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Trends in training physicians
Lcttcrs
and treatment of hypertrophic obstructive cardiomyopathy, Br. Heart J. 33:671, 1971. 5. \I;hiting, R. B., Powell, \V:. J., Jr., Dinsmore, R. E.. et al.: Idiopathic hypertrophic subaortic steno,& in the eldeily, N. I&l. J. bled. 285:196, 1971. 6. Shah, P. A,l., Gramiak, R., and Kramer, D. H.: Ultrasound localization of left ventricular outflow obstruction in hypertrophic obstructive cardiomyopathy, Circulation 50:3, 1969.
Trends in training
physicians
TO the Editor: I note with interest and disagreement that the educators of America consider a genera1 but adequate knowledge of medicine impossible-in short, there is “too much to learn.“’ In view of the extensive mass of ever-increasing knowledge, the brains of even the superior and highly selected youths of America are unable to cope with it all. The solution suggested by the educators to the problem of this ever-increasing knowledge is to reduce the length of time devoted to le:irnina medicine. They “give up!” The objective is to reduce the training period to three years. Some shout with pride that they train “doctor.” in 7 years or even one and one-half years. In f;trt, borne do not even have to learn much at all to become phq-yicians’ assistants. The emphasis is on the qunntity of doctors produced. The advocators of this plan fail to realize that such a practice will only produce an extra year or two of graduates and then the shortened learning period will not even produce greater numbers, only less qualified physicians. Our Russian counterparts realize there is more to learn aud that a longer period is required to learn it. They, therefore, have increased their training period from j to 7 years.* They emphasize quality, scholarly pursuit, and research.? IVe reduce our learning time from 4 to 2 years or even l? i years and emphasize quantity. Sir, should this attitude and practice continue, the center of world medicine will move from America to Russia within the next 10 to 20 years! Patients of all countries will look to Russia for special care, and the youths of the world will seek Russian diplomas, certificates of special training and advanced education. Why not emphasize quality, scholarly pursuits and research as well as quantity? ‘?‘hy not 300 more medical schools with classes of only 75 students or less with adequate scholars of medicine as teachers? Why did some medical schools and educators express pride in their small classes (75 or fewer students) less than 10 years ago but now large classes are the “thing” of the time? Sir, money is the answer! Yes; but what about sick people and lives? With all the great “advancements” of modern times, people still !ong to live longer but live no longer anymore.3 If you could only help to awaken the educators. G. E. Burch, M.D. Tulane University School of iWe&icine New Orleans, La.
to the Editor
429
REFERENCES Burch, G. E.: There is not too much to learn, Am. I. Cardiol. 22:137, 1968. Null&, E., Abdellah, G., Billings, F. T., Hess, E.. Petit. D.. and Ezeberz. 12. 0.: The Soviet heilth sy&e&Aspecti of rilevance for medicine in the United States, N. Engl. J. Med. 286:693, 1972. Burch, G. E.: People live no longer anymore, AM. HEART J. 83:X5, 1972.
Atrioventricular isorhythmic
interaction dissociation
in
To the Editor: In November, 1971, and in January, 1972, Paulay, Damato, and Bobbj and Paulay and Damato6 published two papers referring to the mechanism of synchronization in dogs and in men, respectively, in this JOURNAL. From our own studies on this subject, carried out on cats,2r3 and from previous observations in patients with artificial cardiac pacemakers,’ we can confirm the findings of these authors in most points of view. There are some striking differences, however, with respect to the effect of atria1 stretching. Since Datnato and co-workers do not know our papers from 1965 and 1969, we should be glad to give some comments to the problem mentioned above. The experiments were carried out in 52 anesthetized cats, which remained in spontaneous respiration. Right ventricular pacing was performed by a transvenous approach. Aortic pressure, right atria1 pressure, and right atria1 ECG were studied in every case. Like Damato and co-workers, and in contrast to Levv and Zieske,” we preferred to study the mecha&m of synchronization in animals with intact A-V conduction systems. Five cats were studied, which previously had been treated with reserpine, vagotomy was performed in 26 cats, and betaadrenolysis with propranolol was done in 20 animals. In five cats, experiments were carried out with constant aortic pressure and in eight others with constant right atrial pressure. Our results were similar to those of Damato and co-workers,“s6 and of Levy and Zieske4 with respect to the changes in aortic and right atrial pressure and with respect to the frequency in the appearance of synchronization phenomena. In contrast to Levy and Zieske,4 however, synchronization did not cease when the aortic pressure was kept at a constant level. To illustrate, we tnay be allowed to represent a segment of an original experiment in which the decrease of aortic pressure during asynchronous ventricular pacing was prevented by unclamping a tube leading from the central aorta to a reservoir elevated to a height equivalent to the prevailing mean aortic pressure (Fig. 1). At arrow 1, ventricular pacing begins with a rate little above the spontaneous sinus rate. At arrow 2, the ventricles become depolarized by the artificial pacemaker, whereas the atria are excited on a retrograde pathway. An increase of right atria1 pressure can be observed, whereas the aortic pressure remains constant. At arrow 3, the rate
and treatment of hypertrophic obstructive cardiomyopathy, Br. Heart J. 33:671, 1971. 5. \I;hiting, R. B., Powell, \V:. J., Jr., Dinsmore, R. E.. et al.: Idiopathic hypertrophic subaortic steno,& in the eldeily, N. I&l. J. bled. 285:196, 1971. 6. Shah, P. A,l., Gramiak, R., and Kramer, D. H.: Ultrasound localization of left ventricular outflow obstruction in hypertrophic obstructive cardiomyopathy, Circulation 50:3, 1969.
Trends in training
physicians
TO the Editor: I note with interest and disagreement that the educators of America consider a genera1 but adequate knowledge of medicine impossible-in short, there is “too much to learn.“’ In view of the extensive mass of ever-increasing knowledge, the brains of even the superior and highly selected youths of America are unable to cope with it all. The solution suggested by the educators to the problem of this ever-increasing knowledge is to reduce the length of time devoted to le:irnina medicine. They “give up!” The objective is to reduce the training period to three years. Some shout with pride that they train “doctor.” in 7 years or even one and one-half years. In f;trt, borne do not even have to learn much at all to become phq-yicians’ assistants. The emphasis is on the qunntity of doctors produced. The advocators of this plan fail to realize that such a practice will only produce an extra year or two of graduates and then the shortened learning period will not even produce greater numbers, only less qualified physicians. Our Russian counterparts realize there is more to learn aud that a longer period is required to learn it. They, therefore, have increased their training period from j to 7 years.* They emphasize quality, scholarly pursuit, and research.? IVe reduce our learning time from 4 to 2 years or even l? i years and emphasize quantity. Sir, should this attitude and practice continue, the center of world medicine will move from America to Russia within the next 10 to 20 years! Patients of all countries will look to Russia for special care, and the youths of the world will seek Russian diplomas, certificates of special training and advanced education. Why not emphasize quality, scholarly pursuits and research as well as quantity? ‘?‘hy not 300 more medical schools with classes of only 75 students or less with adequate scholars of medicine as teachers? Why did some medical schools and educators express pride in their small classes (75 or fewer students) less than 10 years ago but now large classes are the “thing” of the time? Sir, money is the answer! Yes; but what about sick people and lives? With all the great “advancements” of modern times, people still !ong to live longer but live no longer anymore.3 If you could only help to awaken the educators. G. E. Burch, M.D. Tulane University School of iWe&icine New Orleans, La.
to the Editor
429
REFERENCES Burch, G. E.: There is not too much to learn, Am. I. Cardiol. 22:137, 1968. Null&, E., Abdellah, G., Billings, F. T., Hess, E.. Petit. D.. and Ezeberz. 12. 0.: The Soviet heilth sy&e&Aspecti of rilevance for medicine in the United States, N. Engl. J. Med. 286:693, 1972. Burch, G. E.: People live no longer anymore, AM. HEART J. 83:X5, 1972.
Atrioventricular isorhythmic
interaction dissociation
in
To the Editor: In November, 1971, and in January, 1972, Paulay, Damato, and Bobbj and Paulay and Damato6 published two papers referring to the mechanism of synchronization in dogs and in men, respectively, in this JOURNAL. From our own studies on this subject, carried out on cats,2r3 and from previous observations in patients with artificial cardiac pacemakers,’ we can confirm the findings of these authors in most points of view. There are some striking differences, however, with respect to the effect of atria1 stretching. Since Datnato and co-workers do not know our papers from 1965 and 1969, we should be glad to give some comments to the problem mentioned above. The experiments were carried out in 52 anesthetized cats, which remained in spontaneous respiration. Right ventricular pacing was performed by a transvenous approach. Aortic pressure, right atria1 pressure, and right atria1 ECG were studied in every case. Like Damato and co-workers, and in contrast to Levv and Zieske,” we preferred to study the mecha&m of synchronization in animals with intact A-V conduction systems. Five cats were studied, which previously had been treated with reserpine, vagotomy was performed in 26 cats, and betaadrenolysis with propranolol was done in 20 animals. In five cats, experiments were carried out with constant aortic pressure and in eight others with constant right atrial pressure. Our results were similar to those of Damato and co-workers,“s6 and of Levy and Zieske4 with respect to the changes in aortic and right atrial pressure and with respect to the frequency in the appearance of synchronization phenomena. In contrast to Levy and Zieske,4 however, synchronization did not cease when the aortic pressure was kept at a constant level. To illustrate, we tnay be allowed to represent a segment of an original experiment in which the decrease of aortic pressure during asynchronous ventricular pacing was prevented by unclamping a tube leading from the central aorta to a reservoir elevated to a height equivalent to the prevailing mean aortic pressure (Fig. 1). At arrow 1, ventricular pacing begins with a rate little above the spontaneous sinus rate. At arrow 2, the ventricles become depolarized by the artificial pacemaker, whereas the atria are excited on a retrograde pathway. An increase of right atria1 pressure can be observed, whereas the aortic pressure remains constant. At arrow 3, the rate