What do Attending Physicians Contribute in a House Officer-Based Ambulatory Continuity Clinic?

OBJECTIVE: To study the educational contributions of attending physicians in an internal medicine house staff ambulatory clinic. DESIGN: Cross-sectional, self-administered survey. SETTING: University-affiliated general internal medicine practice. PATIENTS/PARTICIPANTS: Internal medicine residents and attendings. MEASUREMENTS AND MAIN RESULTS: Attending and resident perceptions of whether attendings made contributions to teaching points, diagnosis (DX), therapy (RX), and health care maintenance (HCM) were assessed in 428 patient encounters. Resident assessments significantly exceeded attending self-assessments of contributions to teaching points (82% vs 74%, P = .001), DX (44% vs 34%, P = .001), RX (61% vs 55%, P = .02), and HCM (19% vs 15%, P = .04). Both residents and attendings perceived that contributions declined progressively with increasing resident year (P<.05). Primary care and categorical residents assessed attending contributions comparably. However, attendings perceived contributing more to RX and HCM for categorical residents than primary care (P<.05). Male and female residents assessed attending contributions comparably. However, attendings perceived contributing generally more to DX in male residents than female (P = .003). In 8% of encounters, either residents or attendings felt that patient evaluation by the attending was needed. In these encounters with personal patient evaluation by attendings, both residents and attendings felt that attendings made more contributions to DX (P = .001) and teaching points than in other encounters. CONCLUSIONS: Attending physicians consistently underestimate their perceived contributions to house officer ambulatory teaching. Their personal patient evaluation increases assistance with DX and teaching points. Given perceived declining contributions by training year, attendings may need to identify other teaching strategies for interactions with senior residents

Geochemistry of the Serifos calc-alkaline granodiorite pluton, Greece: constraining the crust and mantle contributions to I-type granitoids

The Late Miocene (11.6–9.5 Ma) granitoid intrusion on the island of Serifos (Western Cyclades, Aegean Sea) is composed of syn- to post-tectonic granodiorite with quartz monzodiorite enclaves, cut by dacitic and aplitic dikes. The granitoid, a typical I-type metaluminous calcic amphibole-bearing calc-alkaline pluton, intruded the Cycladic Blueschists during thinning of the Aegean plate. Combining field, textural, geochemical and new Sr–Nd–O isotope data presented in this paper, we postulate that the Serifos intrusion is a single-zoned pluton. The central facies has initial 87Sr/86Sr = 0.70906 to 0.7106, εNd(t) = − 5.9 to −  7.5 and δ18Οqtz = + 10 to + 10.6‰, whereas the marginal zone (or border facies) has higher initial 87Sr/86Sr = 0.711 to 0.7112, lower ε Nd(t) = −  7.3 to − 8.3, and higher δ18Οqtz = + 10.6 to + 11.9‰. The small range in initial Sr and Nd isotopic values throughout the pluton is paired with a remarkable uniformity in trace element patterns, despite a large range in silica contents (58.8 to 72 wt% SiO2). Assimilation of a crustally derived partial melt into the mafic parental magma would progressively add incompatible trace elements and SiO2 to the evolving mafic starting liquid, but the opposite trend, of trace element depletion during magma evolution, is observed in the Serifos granodiorites. Thermodynamic modeling of whole-rock compositions during simple fractional crystallization (FC) or assimilation-fractional crystallization (AFC) processes of major rock-forming minerals—at a variety of pressure, oxidation state, and water activity conditions—fails to reproduce simultaneously the major element and trace element variations among the Serifos granitoids, implying a critical role for minor phases in controlling trace element fractionation. Both saturation of accessory phases such as allanite and titanite (at SiO2 ≥ 71 wt%)(to satisfy trace element constraints) and assimilation of partial melts from a metasedimentary component (to match isotopic data) must have accompanied fractional crystallization of the major phases