A B S T R A C T The present study was directed toward determining the role of the kidney in the metabolism of various classes of serum proteins and to define the urinary protein excretion patterns and the pathogenesis of disorders of protein metabolism in patients with proteinuria. To this end, the metabolic fates of a small protein, X-L chain (mol wt 44,000), and a protein of intermediate size, IgG (mol wt 160,000), were studied in controls and patients with renal disease. Controls metabolized 0.28%/hr of circulating IgG and 22.3%/hr of circulating X-L chain. All the IgG and 99% of the X-L chain was catabolized with the remaining X-L chain lost intact into the urine. The kidney was shown to be the major site of catabolism for small serum proteins. Three distinct disorders of protein metabolism were noted in patients with renal tubular disease and tubular proteinuria, glomerular disease (the nephrotic syndrome), and disease involving the entire nephrons (uremia), respectively. Patients with renal tubular disease had a 50-fold increase in the daily urinary excretion of 1540,000 molecular weight proteins such as lysozyme and X-L chains. Serum IgG and X-L chain survivals were normal; however, the fraction of the over-all X-L chain metabolism accounted for by proteinuria was increased 40-fold whereas endogenous catabolism was correspondingly decreased. Thus, tubular proteinuria results from a failure of proximal tubular uptake and catabolism of small proteins that are normally filtered through the glomerulus. Patients with the nephrotic syndrome had a slight increase in X-L chain survival whereas IgG survival was decreased and the fraction of IgG lost in the urine was An abstract of this work appeared in J. Clin. Invest. 1970. 49: 99a. (Abstr.)

Many previous studies have established the value of the autopsy in assessing clinical diagnostic accuracy. None has described, however, the use of the autopsy as an ongoing, prospective audit of clinical and pathologic performance. The authors herein outline the process and report the initial results of a comprehensive quality assessment program on their autopsy service. Particular emphasis was placed on evaluation of the responsiveness of the autopsy to clinical questions and interests. The four parts of the overall program included an epidemiologic survey of causes of death in the authors' patient population, a determination of the clinical significance of autopsy findings, an assessment of clinical factors that may have contributed to death, and a quality control mechanism of the autopsy itself. The process can be adapted to a variety of hospital settings.

The mission of the Department of Veterans Affairs includes patient care, education, research, and backup to the Department of Defense. Because the measurement of physicians' productivity must reflect both institutional goals and market forces, the authors designed a productivity model that uses measures of clinical workload and academic activities commensurate with the VA's investments in these activities. The productivity model evaluates four domains of physicians' activity: clinical work, education, research, and administration. Examples of the application of the productivity model in the evaluation of VA-paid physician-staff and in the composition of contracts for clinical services are provided. The proposed model is a relatively simple strategy for measuring a broad range of the work of academic physicians in VA medical centers. The model provides incentives for documentation of resident supervision and participation in administrative activities required for effective and efficient clinical care. In addition, the model can aid in determining resource distribution among clinical services and permits comparison with non-VA health care systems. A strategy for modifying the model to incorporate measures of quality of clinical care, research, education, and administration is proposed. The model has been a useful part of the process to ensure the optimum use of resources and to meet clinical and academic institutional goals. The activities and accomplishments used to define physician productivity will have a substantial influence on the character of the medical profession, the vitality of medical education and research, and the cost and quality of health care.