We have characterized a small family of four genes encoding one of the three nurse shark Ig L chain isotypes, called NS5. All NS5 cDNA sequences are encoded by three loci, of which two are organized as conventional clusters, each consisting of a V and J gene segment that can recombine and one C region exon; the third contains a germline-joined VJ in-frame and the fourth locus is a pseudogene. This is the second nurse shark L chain type where both germline-joined and split V-J organizations have been found. Since there are only two rearranging Ig loci, it was possible for the first time to examine junctional diversity in defined fish Ig genes, comparing productive vs nonproductive rearrangements. N region addition was found to be considerably more extensive in length and in frequency than any other vertebrate L chain so far reported and rivals that in H chain. We put forth the speculation that the unprecedented efficiency of N region addition (87–93% of NS5 sequences) may be a result not only of simultaneous H and L chain rearrangement in the shark but also of processing events that afford greater accessibility of the V or J gene coding ends to terminal deoxynucleotidyltransferase.

Little is known about physicians' perception of the ease or difficulty of implementing electronic health records (EHR). This study identified factors related to the perceived difficulty of implementing EHR. 163 physicians completed surveys before and after the implementation of EHR in an externally funded pilot program in three Massachusetts communities. Ordinal hierarchical logistic regression was used to identify baseline factors that correlated with physicians' report of difficulty with EHR implementation. Compared with physicians with ownership stake in their practices, physician employees were less likely to describe EHR implementation as difficult (adjusted OR 0.5, 95% CI 0.3 to 1.0). Physicians who perceived their staff to be innovative were also less likely to view EHR implementation as difficult (adjusted OR 0.4, 95% CI 0.2 to 0.8). Physicians who own their practice may need more external support for EHR implementation than those who do not. Innovative clinical support staff may ease the EHR implementation process and contribute to its success.

The ability to generate and use registries-lists of patients with specific conditions, medications, or test results-is considered a measure of physicians' engagement with electronic health record systems and a proxy for high-quality health care. We conducted a pre-post survey of registry capability among physicians participating in the Massachusetts eHealth Collaborative, a four-year, $50 million health information technology program. Physicians who participated in the program increased their ability to generate some types of registries-specifically, for laboratory results and medication use. Our analysis also suggested that physicians who used their electronic health records more intensively were more likely to use registries, particularly in caring for patients with diabetes, compared to physicians reporting less avid use of electronic health records. This statewide project may be a viable model for regional efforts to expand health information technology and improve the quality of care. 1,2 Widespread use of electronic health records is seen as a foundation for health reform.3 However, considerable doubt remains as to how deeply health IT will penetrate US health care and whether it will actually produce the anticipated quality improvements.To foster the adoption of health IT among ambulatory practices, HITECH authorizes the Office of the National Coordinator for Health Information Technology to establish regional extension centers to assist providers in selecting and implementing certified interoperable electronic health records for their practices. These centers aim to disseminate "lessons learned" and "best practices" throughout their communities and to promote participation in health information exchange. 4 Policy makers and leaders of regional extension centers will naturally look to existing models of communitywide efforts to promote the adoption of health IT. One of the most visible examples of such programs is the Massachusetts eHealth Collaborative, a statewide consortium of health care stakeholders founded in 2004 to improve the quality and safety of health care through community-based adoption of health IT. 5-10During 2006-08, the Massachusetts eHealth Collaborative sponsored a program to implement electronic health records within ambulatory medical practices and establish health information exchange. With a $50 million grant from Blue Cross and Blue Shield of Massachusetts, the collaborative used a competitive

Introduction: Inadequately supported clinicians risk burnout, which is prevalent among them. Balint-like groups can be utilized to address clinician stressors and augment interpersonal skills by exploring the clinician-patient relationship. Methods: In January 2012, we initiated the Clinical Case Discussion Group (CCDG), based on Michael Balint's Balint group, at the Boston University School of Medicine Section of General Internal Medicine. The CCDG is an interprofessional group discussion founded on self-reflection of patient cases designed to tease out ethical, psychosocial, and medical issues that impact the clinicianpatient relationship. The format consists of a facilitator-led small group session including 5-10 minutes of case discussion followed by open group discussion. In April 2014, we conducted a cross-sectional survey of clinicians who participated in the CCDG to evaluate the group's ability to foster skills in self-reflection, empathy, response to patient challenges, personal awareness, and tolerance of uncertainty, and to address clinicians' personal and professional stressors. Results: More than 75% of clinicians surveyed agreed that participation fostered skills in tolerating uncertainty, increasing empathy, and navigating difficult patient relationships. All respondents agreed the group developed skills in self-reflection. At least 40% of clinicians reported some degree of isolation, professional stress, and personal stress; group participation addressed these issues at least 70% of the time. Discussion: This self-reflection case discussion group, incorporated into academic clinical practice, supports the professional development of a broad cadre of clinicians and addresses both personal and professional stressors. Clinical departments should consider systematically implementing similar groups in practice.