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“patient centered perspective”. The goal is to instill in the studenta reflex to recognize patients’ potential emotional, social andspiritual problems and concerns. Students are trained to recognizethat patients of different social groups. religious backgrounds orgeographical regions may have very different primary concernseven if the have the same physical problems.Concurrently, PBL students are also required to meet weekly in aclinical setting with community physicians and their patients. During this clinical experience, called “preceptorship”. students aretrained in the taking of history and the performance of physicalexaminations.Additionally, PBL students are required to spend halfaday a weekat a community based medical support organizations such as careprograms for the homeless, hospice. critically ill children, studentbased health organizations. etc. It is the goal of these programs toincrease the clinical and community health exposure of PBL students to accelerate their acclamation and competence in workingwithin and utilizing these environments and resources.As stated above, the purpose of this research is to support thehypothesis that PBL curricula adequately trains physicians to develop equally strong physician-patient relationships when cornpared with traditionally trained physicians. Authors used the ratesof filings of medical malpractice claims against physicians as anobjective assessment of the physician-patient relationship. it is nothypothesized or even suggested that traditional or PBL graduateshave any greater or lesser medical proficiency or knowledge in theactual rendering of diagnoses and treatment to their patients. Itis theopinion of these authors that the instigation of a malpractice actionby a patient against their physician is in most cases not a reflectionon that physician’s ability to render biological treatment. A filing ofa medical malpractice claim is instead, largely an indication of’ afailing in the relationship and communication between that physician and their patient.3 John A Burns School of Medicine (JABSOM):A Unique Opportunity To Compare PBL to Traditional Medical Training.JABSOM is uniquely situated for the comparison of medical malpractice rates between traditionally trained and PBL trained physicians. Between 1975 and 1992 JABSOM followed a traditionallecture based format. However, in 1989. JABSOM adopted a PBLformat and graduated its first PBL trained class in 1993. Additionally. JABSOM s graduates have predominately moved into thefields of primary care (61%- 75% between 1988-2001) (Table I).Because of these facts the authors assert that it is fair to compare theoccurrence of malpractice between the two groups. Thus, in aproximally associated time frame (within 25 yeart) there exist twogroups ot physicians 4raduating m LssLntiall\ thL s imc ticld thatma he compared.A.d.di.tionailv, Hawai.i is a favorah].e. place to assess the rates ofmedical malpractice brought against known physicians. Since 1975the Hawaii law has required that all medical malpractice claimsproceed through the Medical Claims Conciliation Panel (MCCP)before a claim may he filed in court. For strategic reasons(which arebeyond the scope of this project), this MCCP filing requirement hasresulted in many medical malpractice claims being formall instituted (and thus recorded) at the MCCP that would normally have‘been settled by the defendant ordropped by the plaintiff befhre therewas an official record of claim. Thus giving a clearer picture as tothe true numbers of medical malpractice rates than is demonstratedby formal court filings.Research and Design MethodsAs of the writing of this paper JABSOM has graduated 1469physicians since the inception of its four-year program in 1971. Ofthese there have been 1 8 traditionally trained graduating classes and9 PBL graduating classes. The numherofJA BSOM graduates in thetwo groups total 1084 and 489 respectively. However, at the timeof data collection from the MCCP in December of 2000, there wasonly complete data of medical malpractice filings for the years of1974-1999. Thus, the last two JABSOM PBL graduating classes of2000 and 2001 were excluded from statistical analysis, In the finalanalysis the two populations assessed numbered 1084 traditionaland 385 PBL graduates.The rates of malpractice were assessed on the basis of postgraduate year (“PGY”), i.e. first year after graduation, second year aftergraduation, etc. The number of graduates involved in law suits fora given PGY was considered a positive event without any significance given to the number of suits an individual graduate wasinvolved in for a given year. Statistical analysis of the collected databy means of the Continuity Adjusted chi-square and the FishersExact test of the data was then performed.ResultsTable 3 shows the chi-square and Fishers Exact Test values forstatistical analysis of the data collected .As demonstrated in Table3, the population size of the PBL graduates diminishes every PGYby the class size of the graduating class that has not yet reached thatyear of practice.Discussion1. Data:As shown in Table 3, chi-square and Fishers Exact Test analysis failto demonstrate any statistically significant difference in the rate ofmalpractice suit filings for the two study populations. Given therelatively rare event of malpractice filings in a given PGY the PBLpopulation is too small at this time to demonstrate a statisticaldifference.Conclusions and RecommendationsThe data failed to show a statistical difference between the rates ofmedical malpractice filings for traditional vs. PBL graduates. Thisfailure is due primarily to the small size of the PBL population incomparison with the traditional graduates. The problem is compounded by the relatively rare occurrence of malpractice suits on anannual basis in any PGY and the fact that for every PGY thepopulation size of the PBL group decreases. Both of these confounding factors will he overcome with time. The small size anddecreasing nature of the P131, population is a direct result of thenewness of the program and will increase in size and remain stablefor adequate statistical analysis as the program continues andgraduates are added to the population. Furthermore, the rareness ofmalptaLtas. suits in ans gisn PG’ can hi, osi.icorne hs gioupingPGY stogcthi.rina supi.i PG’ group asiththePGY9 inTihlcr.1E[)sDAL. JOURNAL, LOLL LO, APRIL 200274

Now is Ibe limelo cboose TAZOHACFaster, more powerful and as clinically tolerable as Differin cream 01%.31% median reduction at week 4 vs 7% for Differin (P .001)155% median reduction at week 8 vs 25% for Differin (P .001)68% median reduction at week 12 vs 36% for Differin (P .001)1Ak as effective as Dif :rIn cream in inflammatory acne:62% median reduction in papules and pustules at week 12vs 50% with Differin’Ciinica Ny coni arabic tcierabIiiy to Differr cream:Trace levels of burning, dryness, erythema, and peeling withTAZORAC Cream and Differin cream1---TAZORAC Cream is indmted for anne vu oarie The most frequent adverse events reoorted dudno utnea!TZOPC CaCQ 1% f e treatmen arne vu Od’ e e seer r Co SC 3d ’ oauen acoo mcuiei e aescen no order Jesuamat’on Or skm ermn no ourine enact on E e aocjrrmu nit to 50oa vms iv ed urn ma moon 5ac n andALL RCAN

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Table 1University of Hawaii JABSOM Residency Matching Summaries. Between 1 9882OOO, 61 75% of JABSOM graduates enteredprimary care fields. The top soecialhes chosen have been Internal Medicine and Family Prachce.*s.ccc-sFac7ii. PracticeFav Prac5ce OosGyri-Famiiy PracticePsychiatryi:1718I-—--ccc-19211l4-.s- IrnS1—.-—.—.II,III-0i Iit77i,j.I‘1((10ott11r

Table 2.Number of UH JABSOM gr duate named in MCCP malpractice claims by post graduate year (PGYI.Ye CPGYass szeGada:orPGYPGY 6PGYPGY 4PGY 3PGY 2IPGY 9-PGY AL. VO78.APV.

TaPe 3.Comeauson: Tractiona is. PBL Graduates notved in MCCP malpracticeTRAPBLIId11it \ ii11[3’tU\lPHI eu’aI;’‘tkh 11010 1’,ttiflfl’,‘1,IIlitOCtIi1,1IidIl\in’ P131t—no3itup11111t 091iia0Iiiino’c’flUsed by over 10,000Physicians in Japanaot‘‘CiltOh11010th*Available in HawaiiSince 1994*Learn From Our ExperienceAt Your OfficeAt Our Seminars.\t Our OfficetulReferences3 in whtc.h there are I 44 posit cc. events, Projected power analy si.demonstrates that once. th.e.re are 18 graduating. c.t.asses t.if PBLtrained physic ans, a 5% difldrence in malprac.tice suit filingsbetween the two populations i.nPGY super grouping wouldmrmstrate a rtatisticallv sicuilicant dilference in the euro ofmalpractice at the 505 ic\ei of erLuui\Iu1eresttnct ulteritnal aui\ isaud cooiparis000! the per-capita01 malpractice I iltnc it ippears thut lucre ma\ currenth he a000-uaitsncall\ ognhticant trend or lower filing rates acatnst P131.grad notes c.ornpared to traditional graduates. Time and. futurest iwtic d in 3 sw u ill tJ it thircnd is si nil i tntiIntroducingCHITIN PRODUCTSs IittiHelping DoctorsHelp Their Patients1Ie uOticd ohntt PHIut aIittotin ittheciiiilii hata\1t’hiitI1itutII toIIi1An r\pproach ToComplementrv Medicine‘ii*Call today for MoreInformation.y%%.12179\Bt)11\ ICenter Street Ste. 22(1Honolulu, HI 968168O8738-O9938O8553 25551’

Mdial elf usion ss oh a small amount ot ascites m the abdomen andpelvis. The t’enal ultrasound revealed calculus in the left kidner withminimal grade I hydronephrosis. There was an 8 mm calculus in theleft ureter at the ui’eteropelx ic junction. -\ bone scan was normal,Bone ma rrosv aspiration md hiopsr re ealed no abnormalitiesI m ph node biopsy revealed scattered secondars toll icu I ar cellswith actis e cerminal centei’ The intert oIl icular tissue ss as coniI vmphr cvres and plasmaposed of a poli ntorphous popu I ati muResidents’ Case SeriesA 76 Year-Old Man with Anemia,Lymphadenopathy and Pericarditis.Paranee Auethavekiat MD, Baron Wong MD,and Jeffrey Fong MDcells, There was background vascular proliferation. Very rarepolvkarr ocytes svere seen, No metastatic tumor. granulomas, oratypical Ir mphoid population.Floss cr tometrrc inmmunophenotvpic mt the is mph node shosvc—ipi’edoni i nant I peripheral T cells and a snial cr popu Lit m ofpotvcltmnal B cell.Case Report76 ear—o1d Chine’e man prcented to hi’ priniar\ eai’e Isicianwjth a two-sear history 01 prosressis e scieht loss ot’SO pounds andfatigue. The pat cut was referred fur psychiatric evaluation, diag—nosed with depression. and started on t’luoxetine. He did not take anyother medication or herbal remedies. F-fe was then seen h\ anotherphysician and found to has c diffuse l\ mphadenopathv on physicalexanilnation. The patient s as then scheduled br a right axillarlymph node hiopss On the da of the procedure. he developed chestdiscomfort, and an ERG showed diffuse ST segment elevationsconsistent with pericarditi’. Echocardiograni s as performed andshowed minimal pericardial effusion and ihuprofen was initiated.The patient then developed epistaxis and an ENT specialist performed a right- sided nasal packinu. The patient was stabilited andunderss cut axillarv lsmph node biopsy. During the procedure hedeveloped recurrent epitaxis and had nasal packing done again. Inthe recovery room, he was noted to he more anemic with decreasein his hemoglobin by 2 grams. He received packed red blood celltransfusion, and it was noted that his blood was difficult to type andcrossmatch.On phr sical examination alter the lr mph node biops the patientwas al ebrile and normoteusi e. Skin examination revealed no malarrash. periuncual telangiectasia. discoid lupus or alopecia areata. Hehad no obvious cutaneous asculitis. synox ins or arthritis. Thepatient had scattered cervical and minimal axiliar lymphadenopa—thy. There were no oral ulcers. Cardiac examination revealed nomurmurs, rubs or gallop, and there was no hepatosplenomegaly.\eui’olo’’ical exantinatton was normal.l)iagnostic data revealed: \VBC of 4. 10(1/ce 4.3(i0— I 0.500/ccwith II’ i h niphoc\ tes and 7’ monoc tes. Hemoglobin was 10.1g/dL t 13—IS g/dL following transfusion with relativelx normalmdtccs Platclet count ss is 3 000/cc (I 31) 000 40(1 000 c F-SRwas 122 mm/hr (0-20 mm/hr). BUN was 16 mg/dL (10-2) )mg/dLand creatinine was 1 .0 mg!dL 0.8- I .2 iug/dfu. Calcium ss as 8,5 mc.’dL . PT and PiT were m ‘rmal. .-\lbumn sva 1 -1 cni/7dl. 0— 1(1,5 my’dl. 0.5—5.5 cm”dl. and globulin sas 6 crn”dI 2.0—3.1 eni’dL.s as I :25(0 ss ith homogenous pattern. ( omplemcni C 3 ss asless than 25 mg/dl (55-120 mg/dL) and C4 was less than It) mg/dL(20-50 mg/dL). Anti —double stranded DNA was positive at titer ofI :20.Anti-Smith!RNP was negative. ANCA ss as negatis e. DirectCoonibs test ss as posuis c. F- rmalysis showed liii) ine-’dl. of’proteinwith no cells. si enty-four-h mr urine protein ss as 46o irie24hr tJ5)) mg;24hu. The tuberculin skm test was negative.A Head CT scan shoss cr1 fusiforin aneurysm of the basilar arter\with noothersignificantahuormalities. Chest, abdominal and pelvicCT scan showed bilateral pleural effucions and a moderate pericarHospital CoursePatient 55 as diagnosed with sr stemic lupus erythe inatosus and wasstarted on intravenous methvlprednisone 24mg es cry 12 hours. Hisclinical status was markedlr i mpros ed. The patient was then dis—charge w ith oral pi’cdnisone 6(1 mg,’dar DiscussionThis is 76 v-ear—old man who initially presented with generalizedIymphadenopathv and then developed pericarditis. He fulfilled 4criteria of the 1052 ievised ci’iteria for SLfu with serositis, ahematolugical disorder, high ANA titer, and positis e anti—dsDNAantibodies. Hich AN.-\ titei’s are found niore often in SEE than otherautoimmune diseases. The homogenons ANA pattern. svhich svaspresent ni this case. is common in patients svith Sl.E hut is not very’specific. It can he seen in all the connective tissue disorders as svellas in drug-induced FE, This patient had been on only fluoxetine.There has been no report of’ fluoxetine and drug—induced FE. Thelow C3 and C4 les els also sLipport the diagnosis ol’SLF since severeRA. nephritis of non-SEE etiology, and liverdisease were abscnt. Inthis patient. a positis e AN,\ ss ith depressed complement les els, inthe absence of the above mentioned situations, are almost certain tohe associated with SLE,Lymphadenopathr has been reported to occur m 36 to (ml) U ofcases ol SI.E. Hosses er. Ir mphadenopathv as the first clniicalmanifestation, as in this case, is uncommon. in one series of 520patients ss oh SI E enlargement of cci’s ical lymph nodes was thcfirst clinical manifestation in 2 U of the patients. and generalizedlvmphadenopathy had occurred at the time of diagnosis in only I%‘. Therefore svhen this patient initially presented with lyniphad—enopathr . the other possible diagnoses had to he ruled out hr eitherlymph node hiopsr or fine needle aspiration The nodes in SI Fusual Ir are m mntendei’ and discrete, and t her s air m ‘a ic tim ‘m tessmilirnicterc to tm-I centimeters in diameter. Fr inphadenopathr ismore common in children than in adults and most marked amongblack patients. Patients with Ivmphadenopathv have more constitutional sy niptoms including fatigue. fes er and sr eight loss. morecutaneous sOns and symptoms, a hich rate of hepatomeualr andspleiioiimegalr . increased anti—dsDNA antibodies and decreasedcompleniemit Ieyel, There Is no dif[erence in renal mr centralnervous sr stem insmmls ement bcmsc ecu patmcnts ss oh Ir mphadcnopathy and those without Ivmphadenopathr - .A meta-analysis showedthat lymphadenopathy prevalence with late-onset 8FF was lower,-80

than in patients with early-onset SLE’’, The histological findings oflupus lvmphadenopathy are variable, ranging from fllIicuIarhyper—plasia. edema and sinus histiocytos is in the early stages to confluentnecrosis at late stages The characteristic flndmg in the l mph nodesof patients with SLE is a diffuse, reactive h perpIaa. There areh perplastic germinal centers with plasmac\ tosis and ariable numher of immunoblasts in the interfollicular areas. In thc necrotic areasand s dim the sinuses are occasional extracellular amorphousbodies. 5 to 12 microns in diameter. that stain intcnsel\ \ ithhemato\vlin, These “hematox\ liii bodies” sserc first described h(dntlcr and Fox in 194(1 It contains ggrcgate5 01 D\-\, imnmunoclohulins. and polvsaccharides. and ss hen present. thc\ arc considered to he characteristmc of lnpns K mphadcnmpathr Althoughhcmatoxylin hodies can also occur mu other disease-, such as progiessis e s stenuc sclerosis and rareR in patients ss mth h\ pcrlohulinemia. when clinical data is unavailable, the hemalox\ in bodiesCells resembling Rced—Sternhergare pathoenona nc of SEEmorpholo\ also have been described in patients ss nh SLL \entroIhese micro—phiL. eosi nophi Is. and ranulomata are sparsescopic leatures serve to distinenish lupus l inphadenitms from otherinfictiouc. immunologic, and vasculitis conditions- The inolecular genetic finding of olicoc lonal TcR rearrangements ma\ be aleature oh Si .E. or a concurrent but distinct disorder, such as the earlyphase of a lvmphoid ncoplasmThe age and mzender also have e fleets in clinical presentat i on andcourse m SI .E. Most m vest i eators report that female t male rat i Osss oh SLE aflcr age 50 were decreased slightl\ toX: I from 1(1 to IS: IPatients ss ith drug—induced lupus arc distiuctl older and usuall\male, likely because commonR used drugs such as procamnamideand hydralazine are widely used fur conditions in people os er ac 50years. SLE has no predilection for males who are older. but relativeto voungerpatients (less than 50 years old I. the numbers of men withSLE increase with age. One group found that the older SI.E patientpresents clinically more like the patient with drug-induced SEE thanone with idiopathicThis is because these patients have alow incidence of renal disease and, more prominent pleuropericardialand museuloskeletal symptoms’. Such older patients rarely havelow complement levels and native DNA antibodies. v. hich areopposite to the findings in this patient. The meta—aualysis of olderSLE patients revealed that serositis, interstitial pulmonary disease,anti La antibodies, and Sjogren’s syndrome symptoms (secondarysicca) were commonly associated with the disease of the older agegroup. Alopecia. Raynaud’s phenomenon, fever. K mphadenopathy, hypocomplernenternia. and neuropsychiatric disease were uncommon in this group. However, the analysis shoss ed no differences

HAWAII MEDICAL JOURNAL (USPS 237-640) Published monthly hr the Hasu an Medica.i Assoctation licorporeted in S56 under the Ninirelis 101 South Beretauj. Suite (1 Hr dulu. [Lusait ms 1—1-- Ph ne '101 CeO-iC:Eju ytb 5.7 Editors \rnian Goldstein MD