The assessment of poorly performing doctors: the development of the assessment programmes for the General Medical Council's Performance Procedures

BACKGROUND

Modernization of medical regulation has included the introduction of the Professional Performance Procedures by the UK General Medical Council in 1995. The Council now has the power to assess any registered practitioner whose performance may be seriously deficient, thus calling registration (licensure) into question. Problems arising from ill health or conduct are dealt with under separate programmes.

METHODS

This paper describes the development of the assessment programmes within the overall policy framework determined by the Council. Peer review of performance in the workplace (Phase 1) is followed by tests of competence (Phase 2) to reflect the relationship between clinical competence and performance. The theoretical and research basis for the approach are presented, and the relationship between the qualitative methods in Phase 1 and the quantitative methods in Phase 2 explored.

CONCLUSIONS

The approach is feasible, has been implemented and has stood legal challenge. The assessors judge and report all the evidence they collect and may not select from it. All their judgements are included and the voice of the lay assessor is preserved. Taken together, the output from both phases forms an important basis for remediation and training should it be required.

The General Medical Council's Performance Procedures: peer review of performance in the workplace

The General Medical Council procedures to assess the performance of doctors who may be seriously deficient include peer review of the doctor's practice at the workplace and tests of competence and skills. Peer reviews are conducted by three trained assessors, two from the same speciality as the doctor being assessed, with one lay assessor. The doctor completes a portfolio to describe his/her training, experience, the circumstances of practice and self rate his/her competence and familiarity in dealing with the common problems of his/her own discipline. The assessment includes a review of the doctor's medical records; discussion of cases selected from these records; observation of consultations for clinicians, or of relevant activities in non-clinicians; a tour of the doctor's workplace; interviews with at least 12 third parties (five nominated by the doctor); and structured interviews with the doctor. The content and structure of the peer review are designed to assess the doctor against the standards defined in Good Medical Practice, as applied to the doctor's speciality. The assessment methods are based on validated instruments and gather 700-1000 judgements on each doctor. Early experience of the peer review visits has confirmed their feasibility and effectiveness.

Depressive cognition: a test of depressive realism versus negativity using general knowledge questions

This research is an examination of whether cognition in depressed individuals incorporates a realistic view of the world or a general tendency toward negativity. Participants provided two types of probability judgments of the likelihood that they correctly answered general knowledge questions: the probability that they correctly answered each of the individual questions and an aggregate judgment, after completing the questionnaire, of the percentage of all the questions they thought they had correctly answered. These tasks generally elicit overconfidence and accuracy in nondepressives. In accord with theories of both depressive realism and general negativity, in their item-by-item assessments of their answers to the individual questions, depressed participants demonstrated less overconfidence than nondepressed participants. In accord with the theory of general negativity but not with the theory of depressive realism, however, depressed participants demonstrated underconfidence in their aggregate judgments. The implications of these findings on theories of depressive cognition are discussed.

Secondary necrosis is a source of proteolytically modified forms of specific intracellular autoantigens: implications for systemic autoimmunity

OBJECTIVE

Specific autoantigens targeted in systemic autoimmunity undergo posttranslational modifications, such as cleavage, during cell death that could potentially enhance their immunogenicity. In light of the increasing interest in the immunologic consequences of defective clearance of apoptotic cells, we sought to determine whether autoantigens cleaved during apoptosis undergo an additional wave of proteolysis as apoptosis progresses to secondary necrosis in the absence of phagocytosis.

METHODS

Apoptosis was induced in Jurkat cells with etoposide, anti-Fas antibody, or staurosporine (STS), and in HeLa cells with STS. Progression to secondary necrosis was assessed morphologically and quantified by trypan blue uptake. Autoantigen proteolysis during cell death was examined by immunoblotting of cell lysates using highly specific human autoantibodies as detecting probes.

RESULTS

Cells treated with the different apoptosis inducers underwent a rapid apoptosis that gradually progressed to secondary necrosis. During the initial apoptotic stages, several autoantigens, including poly(ADP-ribose) polymerase, topoisomerase I (or Scl-70), SSB/La, and U1-70 kd, were cleaved into their signature apoptotic fragments. Progression of apoptosis to secondary necrosis was associated with additional proteolysis of these and other autoantigens in a caspase-independent manner. Some autoantigens (e.g., ribosomal RNP, Ku, and SSA/Ro) appeared to be resistant to proteolysis during cell death.

CONCLUSION

In the absence of phagocytosis, apoptotic cells may undergo secondary necrosis, a process associated with additional proteolytic degradation of specific autoantigens. Secondary necrosis may occur in vivo in autoimmune disorders associated with impaired clearance of apoptotic cells and serve as a source of modified forms of specific autoantigens that might stimulate autoantibody responses under proinflammatory conditions.

Pathological glial tau accumulations in neurodegenerative disease: review and case report

Abnormal deposits of tau protein accumulate in glia in many neurodegenerative diseases. This suggests that in some instances the disease process may target glial tau, with neuronal degeneration a secondary consequence of this process. In this report, we summarize the pattern of glial tau pathology in various neurodegenerative disorders and add original findings from a case of sporadic frontotemporal dementia that exhibits astrocytic tau pathology. The neurodegenerative diseases span the spectrum of relative neuronal and glial tau involvement, from disorders affecting only neuronal tau to those in which abnormal tau deposits are found only in glia. From this, we conclude that glial tau can be a primary target of the disease process, and that this can lead to neuronal degeneration.

Effectiveness of a formal post-baccalaureate pre-medicine program for underrepresented minority students

PURPOSE

To address the effectiveness of a formal postbaccalaureate (PB) experience for underrepresented minority (URM) students before medical school. The program provided an intense year-long experience of course work, research, and personal development.

METHOD

There were 516 participants from one medical school: 15 URM medical students had completed the formal PB program, 58 students had done independent PB work before matriculation, and 443 students were traditional matriculants. Cognitive and academic indicators [college science and non-science grade-point averages (GPAs); biology, physics, and verbal MCAT scores; and percentage scores from first-year medical school courses] were compared for the three groups.

RESULTS

Both groups of students with PB experience demonstrated competency in the first year of medical school consistent with traditional students even though the students who had completed the formal PB program had lower MCAT scores and lower college GPAs than did the traditional students. Traditional predictors of academic performance during the first year of medical school did not significantly contribute to actual academic performances of students from the formal PB program.

CONCLUSION

The results support the use of a formal PB program to provide academic readiness and support for URM students prior to medical school. Such a program may also improve retention. Noncognitive variables, however, may be important to understanding the success of such students in medical school.

N-Acetyltransferases, sulfotransferases and heterocyclic amine activation in the breast

Heterocyclic amines are mammary carcinogens in rats and their N-hydroxy metabolites are substrates for subsequent metabolic activation by N-acetyltransferases (NAT) and sulfotransferases (SULT) in man. We investigated the expression of these enzymes in human breast tissue and the relationship between NAT genotype and NAT mRNA expression or enzyme activity. Immunohistochemical staining of sections of breast tissue identified expression of NAT1 and NAT2 protein in human mammary epithelial cells, but not in the stroma. We also measured the formation of DNA adducts of the heterocyclic amines 2-amino-3-methylimidazo[4,5-f]quinoline (IQ) and 2-amino-1-methyl-6-phenylimidazo[4,5-b]pyridine in calf thymus DNA after incubation of their promutagenic N-hydroxy metabolites with mammary cytosols prepared from reduction mammoplasty tissue. Experimental observations gained from use of enzyme cofactors and NAT and/or SULT inhibitors on cytosolic enzyme activity, recombinant NAT1 activity and heterocyclic amine-DNA adduct formation suggest that both NAT1 and SULT1A enzymes contribute significantly to the activation of N-hydroxylated heterocyclic amines in mammary tissue. NAT1 mRNA transcript levels were found to be two- to three-fold higher than mRNA transcripts of the NAT2 gene in reduction mammoplasty tissue and mammary epithelial cells. NAT1-specific p-aminobenzoic acid acetylation activity, but not NAT2-specific sulfamethazine acetylation activity, was detectable in mammary cytosols. There was no association apparent between NAT genotype and the levels of NAT mRNA or NAT enzyme activity, or between NAT1 genotype and IQ-DNA adduct formation mediated by mammary cytosols. Western blot analysis of mammary cytosolic protein showed detectable levels of SULT1A1 and SULT1A3.

Genetic counseling impacts decision for prophylactic surgery for patients perceived to be at high risk for breast cancer

BACKGROUND

This study addresses the impact a comprehensive genetic counseling program had on women considering prophylactic mastectomy or oophorectomy.

METHODS

Sixty patients underwent detailed family evaluation and risk was estimated. Recommendations were made regarding testing. Ramifications of testing were discussed in detail.

RESULTS

Thirty-one women (37%) were considering prophylactic surgery believing themselves to be at high risk. Of these, 23 had testing recommended. Seven patients proceeded with prophylactic surgery based solely on high-risk assessment. Ten women were tested; five were positive. Three patients proceeded with prophylactic surgery despite a negative test. One decided against surgery despite a positive test. After counseling, prophylactic surgery was performed in just over half the initial candidates.

CONCLUSIONS

Breast cancer risk estimation and genetic evaluation can be complex. Comprehensive genetic risk assessment programs can play a significant role in the management of patients considering prophylactic surgery for perceived high risk.

The impact of ethnicity on the presentation of polycystic ovarian syndrome

The effect of ethnicity on the prevalence and presentation of polycystic ovarian syndrome (PCOS) was examined in a cross-sectional study of women with clinical - and ultrasound - diagnosed PCOS. European, Maori and Pacific Island women were seen in proportion to the general population, whereas Indian women were over-represented and Chinese women under-represented. European and Maori women were more likely to present with hirsutism than other ethnic groups (43% versus 25%, p < 0.05), while European women were less likely to present with infertility (46% versus 68%, p < 0.01). The Pacific Island women had little or no acne but other signs of PCOS were similar among ethnic groups. Although less than 10% of patients were referred with obesity, the majority of PCOS women were overweight on examination. Maori and Pacific Island women were more obese and had the highest rates of insulin resistance and lipid abnormalities. The adverse metabolic profile of many of these women, particularly the Maori and Pacific Islanders, is very likely to predispose them to early cardiovascular disease.

Tobacco use and oral cancer: a global perspective

For both genders, cancer of the mouth and pharynx ranks sixth overall in the world; it is also the third most common site among males in developing countries. In industrialized countries, men are affected two to three times as often as women, largely due to higher use of alcohol and tobacco. Ethnicity strongly influences prevalence due to social and cultural practices, as well as socioeconomic differences. In population terms, survival rates around the world show little improvement. In terms of etiology, the effects of tobacco use, heavy alcohol consumption, and poor diet together explain over 90 percent of cases of head and neck cancer. All forms of tobacco represent risk factors for oral cancer, but on present evidence, snuff habits as they exist in Scandinavia and probably in the United States carry lower risks of serious health hazards, including oral cancer. Alcohol synergizes with tobacco as a risk factor for all upper aerodigestive tract SCC: this is super-multiplicative for the mouth, additive for the larynx, and between additive and multiplicative for the esophagus. The increase in oral cancer in the Western world has been related to rising alcohol use.

Occupational hierarchy, economic sector, and mortality from cardiovascular disease among men and women. Findings from the National Longitudinal Mortality Study

PURPOSE

Although socioeconomic position has been identified as a determinant of cardiovascular disease among employed men and women in the U.S., the role of economic sector in shaping this relationship has yet to be examined. We sought to estimate the combined effects of economic sector-one of the three major sectors of the economy: finance, government and production-and socioeconomic position on cardiovascular mortality among employed men and women.

METHODS

Approximately 375,000 men and women 25 years of age or more were identified from selected Current Population Surveys between 1979 and 1985. These persons were followed for cardiovascular mortality through use of the National Death Index for the years 1979 through 1989.

RESULTS

In men, the lowest cardiovascular mortality was found for professionals in the finance sector (76/100,000 person/years). The highest cardiovascular mortality was found among male non-professional workers in the production sector (192/100,000 person years). A different pattern was observed among women. Professional women in the finance sector had the highest rates of cardiovascular mortality (133/100,000 person years). For both men and women, the professional/non-professional gap in cardiovascular mortality was lower in the government sector than in the production and finance sectors. These associations were strong even after adjustment for age, race and income.

CONCLUSIONS

Characteristics of government, finance and production work differentially influence the risk of cardiovascular disease mortality. Men, women, professionals and non-professionals experience this risk differently.

The year in a training practice: what has lasting value? Grounded theoretical categories and dimensions from a pilot study

Experienced General Practitioners were asked about lasting value from GP Registrar training. Grounded theory was used to construct eight categories of training behaviours. In each category, dimensions spanned between learner-preferred behaviours and those the learners perceived as less helpful. Learners valued teaching based on evergreen approaches to problems. They welcomed exposure to a wide variety of styles and a safe, blame-free, environment, wherein to develop reflective practice. Modelling by trainers of personal development and team-skills has proved of lasting value in a changing world, particularly where change management is based on completed audit cycles. Help to see family medicine contexts of presenting problems enhanced Registrars' appetite for learning. Trainers centring education on learners, yet maintaining a sense of direction, are highly valued. General practice learners appreciate sensitive positive and negative feedback from their trainers. This work offers new possibilities for assessing and developing trainer behaviour.

Arylamine N-acetyltransferases - of mice, men and microorganisms

Arylamine N-acetyltransferases (NATs) catalyse the transfer of an acetyl group from acetyl CoA to the terminal nitrogen of hydrazine and arylamine drugs and carcinogens. These enzymes are polymorphic and have an important place in the history of pharmacogenetics, being first identified as responsible for the polymorphic inactivation of the anti-tubercular drug isoniazid. NAT has recently been identified within Mycobacterium tuberculosis itself and is an important candidate for modulating the response of mycobacteria to isoniazid. The first three-dimensional structure of the unique NAT family shows the active-site cysteine to be aligned with conserved histidine and aspartate residues to form a catalytic triad, thus providing an activation mechanism for transfer of the acetyl group from acetyl CoA to cysteine. The unique fold could allow different members of the NAT family to play a variety of roles in endogenous and xenobiotic metabolism.

Placental arylamine N-acetyltransferase type 1: potential contributory source of urinary folate catabolite p-acetamidobenzoylglutamate during pregnancy

Human arylamine N-acetyltransferase type 1 (NAT1), better known as a drug-metabolising enzyme, has been proposed to acetylate the folate catabolite p-aminobenzoylglutamate (p-abaglu) to N-acetamidobenzoylglutamate (ap-abaglu) which is a major urinary folate catabolite. Using mass spectroscopic analysis, we demonstrate the formation of ap-abaglu by recombinant human NAT1 and human placental homogenates. Using density gradient centrifugation the placental enzymic activity which acetylates p-aba and the placental enzymic activity acetylating p-abaglu both have an S(20,w) value of 3.25 S. This is the expected value for a monomer of human NAT1 (33 kDa). The specific NAT1 inhibitor 5-iodosalicylate inhibits acetylation of both p-aba and p-abaglu catalysed by either recombinant human NAT1 or placental samples as the source of enzyme. These data demonstrate that NAT1 is the major placental enzyme involved in acetylating p-abaglu.

[Electrocardiographic changes and rhythm problems in the diabetic]

Diabetes is a cause of serious myocardial disease related to an increased incidence of coronary artery disease, probably aggravated by cardiac autonomic neuropathy (CAN). In its incipient form, CAN hardly changes the sinus rhythm with an increase in nocturnal heart rate but without an appreciable effect on the indices of variability. In more advanced forms, "CAN+", there are not only changes in the heart rate variability but also in ventricular repolarisation. It is classical to underline the value of the corrected QT interval but this index has little real value. The "QT dispersion", comparing the duration of ventricular repolarisation on the surface leads, is no better a marker from the theoretical point of view. The dynamics of ventricular repolarisation on the other hand seem to be much more indicative of ventricular myocardial disease. They are studied by evaluating the QT-heart rate relationship and its increase distinguishes clearly CAN diabetics from CAN+ diabetics. In addition, in the latter subjects, diurnal physiological increase in the heart rate dependency of the QT interval (QT/RR slope) disappears or even inverse. It is probably this phenomenon which is responsible for the traditionally increased risk of ventricular arrhythmias and particularly sudden death in diabetics with autonomic neuropathy.