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The authors describe their vision of what continuing medical education (CME) should become in the changing health care environment. They first discuss six types of literature (e.g., concerning learning and adult development principles, problem-based/practice-based learning, and other topics) that contribute to ways of thinking about and understanding CME. They then state their view that the Association of American Medical Colleges (AAMC) has made a commitment to helping CME be more effective in the professional development of physicians. In presenting their new vision of CME, the authors describe their interpretation of the nature and values of CME (e.g., optimal CME is highly self-directed; the selection and design of the most relevant CME is based on data from each physician's responsibilities and performance; etc.). They then present seven action steps, suggestions to begin them, and the institutions and organizations they believe should carry them out, and recommend that the AAMC play a major role in supporting activities to carry out these steps. (For example, one action step is the generation and application of new knowledge about how and why physicians learn, select best practices, and change their behaviors). Six core competencies for CME educators are defined. The authors conclude by stating that collaboration among the appropriate academic groups, professional associations, and health care institutions, with leadership from the AAMC, is essential to create the best learning systems for the professional development of physicians.

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Questionnaires dealing with the 1977 in-training examination for residents in obstetrics and gynecology were sent to residency directors and residents. More than 70% were returned. Responses indicated a generally positive view of the examination, especially the multiple-choice questions (MCQs). There was strong support for the retention of patient management problems (PMPs) and feedback, but there was significant criticism of the format for feedback and the appropriateness of PMP options. Correlational analysis indicated that in evaluating the examination, residents emphasized the quality of the MCQs and feedback, while residency directors based their evaluation on a broader range of examination qualities. The analysis suggested that the questionnaire results were generally representative of the views of residency directors and residents.

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In the four years from 1975 to 1978, 12,712 in-training examinations were administered to residents by the Council on Resident Education in Obstetrics and Gynecology. Whereas the first four tests (1970 to 1974) consisted entirely of multiple choice items (MCQs), these examinations were approximately equally divided between MCQs and patient management problems (PMPs). Discrimination, difficulty, and reliability indices for the total examination have remained relatively constant. The MCQ subtest scores have decreased in validity due mainly to the decrease in the number of items necessary to accommodate the PMPs. However, the overall test performance remains satisfactory to meet its educational objective. Accomplishment of this objective was enhanced by the unique "key word feedback" instituted in 1975. The tests have continued to show a progressive score increase from the first to the fourth years of training. These and other data are presented by year, and the future directions for the examination are discussed.

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PIP: To determine the role of changes in coagulation factors in hermorrhagic complications after intraamniotic infusion of hypertonic saline for therapeutic abortion, 21 women undergoing this operation, ranging 15-38 years in age with an average gestation of 18 weeks, were studied for coagulation factors, fibrinogen survival, and plasma volume. Blood tests were taken before, immediately after, and at 3-hour intervals after infusion of hypertonic saline. Significant changes were found in the following factors: Thrombin clotting time was consistently prolonged from the third hour after infusion. The platelet count dropped significantly from 310,000/cu. mm before infusion to 223,000/cu. mm 18 hours later. Fibrinogen levels dropped significantly from a mean preinfusion level of 393 mg/100 ml to 297 mg/100 ml at 18 hours. Factor VIII levels also fell significantly from 131% of normal at preinfusion to 85% of normal at 6 hours. Factor V levels declined significantly from a preinfusion mean of 104% of normal to 91% at 6 hours, though the rate of decrease varied widely among the patients. Fibrinogan/fibrin, degradation products, negative at preinfusion, appeared in all patients serums. Euglobulin lysis time was not accelerated. Fibrinogen survival studies were conducted in only 5 patients, 4 of whom showed a significant decrease, notably immediately preceding abortion, with a highly significant correlation to the time from infusion. Plasma volume increased significantly with a corresponding decrease in hematocrit. It is concluded that a mild form of diffuse intravascular coagulation develops after the intraamniotic infusion of hypertonic saline, but further research is necessary to pinpoint the cause of serious coagulopathy and hemorrhage.^ieng

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PIP: To determine the relationship of coagulapathy to saline infusions for abortion, plasma volume, electrolyte, and coagulation factors were studied in 6 patients of a gestational average of 18 weeks undergoing intraamniotic hypertonic saline infusion for therapeutic abortion. Blood samples were taken before the operation and afterwards at 3-hour intervals for 30 hours. Mean plasma volume increased by 8.9% of the base-line values by 15 hours. The direct correlation found between fluid intake, weight, and plasma volume indicates that unlimited fluid intake may be allowed following saline infusion. Serum electrolytes showed no significant change. Urine sodium and chloride increased at 3 hours, reaching a peak of 60 meg at 27 hours, and returning to base-line values at 36 hours. Urine potassium decreased at 3 hours and remained slightly below base-line values for the remainder of the test period. Disperse variations in the coagulation factor studies might suggest mild diffuse intravascular coagulation, but further research is required.^ieng

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