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Islet cell tumors are rare pancreatic or peripancreatic neoplasms that produce and secrete hormones to a variable degree. These tumors are best divided on clinical grounds into those that produce a recognizable, clinically evident endocrine syndrome (ie, functioning) and those that exhibit no clinical evidence of hormone production (ie, clinically silent). Clinically silent tumors produce symptoms due to mass effect because of their large size. They are often partially cystic or necrotic. Functioning islet cell tumors usually manifest earlier in the course of the disease because of the distinctive signs and symptoms of the associated endocrine syndrome. Clinically silent and functioning tumors cannot be histologically distinguished reliably even with the use of immunohistochemical stains. Insulinoma and gastrinoma, the two most common functioning lesions, are typically small homogeneous masses. Other functioning islet cell tumors include glucagonoma, somatostatinoma, vipoma, and adrenocorticotropic hormone-producing tumor. Larger tumors are associated with calcification, cystic degeneration and necrosis, and a more aggressive behavior (local and vascular invasion as well as distant metastases). There are many different techniques for detection and characterization of these lesions that are usually chosen according to the radiologist's experience and preference. Treatment and prognosis of these lesions depend on the hormone produced, their size, and their behavior.

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OBJECTIVE: The purpose of our study was to correlate the imaging and pathologic features of islet cell tumors with regard to tumor size, necrosis and cysts, calcification, malignant behavior, and functional status. MATERIALS AND METHODS: We retrospectively reviewed the clinical, pathologic, and imaging features of all 133 cases of pathologically proved islet cell tumors of the pancreas seen at the Armed Forces Institute of Pathology. Clinical data, including the patients' symptoms and serologic characteristics, were used to distinguish hyperfunctioning tumors (those causing symptoms related to elevated serum polypeptide levels) from nonhyperfunctioning tumors; hyperfunctioning tumors were divided further into insulin-producing and non-insulin-producing types. All patients had at least one cross-sectional imaging study, including CT (n = 118), sonography (n = 42), or MR imaging (n = 22). Clinical, pathologic, and imaging features were evaluated and correlated with tumor size, necrosis and cysts, calcification, local invasion, vascular invasion, metastases, and functional status. RESULTS: Islet cell tumors with areas of necrosis or cystic change found pathologically and on imaging studies (56/133) were larger (8.4 cm in mean transverse diameter) than homogeneous solid lesions (2.9 cm in mean transverse diameter) and were predominantly non-insulin producing (48/56) and nonhyperfunctioning (36/56). Of the 43 insulinomas, 35 were small (2.2 cm in mean transverse diameter), solid, and homogeneous. Larger size also was associated with calcification and malignant behavior, including local invasion, vascular invasion, and distant metastases. CONCLUSION: Our findings show that cystic and necrotic islet cell tumors are usually non-insulin-producing and nonhyperfunctioning neoplasms and larger than the typically solid and small insulinomas. Calcification, local invasion, vascular invasion, and metastatic disease are more commonly seen with larger neoplasms.

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Increasing interest in skills training has been prompted by concerns over risks posed by new, complex clinical environments and the need for medical students to function effectively in such settings. To gain a better idea of the type of instruction currently provided to U.S. medical students, a national survey was conducted in 1991. A survey instrument was prepared after a literature review on practical skills training. Eleven skill and knowledge areas were selected for analysis; six were considered "basic" and five "advanced." Mailings were directed to the deans of 126 U.S. medical schools. Based on a 94% response rate (118/126), the skill and knowledge areas taught most commonly included universal precautions, phlebotomy, intravenous line placement, advanced cardiac life support, and suturing lacerations. Fifty-one (43%) of 118 respondents reported that they conducted "transition courses" for practical skills training. At most such institutions, basic skills were taught more frequently than advanced skills. Where there was no transition course, formal instruction was provided in standing courses and clerkships. The survey indicates that five skills areas are formally taught in the majority of U.S. medical schools. These include universal precautions, phlebotomy, starting intravenous lines, suturing lacerations, and advanced cardiac life support. In most cases, evaluation and certification procedures are infrequent. Further studies are necessary to gain a better idea of what practical training should be undergone by all U.S. medical students.

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The objective of this analysis was to assess the practical value of the training experience for graduates of U.S. internal medicine residencies. Six alumni surveys were selected for analysis, wherein training items were grouped into comparable categories. Results of the studies were compared, using simultaneous preparation/importance ratings as the basis for assessment of items in each category. Six recent alumni surveys depict internal medicine residency training as a technical experience, wherein basic skills and practice-related issues may be underemphasized. Such surveys are useful for periodic re-evaluation of program goals and outcomes.

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OBJECTIVE: To determine the reliability and validity of "standardized patients" to assess clinical performance of internal medicine residents. DESIGN: Each resident spent 2 half-days interacting with 19 standardized patients (nonphysicians taught to portray patients in a reproducible fashion). Each resident was asked to obtain focused histories, perform relevant physical examinations, and provide patient education or counseling. At the end of each 10- to 15-minute encounter, the resident was asked to identify positive findings on physical examination and to prioritize a differential diagnosis. Other, more traditional indicators of clinical skills were also obtained. PARTICIPANTS: Three hundred ten residents from nineteen internal medicine training programs in the New England region of the United States. RESULTS: Reproducible estimates of data gathering and interviewing skills were achieved with 1 day of testing. Validity analyses were difficult to interpret because of the lack of an external "gold standard." However, faculty judgments of performance from reviewing videotapes corresponded with standardized-patient-based scores. Differences in group performance were also demonstrated across years of training and between U.S. or Canadian and foreign medical graduates. CONCLUSIONS: Systematic and effective procedures for developing standardized-patient-based test materials and for training standardized patients have been developed. This technique is best used for measuring data gathering and interviewing skills. Correlations with commonly used evaluation methods were generally low; this may be because standardized patients measure different skills. Local use of this technique by residency programs and the development of regional consortia sharing resources, costs, and expertise are advocated.

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Medical grand rounds is a time-honored weekly conference at United States teaching hospitals. We surveyed 122 departments of medicine to test the hypothesis that grand rounds may have changed with the changing training environment. Our goal was to gain a new perspective on the way physicians learn clinical medicine and maintain their fund of information. A questionnaire was designed to assess several aspects of grand rounds, including format, objectives, popularity, and changes over time. The questionnaire was directed to department heads of 122 U.S. medical schools. Seventy-five percent of respondents were department chairs; the remainder were chief residents and other faculty. Survey response rate was 96%. According to respondents, the major objective of grand rounds was to provide "updates in diagnosis and treatment." Case presentations were regularly included in about one third of departments; patients were rarely present for examination or interview. The popularity of grand rounds was thought to have decreased. These data support the impression that medical grand rounds is still considered important in most academic medical centers. Suggestions are made for increasing the clinical relevance of the conference. New techniques for presenting clinical material are reviewed, and an argument is made for returning to a basic strategy of "solving the patient's problem."

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UNLABELLED: Antibiotics have accounted for an increasing percentage of hospital pharmacy charges. Recently, an inexpensive method, automated peer comparison feedback, has been developed to influence physician use of resources. The documented success of several implementations of this strategy led to a one-year experiment to influence hospital antibiotic utilization. Each month, attending physicians in the top 50 percentiles for expenditure were notified of their status in relation to their peers. Expenditures by feedback and control groups were compared to determine whether feedback would result in reduced expenditures by individuals, or whether there would be a generalized reduction in expenditure by the entire group (Hawthorne effect). Over the year, no significant reduction in expenditure was noted. However, some important utilization patterns were identified. Although more surgical patients received antibiotics than did nonsurgical patients, surgical antibiotic costs were less. Surgical therapy was typically of shorter duration and involved the use of less expensive antibiotics. Multiple-antibiotic prescribing was less frequent on surgical services. Thirty percent of attending physicians were responsible for 80 percent of all antibiotic costs; 60 percent of those in this top group were members of the medical cohort. IN CONCLUSION: (1) As implemented in the current study, automated peer comparison feedback was not an effective method for reducing antibiotic utilization; (2) Differences in prescribing patterns between services may dictate the best strategies for improving antibiotic utilization; (3) More attention should be directed toward the relatively small "reference group" of physicians responsible for most hospital antibiotic prescribing.

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To evaluate the adequacy of preparation for medical practice, we surveyed 320 internal medicine program graduates. The 210 respondents gave their perceptions regarding preparation in training and importance in practice of eight clinical practice skills and 27 clinical procedure skills. The skills with highest preparation scores were venipuncture, intravenous line placement, and arterial puncture for blood gases. The skills rated as the most important in practice were history taking, physical examination, and selection of diagnostic tests. For 13 of the 27 clinical procedure skills, mean preparation scores were significantly higher than mean importance scores, suggesting "overpreparation." In contrast, seven of the eight clinical practice skills had mean preparation scores significantly lower than mean importance scores, suggesting "underpreparation." Furthermore, greater preparation during training was reported by more recent graduates for five of the overprepared skills. We concluded that skills emphasized in internal medicine training are not necessarily those important for practice and that recent changes in the training and practice environments may be increasing these discrepancies.

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The advent of the small computer as a basic clinical tool will have a significant impact on clinical practice and medical training. The application of probability theory to clinical diagnosis has led to the development of several practical diagnostic programs which run on small computers. Expert systems--interactive programs which function as 'electronic consultants'--have now been successfully developed for a number of clinical situations. Experience with two of these, INTERNIST/CADUCEUS and MYCIN, has provided insight into problems and prospects for expert systems in medicine. Less complex programs, particularly those employing clinical prediction rules, and expert system shells, seem well suited for clinical environments. Although computerized medical diagnosis holds great promise as an aid to clinicians, its success will largely be determined by the quality of the information that clinicians provide for analysis. A brief review of the status of bedside diagnosis reveals that data-gathering strategies and techniques must be better understood. In order to take full advantage of computer programs for diagnosis, basic diagnostic skills must be more heavily emphasized in clinical training.

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