Letters

The Editors welcome submissions for possible publication in the Letters section. Authors of letters should: • Include no more than 400 words of text, three authors, and five references • Type with double-spacing • Send with the letter a transfer-of-copyright form (see Table of Contents for location) signed by all authors • Provide a self-addressed envelope if they want to be notified that the letter was received Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified only if their letter is accepted. Unpublished letters cannot be returned. Community Hospitals and Graduates of Foreign Medical Schools To the Editors: In their editorial, Drs. Bogdonoff and Fins (1) speak of "programs staffed by graduates of U.S. medical schools and those staffed by graduates of foreign medical schools." A third type of residency program exists in which no great distinction is made between these two types of graduates. Graduates of foreign medical schools are not a homogeneous group. Generalizations, such as " a clear qualitative difference exists between foreign and U.S. medical schools," are inaccurate. Note that graduates of Cape Town, Cambridge, and Cologne are all graduates of foreign medical schools. I think that a resident who can feel a spleen is more valuable to the patient than one who is versed in "biochemistry, physiology, and molecular biology that pertains to a patient's illness" but who misses the spleen in a patient with anemia. In expressing this bias, note that I have not linked these characteristics to an institution or to "foreignness." The anecdote about the resident who "had difficulty in recounting even a routine history and physical examination" and who then showed striking improvement (with their instruction) was disturbing. Is this anecdote not at the root of all teaching? Have the authors never encountered this problem except in a foreign graduate? I appreciate the authors' efforts to reach out to programs for graduates of foreign medical schools. Nowhere in their editorial, however, do they suggest that more foreign graduates should be accepted at their own university training program to "provide a vital social contribution to the larger community." Is the air in their institution so rarefied that mere mortals (and foreign graduates) would not survive? Abraham Verghese, MD 1922 Plaen View Drive Iowa City, Iowa 52246

Reference 1. Bogdonoff MD, Fins JJ. University medical center participation in residency training programs for graduates of foreign medical schools [Editorial]. Ann Intern Med. 1991;114:426-7.

To the Editors: Bogdonoff and Fins (1) attempt in their editorial to define quality resident training by comparing U.S. 1062

with foreign education and community with university training. They have, however, neglected several important issues. First, university-based physicians, such as Bogdonoff and Fins, should examine the possibility that internal medicine residency training programs such as theirs may have contributed significantly to the exodus of U.S. medical graduates from internal medicine (2). The teaching rounds they describe are also mentioned by medical students when asked why they have not chosen internal medicine over other specialties. The students, however, use terms such as "belittling," "intimidating," "irrelevant," and "one-upmanship" to describe these rounds. Bogdonoff and Fins claim that the "chemistry, physiology, and molecular biology that pertain to a patient's illness" are missing from community hospitals' curriculum. This is a curious way of describing the "beaker (or lectern) for stethoscope" syndrome that exists in many university settings. Although physicians who take time from basic science research or lecturing activities to teach residents and students have much to offer, they have no basis for denigrating clinicians who take time from a busy office to engage in clinical teaching activities. Indeed, many U.S. trained physicians have difficulty in recalling general internists on the faculty of their medical schools. Those that were there seemed to be short-term, untenured physicians on the "clinical track." Bogdonoff and Fins also examine the "participation of both senior faculty and fellows" in resident training. Fellows clearly have much to offer internal medicine residents from an educational standpoint. However, senior faculty members, being involved with many other projects, often consider fellows to be faculty surrogates when it comes to teaching house staff and students. Although community programs benefit a great deal from university affiliations, university programs with the philosophy described by Bogdonoff and Fins may best devote their energies to putting their own house in order. Meanwhile, although community programs have issues of their own to address, many involved in these programs do not feel "academania" is the solution. Dana S. Kellis, MD Conemaugh Valley Memorial Hospital Johnstown, PA 15905-4398 References 1. Bogdonoff MD, Fins JJ. University medical center participation in residency training programs for graduates of foreign medical schools [Editorial]. Ann Intern Med. 1991;114:426-7. 2. Babbott D, Levey GS, Weaver SO, Killian CD. Medical student attitudes about internal medicine: a study of U.S. medical school seniors in 1988. Ann Intern Med. 1991;114:16-22. To the Editors: As a graduate of a foreign medical school, I read with interest the editorial by Drs. Bogdonoff and Fins (1). Although the editorial highlights problems with foreign graduates who receive their training in community hospital residency programs, it tends to stereotype these graduates as having received a poor undergraduate medical education and as having a limited capacity to "sharpen clinical skills and to master new scientific developments." It is particularly disconcerting to see such an editorial in Annals, because it is based on the author's experience at only one program. My alma mater, Madras Medical College, in South India, celebrated its 150th anniversary in 1984 and proudly carries on

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its rich traditions of excellence in medicine. In the British style, preclinical years were long and arduous, and laboratory exercises were by no means "occasional." Students received clinical training in internal medicine for 8 months spread over 3 years (4 months during the third year, 1 month during the fourth year, and 3 months during the fifth year). Emphasis on bedside clinical skills was the rule rather than the exception, and my teachers were master clinicians at the bedside, astounding us with their clinical acumen. Osier, Traube, Skoda, Virchow, and others were mentioned at every opportunity at the bedside, and the clinical and medical-history-taking skills demonstrated left a lasting impression on students. Admittedly, problems exist with medical education in India and in other countries (2); however, reliance on didactic lectures, lack of coordination between basic science and clinical courses, and poor courses in clinical skills plague medical education even in this country (3, 4). I am deeply concerned about the poor bedside clinical skills that are obvious during the postgraduate year 1 clinical competency examinations; graduates from established foreign schools seem to do as well as and, at times, better than graduates of U.S. medical schools. Anand Karnad, MD James H. Quillen College of Medicine East Tennessee State University Johnson City, TN 37614-0002

References 1. Bogdonoff MD, Fins JJ. University medical center participation in residency training programs for graduates of foreign medical schools [Editorial]. Ann Intern Med. 1991;114:426-7. 2. Richards T. Medical education in India—in poor health. Br Med J. 1985;290:1132-5. 3. Tosteson DC. New pathways in general medical education. N Engl J Med. 1990;323:234-8. 4. Greganti MA. Where are the clinical role models? Arch Intern Med. 1990;150:259-61.

In response: Rather than respond to each letter separately, we prefer to comment on two issues that are raised by each letter. First, as to the accuracy of our description of foreign medical school education: Our picture was derived from what we have been told by several of the residents (approximately 20 of the 50 or more with whom we have worked). We, of course, conducted no critical survey and clearly acknowledge that there is great diversity in the quality of foreign medical education. We agree that didactic lecturing is overused in far too many U.S. medical schools, and we believe that such an approach limits a student's imagination and creativity. Second and far more important, our comments were considered to be paternalistic, simplistic, insensitive, condescending, and unfair. These are strong words. We can say only that no such injury was intended and that such an effect is perhaps more distressing to us than to those who feel offended. Our purpose was to help a group of residents, many of whom openly say that they have not had equal access to most, but, of course, not to all university medical center training programs. Most important, our position is consistent with an increased participation of university programs in all facets of graduate medical education. Further, if our style did not acknowledge the many important contributions made by graduates of foreign medical schools to American medicine, it is because the problem lies not in the tale of their successes, but rather in the far more frequent limitations that these graduates encounter in career opportunities, limitations that derive unfortunately from training programs that are not comparable to those at Conemaugh Valley Memorial Hospital. Morton D. Bogdonoff, MD Joseph J. Fins, MD The New York Hospital-Cornell Medical Center New York, NY 10021

Hypertensive Effect of Erythropoietin To the Editors: In reviewing the use of erythropoietin in patients receiving dialysis, Dr. Nissenson (1) asserts that the drug itself has no known direct pressor activity. Preliminary clinical and experimental data indicate that this probably is not the case (2-4). In a patient receiving hemodialysis with hypertensive encephalopathy after 8 weeks of therapy with erythropoietin, Edmunds and Walls (2) observed that the rate by which hemoglobin concentration rose was modest and that the final value was similar to that achieved with transfusions on previous occasions. Baskin and Lasker (3) recently reported the cases of five patients who had important increases in blood pressure with no change in hematocrit after treatment with erythropoietin, postulating a direct hypertensive effect of the drug. Finally, Heidenreich and colleagues (4) recently showed in-vitro erythropoietin-induced contractions on proximal resistance vessels of the kidney and mesenteric vasculature of normotensive Wistar-kyoto rats. These investigators observed that this pressor eflfect was endothelial independent, attenuated in calcium-free solutions, and not significantly affected by the presence of verapamil, phentolamin, or saralasin. In trying to distinguish between the effect of increased red cell blood mass and a direct pressor effect of erythropoietin, we have compared blood pressure changes in hypertensive patients receiving hemodialysis and drug therapy. Patients receiving low-dose erythropoietin {n = 6) were compared with patients receiving intravenous iron alone (n = 4) and with patients receiving androgens alone (n = 5). Baseline hematocrits were similar in the three groups. After 4 weeks of treatment, hematocrit had minimally increased in patients receiving erythropoietin (23% ± 2% compared with 24% ± 3%), and blood pressure remained controlled only after substantially increasing the dosage of antihypertensive medication (minoxidil was also used in two patients). In contrast, in iron- and androgen-treated patients, blood pressure remained at baseline levels and antihypertensive medication was not modified despite significant rises in hematocrits (iron group, 25% ± 2% compared with 28% ± 4% after 4 weeks; androgen group, 23% ± 3% compared with 28% ± 6% after 7 weeks). These results provide additional evidence of a direct pressor effect of erythropoietin, independent of the increase in red cell blood mass. Julia Pascual, MD Jose L. Teruel, MD Joaquin Ortuno, MD Hospital Ramon y Cajal 28034 Madrid, Spain

References 1. Nissenson AR. Recombinant human erythropoietin and renal anemia: molecular biology, clinical efficacy, and nervous system effects. Ann Intern Med. 1991;114:402-16. 2. Edmunds ME, Walls J. Blood pressure and erythropoietin [Letter]. Lancet. 1988;1:352. 3. Baskin S, Lasker L. Erythropoietin-associated hypertension [Letter]. N Engl J Med. 1990,323:999. 4. Heidenreich S, Rahn KH, Zidek W. Direct vasopressor effect of recombinant human erythropoietin on renal resistance vessels. Kidney Int. 1991;39:259-65.

Coxsackie Thyroiditis To the Editors: Although subacute thyroiditis is a common disease, its pathogenesis is still uncertain. Because of the clinical similarities between viral diseases and subacute thyroiditis, this disease is generally thought to be of viral origin. Despite suggestive clinical observations, the definite demonstration of a viral etiology has proved elusive. We report the case of a 55-year-old man who presented with 15 days of fever associated with anterior neck pain and weight loss. His thyroid gland was swollen and tender. Laboratory findings included an erythrocyte sedimentation rate of 112 mm/h, a fibrinogen level of 8.2 g/L, and a C-reactive protein level of 124 mg/L. High values of free T3 and free T4 indicated

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that the patient had hyperthyroidism. No autoantibodies against thyroglobulin, microsomes, antinuclear antibodies, or rheumatoid factor were detected. Serum concentrations of alanine aminotransferase, gamma-glutamyl transpeptidase, and alkaline phosphatase were increased with titers of 57 IU/L, 162 IU/L, and 421 IU/L, respectively. Histopathologic examination of a needle biopsy specimen from the liver showed mild periportal inflammation and granulomas. The diagnosis was established serologically using serum neutralization tests. A serum specimen obtained during the acute phase showed IgM and IgG antibodies against coxsackie B4 virus at a titer greater than 1024. The serum collected 1 month later during recovery from illness showed an IgG titer of only 512 against coxsackie B4 virus and no IgM. No change in titer was observed for the other frequently tested viruses, including other coxsackieviruses, echoviruses, enteroviruses, polioviruses, and mumps virus. If we consider a fourfold rise in antibody titer or the presence of viral-specific IgM suggestive of recent infection, few reports implicate viruses as the cause of subacute thyroiditis (1). Volpe (2) and Kobayashi (3) found no relation between circulating viral antibodies and inflammatory lesions of the thyroid gland. Moreover, except for mumps virus (4), viruses have not yet been isolated from the thyroid or from body fluids during the acute phase of subacute thyroiditis. This serologically diagnosed case is consistent with the viral etiology hypothesis. P. Brouqui, MD D. Raoult, MD, PhD Centre National de Reference des Ricketsioses, CHU Timone 13385 Marseille cedex 5, France B. Conte-Devolx, MD Endocrinologie et Maladies Metaboliques, CHU Conception 13385 Marseille cedex 5, France References 1. Fennell JS, Tomkin GH. Sub-acute thyroiditis and hepatitis in a case of infectious mononucleosis. Postgrad Med J. 1978;54:351-2. 2. Volpe R, Row VV, Ezrin C. Circulating viral and thyroid antibodies in sub-acute thyroiditis. J Clin Endocr. 1967;27:1275-84. 3. Kobayashi N, Tamai H, Nagai K, et al. Studies on the pathogenesis of sub-acute thyroiditis. Folia Endocrinol. 1985;61:737-43. 4. Eylan E, Zmucky R, Sheba CH. Mumps virus and sub-acute thyroiditis: evidence of a causal association. Lancet. 1957;1:1062-3.

Serodiagnosis of Lyme Disease To the Editors: Rahn and Malawista (1) rightly point out that serologic testing for Lyme disease is poorly standardized. In addition to the problem of interlaboratory reproducibility of results, another problem must be considered: None of the currently used antibody tests has been rigorously proved to detect antibodies specific for Borrelia burgdorferi. Too few control sera specimens have been studied to evaluate specificity adequately, given the widespread use of these tests. Wilske and colleagues (2) and Hunter and coworkers (3) studied 13 sera specimens with anti-Z?. burgdorferi immunofluorescent antibody (IFA) titers of 1:256 or higher from patients with well-documented Lyme disease. Absorption of these sera with Treponema phagedenis reduced the titer of 3 of these specimens to undetectable levels and decreased the titers of the remaining specimens by 2- to 20-fold. If B. burgdorferi can stimulate antibodies that cross-react with T. phagedenis, the opposite may be true: Mouth or intestinal treponemes that commonly colonize humans may stimulate antibodies that cross-react with the Lyme spirochete. Abundant evidence indicates that antibodies against the spirochetes commonly colonizing mucous membranes are present in human sera (4). Antibodies against T. pallidum, T. phagedenis, T. refringens, and T. vincentii produced in guinea pigs or rabbits are crossreactive against multiple peptides of these organisms by Western blot analysis (5). Could not naturally occurring human antibodies against the last four species recognize cross-reactive 1064

epitopes of B. burgdorferi components separated on a Western blot? Investigators studying Lyme disease have an obligation to address the specificity of serologic tests for the disease. For IFA and enzyme-linked immunosorbent assay (ELISA) using whole or sonicated B. burgdorferi, a very large sample of persons who do not live in endemic areas and whose travel histories preclude exposure to the tick vector of the infection should be tested to determine the distribution of antibody titers in such a population. If an appreciable number of persons in such a sample had antibody titers above the cutoffs being used by commercial laboratories to categorize sera as "positive when an appropriate clinical picture is present," the wisdom of presenting test results in this manner would be questionable. The same specificity concerns apply to Western blot assays. A component of B. burgdorferi detected on a blot could carry an epitope that cross-reacts with an analogous component of spirochetes known to colonize oral and gastrointestinal mucosae. Western blotting can be used to validate the IFA or ELISA only if it is proved conclusively that antibodies detected by blotting are truly specific for a B. burgdorferi epitope. To solve specificity problems, it may be necessary to clone peptides from the Lyme spirochete that react only with Lyme spirochete-induced antibodies. Every year, my colleagues and I encounter many patients who have had "positive" Lyme serologies and who have been disappointed that the ceftriaxone they received did not improve their symptoms. In many instances, their symptoms were fatigue, vague arthralgias or myalgias, or ill-defined neurologic complaints. The data that I have obtained by surveying laboratories in Wisconsin that perform Lyme serologic tests indicate that at least 60 000 such tests are done annually in the state. It is remarkable that issues of test specificity have not been resolved when the tests are being so widely applied. Jeffrey M. Jones, MD, PhD University of Wisconsin Health Sciences Center William S. Middleton Veterans Hospital Madison, WI 53705 References 1. Rahn DW, Malawista F. Lyme disease: recommendations for diagnosis and treatment. Ann Intern Med. 1991;114:472-81. 2. Wilske B, Schierz G, Preac-Mursic V, Weber K, Pfister HW, Einhaupl K. Serologic diagnosis of erythema migrans disease and related disorders. Infection. 1984;12:331-7. 3. Hunter EF, Russell H, Farshy CE, Sampson JS, Larsen SA. Evaluation of sera from patients with Lyme disease in the fluorescent treponemal antibody-absorption test for syphilis. Sex Transm Dis. 1986;13:232-6. 4. Blanco DR, Radolf JD, Lovett MA, Miller JN. Correlation of treponemicidal activity in normal human serum with the presence of IgG antibody directed against polypeptides of Treponema phagedenis biotype Reiter and Treponema pallidum, Nichols strain. J Immunol. 1986;137:2031-6. 5. Wos SM, Wiener K. Extensive cross reactivity between Treponema pallidum and cultivable treponemes demonstrated by sequential immunoadsorption. Int Arch Allergy Appl Immunol. 1986;79:282-5.

Leishmania in Bronchoalveolar Lavage To the Editors: Visceral leishmaniasis is an endemic disease in southeastern France, with well-known clinical features. However in human immunodeficiency virus (HlV)-infected patients, bioclinical aspects are often atypical and parasites may be found in unusual sites (1-3). In this case report, Leishmania were found in bronchoalveolar lavage fluid and blood. To our knowledge, this finding has not been previously reported. A 40-year-old heterosexual HIV-seropositive man was admitted for fever, weight loss, cough, and headache. Clinical examination revealed hepatomegaly without splenomegaly and adenopathy. Laboratory studies were as follows: leukocyte count, 1.4 x 109/L; lymphocyte cdunt, 0.58 x 109/L; hemoglobin concentration, 5 mmol/L; platelet count, 71 x 109/L; gammaglobulin concentration, 53 g/L; and CD4 lymphocyte count, 0.01 x 109/L. Spinal fluid analysis led to the diagnosis of cryptococcal meningitis. A chest radiograph was normal. Bron-

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choalveolar lavage showed neither Pneumocystis carinii nor Cryptococcus, but it unexpectedly revealed intra- and extramacrophagic Leishmania. Bone marrow examination and culture using Novy, McNeal, and Nicolle's (NNN) medium confirmed visceral leishmaniasis. Fifteen days later, blood cultures showed Leishmania infantum promastigotes. Perendoscopic biopsy specimens showed stomac and duodenojejunum parasitization. An indirect immunofluorescence serologic test {Leishmania infantum) was positive 1/1280. A specific treatment with N-methyl-glucamine was started. These unusual localizations along with the high incidence of visceral leishmaniasis in patients with the acquired immunodeficiency syndrome (AIDS) in southeastern France (4) confirm Leishmania as an opportunistic agent in immunocompromised hosts, as others have suggested (5). In our opinion, Leishmania in mediterranean countries constitutes a reflected image of Histoplasma capsulatum in some southern U.S. states. Thus, as disseminated histoplasmosis, extrahematopoietic disseminated visceral leishmaniasis should be considered a sufficient criterion for diagnosing AIDS in the presence of HIV seropositivity. The worldwide spread of HIV infection modifies the expression of regional diseases. In endemic countries, visceral leishmaniasis has to be evoked in HIV-infected patients, even in cases of an atypical bioclinical picture. Whether discovery of Leishmania in blood culture may modify epidemiologic features of Leishmaniasis remains an unanswered question. Eric Rosenthal, MD Pierre Marty, MD Alain Pesce, MD Hopital de Cimiez 06003 Nice cedex, France References 1. Datry A, Similowski T, Jais P, et al. AIDS-associated leishmaniasis: a gastro-duodenal presentation. Trans R Soc Trop Med Hyg. 1990; 84:239-40. 2. Pesce A, Saint-Paul MC, Vinti H, et al. Leishmaniose gastrique chez un malade atteint d'immunodeficience acquise. Presse Med. 1990; 19: 178. 3. Rosenthal PJ, Chaisson RE, Hadley WK, Leech JH. Rectal leishmaniasis in a patient with acquired immunodeficiency syndrome. Am J Med. 1988;84:307-9. 4. Marty P, Pesce A, Fuzibet JG, et al. Aspects biocliniques de la leishmaniose visc6rale chez les sideens. Bull Soc Fr Parasitol. 1989; 7:159-61. 5. Badaro R, Carvalho EM, Rocha H, Queiroz AC, Jones TC. Leishmania donovani: an opportunic microbe associated with progressive disease in three immunocompromised patients. Lancet. 1986;1:647-8.

All Niacin Is Not the Same To the Editors: Niacin (nicotinic acid) is recognized as a drug of first choice for the treatment of the hyperlipidemias (1). Niacin is produced as a dietary supplement, but it has become increasingly clear that all preparations are not the same. A dramatic example of intolerance to a "regular'' niacin preparation follows. A fifty-six-year old man was prescribed cholestyramine in February 1987 for hypercholesterolemia. In 1988, niacin was added as a second lipid-lowering agent with the dosage advanced to 1.5 g three times a day. "Crystalline Pure Niacin," dispensed in a 500-mg hard gelatin capsule (TWINLAB, Twin Laboratories, Ronkonkoma, New York), was purchased and used after initiation of treatment with 100-mg capsules. The characteristic niacin flush noted initially subsided with dose advancement. Hepatic transaminase determinations obtained during the administration of this niacin product were repeatedly normal. On 29 June 1990, the patient purchased "Nature's Plus, Niacin-500" (Nature's Plus, Farmingdale, New York), substituting it for the usual niacin preparation at an equivalent dosage (4.5 g/d). On 3 July, he noted the onset of weakness and mild nausea. Five days later, he had blood drawn after complaining of severe weakness and was told he had hepatitis. Niacin and cholestyramine were withdrawn. Consecutive alanine transaminase determinations on 8, 12, 24, and 30 July and

on 13 August were 957, 554, 53, 42, and 27 U/L, respectively. Bilirubin remained normal. Cholesterol, which averaged 4.92 mmol/L in 1990 before July, was 2.84, 6.67, and 7.21 mmol/L on 8, 12, and 24 July, respectively. Tests for hepatitis B surface antigen, hepatitis B core antibody IgM, and hepatitis A virus IgM, obtained 8 July, had negative results. After 4 days of bed rest, he felt better and returned to work. He had recovered by 16 July 1990. In recent years, many niacin preparations have been marketed. Patients now frequently present with various symptoms associated with niacin, most commonly the triad of nausea (rarely vomiting), elevated hepatic transaminase levels (usually mild), and hypolipidemia. In many, but not all, instances, these niacin-associated symptoms occur after the patient has consumed a time-release preparation or switched from regular niacin to a time-release preparation. This difference in side effect profile and tolerance has been discussed (2-4). In recent months, patients consuming "regular" niacin have presented with this symptom triad or, on occasion, with a toxicity syndrome mimicking hepatitis. Problems usually occur after changing brands of regular niacin or after exposure to a different batch of niacin. Philip H. Frost, MD University of California San Francisco, CA 94143-0326

References 1. Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults. The Expert Panel. Arch Intern Med. 1988;148:36-69. 2. Knopp RH, Ginsberg J, Albers JJ, et al. Contrasting effects of unmodified and time-release forms of niacin on lipoproteins in hyperlipidemic subjects: clues to mechanism of action of niacin. Metabolism. 1985;34:642-50. 3. Henkin Y, Johnson KC, Segrest JP. Rechallenge with crystalline niacin after drug-induced hepatitis from sustained-release niacin. JAMA. 1990;264:241-3. 4. Hodis HN. Acute hepatic failure associated with the use of low-dose sustained-release niacin [Letter]. JAMA. 1990;264:181.

Training in Heart Auscultation To the Editors: Cardiac auscultation must be done in a compulsive, systematic way, with the physician listening intently for one event at a time (1). Auscultation focuses more on the timing of events within the cardiac cycle than on their intensity or on the site at which they are heard best (2). Training in heart auscultation should begin with teaching the student to identify the first sound, perceived simultaneously with the carotid pulse (3). This can be taught only on an individual basis. We use a flash of light—either video-recorded or emitted in real time—that is presented simultaneously with the first heart sound as the first step in collective training in cardiac auscultation: identification and recognition of the first heart sound. The students are trained to briefly abduct their left thumb (or their right thumb in left-handed students) simultaneously with the light flash and the first heart sound. This procedure replaces the tactile stimulus (the carotid pulse), which at the bedside would identify the first sound, with an optic stimulus (the light flash) plus a propioceptive stimulus. Although the thumb movement is initially voluntary, it becomes almost automatic and mentally substitutes for palpation of the carotid pulse. We used this technique in a group of 95 pregraduate and postgraduate medical students who said that they had received minimal training in cardiac auscultation. All 95 students completed a 15-hour audiovisual training course, which consisted of one daily seminar (100 to 120 minutes) for 8 days. The daily seminar included instruction in basic theory, practical exercises in audiovisual training, and an audiovisual self-test on the previously shown auscultatory syndromes. The students judged the course to be highly effective, and, in fact, my own expectations as to the success of this teaching method were surpassed. At the end of the course, skill in

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auscultation was tested in 92 students, 91 of whom were able to identify correctly three or more of the five auscultatory syndromes presented. This comparatively brief course in collective instruction was successful in training the students to synchronize light and propioceptive and acoustic stimuli mentally, thus creating a reflex habit that facilitated automatic mental pairing of the carotid pulse and the first sound. When the students were asked to do individual bedside auscultation in a conventional clinical setting, the reflex habit facilitated their sequential analysis of the successive heart sounds and enhanced their ability to time the auscultatory events within the cardiac cycle. Antonio Guijarro Morales, MD School of Medicine, University of Granada E-18071 Granada, Spain References 1. Shaver JA, Salerni R. Auscultation of the heart. In: Hurst JW, Schlant RC, Rackley CE, Sonnenblick EH, Wenger NK, eds. Arteries and Veins. 7th ed. New York: McGraw-Hill; 1990:176. 2. Solokow M, Mcllroy MB, Chetlin MD. Clinical Cardiology. 5th ed. Norwalk, Connecticut: Appleton & Lange; 1990:56. 3. Delman AJ, Stein E. Dynamic cardiac auscultation and phonocardiography. Philadelphia: W.B. Saunders; 1979:62.

Students' Attitudes about AIDS To the Editors: There has been an increased interest in the human immunodeficiency virus (HIV) epidemic's effect on the nature of the practice of medicine. Recent research on house officers has shown that concern about possible job-related infection may influence choice of specialty and career objectives. In addition, Hay ward and Shapiro (1) reported that 23% of residents in internal medicine or family practice in a national sample would not work in an area with a high prevalence of the acquired immunodeficiency syndrome (AIDS) for fear of contracting the virus. To learn about medical school's effect on the evolution of attitudes about HIV, we surveyed the entering and the leaving class of a medical school in California. Response rates of 89% of first-year students (75 of 84) and of 55% of senior students (41 of 74) were obtained using an anonymous, written questionnaire. There is wide-spread concern among these medical students

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about HIV; 77% of the first-year respondents and 93% of the graduating respondents reported having seriously considered the occupational risk for becoming infected with HIV during their career. At the same time, misperceptions about transmission of HIV in the health care setting exist: 26% of first-year respondents and 36% of senior respondents believed that HIV could be transmitted through the aerosolization of body fluids. Ninety-nine percent of entering and 93% of graduating respondents thought that a physician has the right to know the HIV status of her or his patients. Forty-three percent of firstyear and 32% of senior respondents thought that a physician has the right to refuse to treat persons with HIV infection, and 4% of first-year and 10% of senior respondents reported that they personally would refuse to treat persons with AIDS. In contrast, 50% of entering and 76% of graduating respondents thought that health-care workers should not be regularly tested for HIV infection. Additionally, 40% of the entering and 39% of the graduating respondents reported that concerns about HIV infection would influence their decisions about which area of medicine they would practice. The effect of HIV on the practice of medicine is being felt on many levels. Among medical students, there is a high degree of concern about occupational HIV infection, and this concern is influencing career choices. Misperceptions about the means of transmission of the virus may be a part of these concerns and may influence the standard of care provided to certain patient populations. Although 4 to 5 years of medical school education separate the two groups in this study, the responses to the survey questions are remarkably similar. In the future, focusing on education about HIV issues during medical school may be critical in dispelling commonly held misperceptions about HIV. Such education may not only create more knowledgeable physicians, but may also increase the number of physicians who are willing to work with HIV-infected patients. Reuben Granich Jonathan Mermin P.O. Box 11382 Stanford, CA 94309 Reference 1. Hayward RA, Shapiro MF. A national study of AIDS and residency training: experiences, concerns, and consequences. Ann Intern Med. 1991;114:23-32.

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