Faculty Bibliography

A pill user is three times more likely than a nonuser to have a fatal heart attack. Among 100,000 women 20 to 29 years old who use the pill, three would be expected to have a heart attack each year, and two of the three attacks would be attributable to the pill, according to Family Planning Perspectives, the professional journal of the Alan Guttm@a@c@her Institute in New York. Among 100,000 women aged 40 to 44 who take the pill, 75 will have a fatal heart attack, with 50 of the deaths attributable to the pill. Doctors have long observed that women who have rheumatoid arthritis go into remission in pregnancy. But few experts suspected that the pill might reduce by half the incidence of rheumatoid arthritis, as a study by the Royal College of General Practitioners reported in 1978. The study concluded that the pill offered a small degree of protection against rheumatoid arthritis. Each year, one woman in 3,000 pill users would develop the disorder if she were not taking the pill.Even so small an effect could provide observations that could be valuable in determining the cause of this common disorder. Will the protective effects wear off as the women who were in the studies grow older? It is too early to tell, as it is too early to recommend that all women, regardless of sexual activity, take the pill for its noncontraceptive effects. Because it takes years for cancers to develop, experts consider the new data preliminary. Nevertheless, the May-June issue of Population Reports, published by the the Population Information Program of the Johns Hopkins University, says: ''Given the extensive research on the pill, it is less and less likely that any significant risk of cancer remains undetected.'' Although the pill is perhaps the most studied drug in history, and there are 22 years of experience with it in this country, experts say that continued long-term surveillance of the pill is essential

''Is this the same thing that is going on in homosexual men and intravenous drug abusers?.'' he said. ''If so, what does that mean? What is the unifying hypothesis or cause? The answer is we do not know.'' Dr. [James W. Curran] said the Haitian and other outbreaks appeared similar on the basis of clinical and laboratory tests. The Atlanta epidemiologists learned of the Haitian cases several months ago as a result of the diagnoses of toxoplasmosis at postmortem examinations in Florida. At that time, Dr. Curran said, it had not yet become clear that a high proportion of the victims were Haitians who had recently moved to this country. Initially, questions were raised about links of the illnesses to dietary habits. Diagnoses and Clarification Dr. Curran said that ''it wasn't until there were a number of living patients that the team was able to perform immunologic studies,'' observe the cases, determine that other unusual infections were involved, and that the cases were ''very similar'' to the immune deficiency disorder previously reported

''Merck Sharp and Dohme, Smith Kline and French, and others appear to be convinced,'' the report said, ''that the interpersonal relationship and exchange of information between medical representative and M.D. will continue to be the single most effective promotional tool during the foreseeable future.'' It is perhaps a sad commentary on medical education that detailmen are an important educational force. Earlier in this century, Sir William Osler, then the leading medical educator in North America, warned his colleagues that what he called ''the drug-house drummer'' was a ''dangerous enemy'' to the effectuality of the general practitioner. Yet medicine has changed drastically since Dr. Osler's day. For example, many drugs now in standard use were then unknown, and yet newer classes of drugs are on the horizon for many disorders. Many medical leaders have said that doctors do not receive enough training in pharmacology. Some drug companies have formed speakers' bureaus and pay for these professors to lecture at continuing medical education programs, with the aim of promoting more prescriptions of that company's products. To some critics, the professors are modern examples of Osler's ''drug-house drummers,'' and a problem deserving of more attention from doctors, patients and the public

Dr. Thomas's point seems to have been underscored in a new report by Dr. David P. Yens and Dr. Barry Stimmel of the Mount Sinai School of Medicine in New York. Students who did not major in a science as undergraduates ''performed as well or better than traditional science trained students on almost all performance measures,'' they said in the June issue of the Journal of Medical Education. Dr. Fred T. Valentine, a specialist in infectious diseases and immunology at New York University who is one of the best teachers I know, said he believes the least important aspect of a lecture is to transmit facts. The main purposes, he said, ''are to stimulate the enthusiasm of students for the subject; to correlate information and to explain lines of reasoning because the better one understands a subject the less he has to memorize; and to teach what is not known as well as what is known.'' It is not the students, but the system that is the focus of the debate over reforms in medical education. Even critics of the present system express optimism about the newest medical school graduates. As one highly respected physician said, ''If you've got bright students, they'll survive no matter how you teach them.''

''We think the findings are important but they don't solve the problem,'' Dr. Harold W. Jaffe, one of the epidemiologists at the Centers for Disease Control in Atlanta, said in an interview. ''They do show pretty convincingly that this is not occurring as a random event among homosexual men.'' ''The more cases you put together in a diagramatic fashion, the more that supports an infectious agent, although it certainly does not exclude other possibilities,'' Dr. Jaffe said. ''We would like to see how far we can go pursuing connections outside of southern California.'' Scientists are using ''as many ways as we can think of to identify'' the infectious agent in the laboratory, he said.However, the epidemiologists said in their weekly report that they were still considering alternative hypotheses. One, they said, is that sexual contact with patients with GRID syndrome does not lead directly to the breakdown of the immunological system, ''but simply indicates a certain style of life.''

''Within two minutes after withdrawing the wire, someone shouted that the man's electrocardiogram was normalizing and all signs of a heart attack were disappearing,'' Dr. [K. Peter Rentrop] said. ''At the same time the patient said the pain was going away.'' The physician then determined that the coronary artery had opened. In subsequent heart attack cases, he began injecting streptokinase. His group's dramatic report then led several research teams in European and the United States to do further experiments with streptokinase, and preliminary data show that it dissolved clots in 80 percent of the heart attack cases in which was used. Dr. Rentrop, who now works at Mount Sinai Medical Center in New York, said that, from the preliminary results, ''it looks like streptokinase may preserve the heart's primary function, which is to pump blood.'' Many cardiologists are both cautious and optimistic. ''It's a very promising approach,'' said Dr. K. Lance Gould, chief cardiologist at the University of Texas Health Sciences Center and Hermann Hospital in Houston. ''We can open up clotted arteries in people who have had heart attacks, which is the first time we can salvage heart muscle that would otherwise die in a heart attack.'' But Dr. Gould, who is a leading researcher in streptokinase therapy for heart attacks, added, ''The key question is: How much does it benefit them?'' Streptokinase could possibly dissolve the clots, but the damage somehow might still occur anyway, though present evidence indicates that this does not appear to be the case. Although experimentation and the data gathered thus far indicate that the therapy works, further study is regarded as necessary and is being pushed at several medical centers around the world

In an interview yesterday, Dr. Tosteston said he was challenging the medical school's faculty to re-examine the question ''What is it that all doctors should share in knowledge, skills and attitudes?'' The earliest that a pilot program could be introduced into the Harvard curriculum would be for the class entering in the fall of 1983, and ''that would be a most optimistic target,'' Dr. [Daniel C. Tosteson] said. Dr. Tosteson, too, recognizes the difficulties in transforming his idea into Harvard policy. He said he was ''very aware of the formidable practical problems ahead.''

Dr. [Aaron Kellner] also said Dr. [Wolf Szmuness] had ''an impeccable, toughminded honesty. He didn't fool himself. His experiments either demonstrated what they were supposed to do or they were discarded and other experiments were designed.'' ''Within a few months it was perfectly apparent that Wolf was capable of being far more than someone else's technical assistant,'' Dr. Kellner told Miss [June Goodfield]. ''Within a few months he was designing his own experiments. Within two years, he had his own laboratory. Within five, he was an international figure in epidemiology and the field of hepatitis.'' ''Szmuness was clearly the man to do'' the vaccine trials, Dr. Kellner said. ''Indeed, he was almost the only man to do it.'' His studies are now considered classics in the field

Before the availability of pertussis vaccine, there were 265,000 cases and 7,000 deaths from whooping cough each year in this country. Now, each year, on the average, there are 2,300 cases and 10 deaths. The drop is generally credited to pertussis vaccine rather than improved socioeconomic factors, but the link cannot be firmly made because the incidence of the disease was falling when the vaccine first became widely available by the 1950's. Whooping cough itself causes similar reactions. But there are two key problems in defining the relative risks of the vaccine against the disease. One is that doctors do not have a specific laboratory test to determine which case of brain damage is caused by pertussis vaccine. The other is the vaccine is given at an age when seizures commonly occur for unknown reasons that are unrelated to the administration of pertussis vaccine. The diagnosis of pertussis vaccine reaction cannot be made with certainty in a specific case. As vaccines go, pertussis is relatively crude because it is derived from whole bacteria, which makes it more toxic than those derived from specific cellular components. Scientists conducting the basic research on finding a better and safer pertussis vaccine have been hampered by the lack of a satisfactory animal model and by the complexity of the bacterium that causes pertussis

The survey also reflected a common problem for physicians. Patients who are confronted with difficult decisions concerning major surgery and risky procedures often ask their physicians: ''What would you do if it were you, Doc?'' Unlike the doctors in Texas, who were reportedly taking aspirin each day, only 7 percent of the Harvard physicians were. The survey also found that the doctors who admitted to ''unhealthy'' practices - cigarette smoking, for example - were troubled about their habit. A total of 49 doctors, or 8 percent of the sample, said they smoked. Of the 49, 13 smoked more than one pack per day. ''It's hard to imagine why erroneous claims might be made'' for the questions asked, Dr. [Stephen E. Goldfinger] said