove that a computer system saved a life, Dr. Warner admits, but the same is true for a coronary bypass operation. He says there is a great deal of anecdotal evidence, however, that medical decision-making based on computerized models is extremely useful. A physician orders digitalis for a heart condition in a patient with a low serum potassium value. But unless a potassium supplement is ordered, there could be a serious toxic reaction. This is a common example, according to Dr. Warner, of how the computer can prompt the pharmacist to check with the physician. "Medicine is full of complex situations. It's hard to keep them all in mind. "The doctor still plays a major role in value judgments," Dr. Warner adds. "It is a question of medicine being an art or science. The computer is a key to making knowledge available for objective decision- making." strip, the physician can get possible diagnoses from the calculator. "This is a whole new idea in medical communic? tion," observes Dr. Warner. "Instead of just reading, tl,^^ physician has access to an algorithm which will do the work for him." The 25,000 bits of information in each module will be distributed to physicians subscribing to the "Journal of Medical Decision Algorithms." Contributions to the " Journal" will come mostly from medical academicians, although Dr. Warner hopes that the publication will be widely read by practicing physicians. "I want to encourage talented, medically-oriented people to work in this area," the Biophysics Department Chairman says. "They will need expertise in both medicine and computers." The " Journal" will also be available next year, although it will be some months before modules with medical information are available. The first two circuits for the micro-computers contain medical history and pharmacologic information. Special nodules hold 25,000 bits of information to assist phy sicians in making diagnoses. Unique information medium developed by Homer Warner The publication of Medical Decision-Making in the Computer Age will be followed by another first. Dr. Homer Warner is working on the initial issues of the "Journal of Medical Decision Algorithms," a quarterly publication that will be devoted to one medical problem at a time. The "Journal" will include a thumbnail-sized module that plugs into a hand- held calculator. The circuit has 5,000 program steps which express the medical logic for the given problem. With the addition of a patient information Dr. Burgess receives important appointment Medical Center cardiologist Mary Jo Burgess, M.D., recently was made a member of the American Society of Clinical Investigation. She was elected at the group's annual meeting in San Francisco where sb'" presented a paper on an electr^^ cardiographic method of determining the size of myocardial infarc-tions. Dr. Burgess is the ninth member of the Department of Internal Medicine to become a member of the Society, according to Department Chairman George E. Cart-wright, M.D. "Only 50 investigators Dr. Mary Jo Burgess in the United States are selected each year," he says, "so it's a highly prestigious appointment." Dr. Burgess, associate professor of medicine, has taught and conducted research at the University of Utah Medical Center since 1968. Currently she is director of the hospital's heart station and president- elect of the Utah Heart Association. As part of her research in cardiac electrophysiology, Dr. Burgess is working to determine the relationship be-tween the form of the electrocardiogram's "T" wave and the likelihood that a patient will develop arrhythmias. She is also involved in a group effort to develop an improved elec-trocardiographic examination, using body surface isopotential maps. FORUM "Faculty Journal" is being published out of the con-viction that communication in the College of Medicine has not been optimal. Our research activities, particularly, need more at-tention. Too often we have to go to a national meeting to hear about work going on across the hall. Other forums exist for dealing with problems of teaching and clinical work, but there are few internal mechanisms for disseminating research information. As the name implies, " Faculty Journal" is intended to present developments about and of interest to the faculty. And our goal is not to be comprehensive, but to spotlight items of interest to the broad spec-trum of scientists at the University of Utah Medical Center. At least half of each issue will be devoted to research activities of the faculty. We plan to be a journal " of record" in that a comprehensive list of grant awards and publica-tions will be provided. Certain of these will be spotlighted for longer discussion. We also plan to cover ^^ ean G. Richard Lee, clinical service, teaching innova- M. D. tions and other aspects of faculty activity. Your ideas are welcomed and solicited. Story ideas, guest commentaries and correspondence should be for-warded to " Journal" editor Mark Sands or contributing edi-tor Shery Harris. We hope that the Faculty Forum section will stir conversation and even debate. In addition to this column, there will be an ongoing dialogue on interesting issues. We encourage controversy, so feel free to write. In this space each issue, I will highlight items of institutional concern or of special interest to the faculty. State and national legislative issues will be a particular focus. Responses are invited. Faculty members in clinical departments will receive an addendum dealing with medical staff issues such as re-ports of the hospital Quality of Care Evaluation Committee. Replies to these reports are also welcomed. COMING IN THE NEXT ISSUE February- March 1979 Allen Edmundson: Pure research for science's sake. Faculty Tenure: A Protection of academic freedom or in-competence? The Bakke Decision: What Chuck Nabors REALLY thinks! Dr. Thomas Caine Geriatrics: the missing dimension in medical curricula Increasing economic and political forces have concen-trated attention on our growing geriatric population. As a result, increased federal and private funding is being directed toward research, education and ser-vice programs in gerontology and geriatrics. In response to these forces, an ad hoc committee has been appointed by the Dean to evaluate our local activities in geriatrics and make recommendations for changes where needed to better meet the growing challenge in this area of health care. Representatives on the committee include: David Sundwall, M. D., Family and Community Medicine; A. Mason Redd, M. D., Psychiatry; Gerry Tikoff, M. D., Medicine; James Swenson, M. D., Rehabilitation; Josephine Kasteler, Ph. D., Family and Community Medicine; and Helen Kee, R. N., Assistant Uni-versity Hospital Administrator. The provocative article written by Dr. Kasteler re-flects her views in regard to geriatric training. Thomas H. Caine, M. D., Medicine Geriatric Committee Chairman The sheer number of patients in the 55+ age cate-gory who will be seen by physicians in the future creates a problem of great magnitude for the medical profession, but the fact that so few of these physicians will have had any formal training in geriatrics makes the situation grave, indeed. Approximately 5,000 persons enter this segment of the population each day and bring with them an accumula-tion of health problems, yet medical schools have been slow to recognize the need for specialized training in health care for elderly people. There is a body of knowledge in geriatrics that can be taught. Students in medicine are well- schooled in the classic symptoms of disease, but diseases may present dif-ferently in the older patient. Drugs often require different dosages and may act differently in elderly persons. Geriatric patients become complex diagnostic prob-lems. In contrast to a younger person with a single acute problem, an older patient may have osteoporosis, diabetes, arthritis, anorexia, insomnia, emphysema, generalized arte-riosclerosis and congestive heart failure. It is not unusual for a physician to see these many problems in an older person. Doctors who work with elderly people have an important adjustment in timing to make- a different pacing of medical care. The older person's reaction time is slower and if doctors are impatient, or if they try to hurry the patient, he is likely to become confused and not able to react at all. Emotional states tend to become exaggerated in old age. Small talk by the physician will often allay anxiety, reduce depression, and provide reassurance in the case of fear. There are losses and changes that take place in the Dr. Josephine Kasteler immune system with age, making it less able to produce anti-bodies. Consequently, vulnerability to viruses, bacteria or any other foreign matter is in-creased. Persistent virus infections which produce slowly progressing changes over a long period of time are believed to play a role in such degenerative diseases as chronic cardiovascular disease and arterio-sclerosis. Doctors need to recognize and treat virus infections with greater care in the elderly. What might be a trivial infection in a younger per-son may be fatal to the elderly pa-tient. Minor skin infections, for example, become major problems because the components of the blood necessary for protection are not available due to an impaired vascular system. Another fundamental difference in the treatment of the elderly is in the diagnosis of symptoms. Symptoms can be very misleading in older patients as when heart disease presents as anorexia, insomnia, fatigability, vomiting and nocturia. On the other hand, hyperthyroidism frequently presents with cardiovascular symptoms. An appendiceal abscess may present itself with no other clinical manifestations than an abdominal mass. The older patient may slip into hyperglycemia, dehydration and coma before the diagnosis of diabetes mellitus is evident be-cause of the absence of earlier symptoms. Chronic diseases are usually insidious in their onset in the older patient and symptoms are often masked by other health problems. A mass in a lumpy breast due to fibrocystic disease may be extremely difficult to detect with-out proper training. These few simple illustrations of the complexity of evaluating an older patient partially demonstrate the neces-sity for medical students to be exposed to the accumulating body of knowledge in geriatric medicine. The American Medical Student Association, as a body, is pleading for more geriatric training in medical schools. As students get into their clinical years, increasingly they are faced with the recognition of their inability to treat older patients. Dean Lee has appointed a special committee to as-sess the need for more geriatric training in the Utah school and to propose suggested action. It may not be wise at the present time to envision a specialty in geriatrics, although geriatrics exists in Europe as a specialty, with ten University chairs in England alone. It is clear, however, that medical schools find it politically and socially expedient to consider some kind of geriatric education. As the need for geriatric training becomes more ap-parent, it is hoped that medical schools everywhere will respond to this missing dimension in medical education and future students will be more adequately prepared to manage the geriatric patient population than are doctors entering practice today. Josephine Kasteler, Ph. D. Assistant Professor Department of Family and Community Medicine Preventive medicine To the Editor: In the medical school setting, prevention and trea' ment are frequently seen as competitors, rather than tear?^ mates. I'm often challenged about the validity of preventive medicine. Can disease really be prevented? The data are compelling in support of the conclusion that preventive rather than treatment measures have been responsible for most of the improvements in health status and longevity observed in the past three centuries. Many of the current high- prevalence causes of morbidity and pre-mature mortality may be eliminated through preventive technology. New federal legislation and funding aimed at curb-ing the rising costs of health care increasingly stress the importance of prevention. To those steeped in the curative philosophy this diversion of funds is threatening, especially at this time when the taxpayer is revolting against the notion that resources for health services are not unlimited. Many of preventive medicine's past accomplish-ments utilized engineering and public health measures which required only passive participation by the individual. More of today's preventive concepts directed at changing current morbidity and mortality trends ( fluoridation being a notable excep-tion) require active individual be-havior change rather than a health department intervention. Respon-sibility for proper nutrition, to-bacco use, alcohol and other suE stance abuse, adequate exercise an seatbelt usage lies with the indi-vidual. Performing routine history and physical examinations in the ab-sence of symptoms is beginning to be replaced by prospective medicine, which uses modalities such as the Health Hazard Appraisal. Mortality/ morbidity risk assessment and selective laboratory screening based upon the age, sex, and genetic characteristics of the individ-ual are modern health tools which are being used to advance and consolidate health promotion and disease prevention. Perhaps it is understandable that treatment- oriented physicians find the past and present contributions of com-munity ( preventive) medicine threatening. Preventionists often overstate their position and claim that treatment is excessively expensive and has little net benefit. Such contro-versy is counterproductive. Our job in community medicine is not to denigrate treatment services, but to encourage the broader application of the concepts, principles, and services of disease prevention and health promotion. Curative medicine of high quality is important for patients ill with conditions responsive to treatment. Conversely, dietary change, early hypertension control and adequate exercise may exert an even greater influence on the currently observed downtrend in heart disease death rates than coronary care units and improvr emergency services. ^^ Health promotion concepts which will reduce or postpone individual risk to coronary artery and cerebral vascular disease, cancer, accidents and other leading causes of death are probably best communicated to the general Dr. James Mason public by their own physicians. The local health department must continue to be responsible for providing a safe water supply and community sanitation, and it should encourage '- nmunization and other preventive health practices. How-the physician is in the best position to modify individ-ual behavior by teaching and encouraging a health- promoting lifestyle. Prevention and treatment can complement each other in achieving worthwhile social goals. The question is not whether we should have prevention or treatment, but rather, how can we achieve the best mixture of both. Instead of debating whether dollars would be better spent for pre-vention than for treatment, we need to join forces to promote the most cost- justifiable methods of enhancing health. We would be happy to cooperate with any of the clinical services in augmenting health- promoting concepts which can be woven into the fabric of curative medicine. James O. Mason, M. D. Division of Community Medicine Department of Family and Community Medicine Immunologic research To the Editor: Historically, the Department of Obstetrics and Gynecology has emphasized research in genetics, maternal-fetal medicine and infertility. Under the new chairmanship of Dr. James Scott, the department now has expanded into the area of immunological research. Rh immunization is the classic immunological prob- "° m in obstetrics, but today the role of the maternal immune ^• system in normal fetal development is also being seriously investigated. The fetus, being the product of two genetically non- identical parents, is immunologically foreign to the mother and is the potential target of a destructive maternal response. Therefore, the reason the fetus normally survives in an immuno-logically hostile environment is not only relevant to obstetricians but also has significance to transplanta-tion and tumor immunologists. Immunology is clearly relevant to gynecological oncology. Gyneco-logical cancers have been reported to contain tumor- associated anti-gens, generate circulating immune complexes, and induce an immune response in the patient. Our department has begun to attract faculty mem-bers whose research interests are in the area of immunology. Dr. James Scott has published both on the problems of Rh sensitization and aspects of maternal cellular immunity. Dr. Gary Smith, an oncologist who received much of his training at M. D. Anderson Hospital in Houston, is interested in evaluating the immunological status of patients with gynecological neoplasms and determining the immunologi-cal parameters useful in obtaining an accurate clinical rognosis. - I have recently arrived from the Division of Surgical Oncology at UCLA where we published on the detection and purification of tumor- associated antigens in the urinary excretions of patients bearing solid neoplasms. That work will be continued here with the cooperation of Gynecological Oncology. Our prime goal is to develop an active reproductive immunology section. Being essentially a clinical department committed to the development of a basic research program, we must be able to integrate the needs of both the basic scientists and the clinicians. We welcome collaboration, comments, or advice from members of other departments who have similar research efforts. Neal S. Rote, Ph. D. New chairmen outline plans for departments New Chairmen for the Departments of Psychiatry and Biochemistry have been named by the Dean of the Col-lege of Medicine and approved by the College's Executive Committee. Bernard I. Grosser, M. S., M. D., has accepted the Chairmanship of the Department of Psychiatry for a limited term ending in the fall of 1980. Hans C. Rilling, Ph. D., has been appointed Acting Chairman of the Department of Biochemistry. " I plan to be an active chair-man," Dr. Grosser says, " Emphasis will be placed on a well- rounded research program, a fuller teaching: program, an expanded consultation and liaison service and an increase in the number of faculty and resi-dents in the adult and child psy-chiatry programs." Dr. Rilling is concerned with the problem of eventually attract-ing a new chairman. " This will be important because of the University's increasing emphasis on genetic research. An in-dividual with a background in biochemical genetics will be sought as chairman." There is also a need to strengthen the graduate teaching program in biochemistry, according to Dr. Rilling, and to bring faculty with common research interests to the Stangl Building because of the availability there of research space. Dr. Grosser replaces Eugene L. Bliss, M. D.