Teaching fearlessness: a manifesto.

CONTEXT: Negative role modeling is a plague medical educators fight once students enter the clinical arena. The literature is replete on the fact that students routinely encounter faculty who display attitudes and behaviors inconsistent with the values taught throughout the medical curriculum, particularly in the preclinical years. APPROACH: Using a back and forth between the text of a third-year student's reflective essay and two of her faculty's observations on her negative encounters with several clinical faculty, the authors propose 'teaching for fearlessness.' DISCUSSION: Using Papadimos and Murray's use of 'fearless speech' derived from Foucault's thinking on parrhesia, the authors build a case that students should be encouraged to expose and challenge inequities on behalf of their patients, themselves and the profession at large. CONCLUSIONS: Medical educators should model and provide students with opportunities to develop and use 'fearless speech' as a way to reshape the culture of medical education and patient care.

Identification of the target cells of Orientia tsutsugamushi in human cases of scrub typhus.

Orientia tsutsugamushi is the etiologic agent of scrub typhus, a chigger-borne zoonosis that is a highly prevalent, life-threatening illness of greatest public health importance in tropical Asia and the islands of the western Pacific Ocean. The target cell of this bacterium is poorly defined in humans. In this study, O. tsutsugamushi were identified by immunohistochemistry using a rabbit polyclonal antibody raised against O. tsutsugamushi Karp strain in paraffin-embedded archived autopsy tissues of three patients with clinical suspicion of scrub typhus who died during World War II and the Vietnam War. Rickettsiae were located in endothelial cells in all of the organs evaluated, namely heart, lung, brain, kidney, pancreas, and skin, and within cardiac muscle cells and in macrophages located in liver and spleen. Electron microscopy confirmed the location of rickettsiae in endothelium and cardiac myocytes.

Ecological forecasts: an emerging imperative.

Planning and decision-making can be improved by access to reliable forecasts of ecosystem state, ecosystem services, and natural capital. Availability of new data sets, together with progress in computation and statistics, will increase our ability to forecast ecosystem change. An agenda that would lead toward a capacity to produce, evaluate, and communicate forecasts of critical ecosystem services requires a process that engages scientists and decision-makers. Interdisciplinary linkages are necessary because of the climate and societal controls on ecosystems, the feedbacks involving social change, and the decision-making relevance of forecasts.

Physician views on practicing professionalism in the corporate age.

Arnold Relman argues that medical education does not prepare students and residents to practice their profession in today's corporate health care system. Corporate health care administrators agree: Physicians enter the workforce unskilled in contract negotiation, evidence-based medicine, navigating bureaucratic systems, and so forth. What about practicing physicians? Do they agree as well? According to this study, they do. Feeling like decentered double agents and unprepared, physicians find themselves professionally lost, struggling to balance issues of cost and care and expressing lots of negativity toward the cultures of medicine and managed care. However, physicians are resilient. A group of physicians, who may be called proactive, are meeting the professional demands of corporate health care by becoming sophisticated about its bureaucratic organization and the ways in which their professional and personal commitments fit within the system. Following the lead of proactive physicians, the authors support Relman's thesis and education for both students and physicians requires a major overhaul.

The development of professionalism: curriculum matters.

The authors propose that professionalism, rather than being left to the chance that students will model themselves on ideal physicians or somehow be permeable to other elements of professionalism, is fostered by students' engagement with significant, integrated experiences with certain kinds of content. Like clinical reasoning, which cannot occur in a vacuum but must be built on particular knowledge, methods, and the development of skills, professionalism cannot flourish without its necessary basis of knowledge, methods, and skills. The authors present the need for an intellectual widening of the medical curriculum, so that students acquire not only the necessary tools of scientific and clinical knowledge, methods, and skills but also other relevant tools for professional development that can be provided only by particular knowledge, methods, and skills outside bioscience domains. Medical students have little opportunity to engage any body of knowledge not gained through bioscientific/empirical methods. Yet other bodies of knowledge-philosophy, sociology, literature, spirituality, and aesthetics are often the ones where compassion, communication, and social responsibility are addressed, illuminated, practiced, and learned. To educate broadly educated physicians who develop professionalism throughout their education and their careers requires a full-spectrum curriculum and the processes to support it. The authors sketch the ways in which admission, the curriculum (particularly promoting a sociologic consciousness, interdisciplinary thinking, and understanding of the economic/ political dimensions of health care), and assessment and licensure would function.

Mycoplasmal infections alter gene expression in cultured human prostatic and cervical epithelial cells.

To better understand how infections by mycoplasmas affect gene expression in human cells, we quantitatively measured the transcripts of 38 cytokine genes in HPV E6- and E7-immortalized cervical and prostatic epithelial cells before and after infection by four human urogenital mycoplasmas, M. fermentans, M. genitalium, M. hominis and M. penetrans. Using the multi-probe RNase protection assay (RPA), 22 and 23 cytokine gene transcripts were detected in the non-infected control prostatic and cervical epithelial cells, respectively. Although there were no discernible changes in cell morphology and growth kinetics following 72 h of mycoplasmal infection, 55-74% of the cytokine genes expressed in the two human epithelial cell lines were altered. Most changes reflected an increased expression of these cytokine genes, while expression of some cytokine genes significantly decreased. The effects varied with host cell type and species of infecting mycoplasmas. These alterations in gene expression were more profound in the cervical epithelial cells than in the prostatic cells. M. fermentans produced the most significant effects, followed by M. penetrans, M. genitalium and M. hominis. Some alterations in the gene expression were transient, but most persisted over the course of chronic (9 months) mycoplasmal infection. Prolonged gene expression changes induced by chronic mycoplasmal infection may gradually alter important biological properties in the infected mammalian cells and produce a unique form of disease process.

Lack of serological evidence for Mycoplasma fermentans infection in army Gulf War veterans: a large scale case-control study.

Mycoplasma firmentans is suspected in the development of 'Gulf War illness' in veterans of Operation Desert Storm. We conducted a matched case-control study for the prevalence of M. firmentans-specific antibodies before and after the operation, as well as seroconversion rates in veterans with and without complaints of 'Gulf War illness'. Cases consisted of Gulf War veterans, who complained of various illnesses and were enrolled in the second phase of the health evaluation by the Army Comprehensive Clinical Examination Program (CCEP). Controls were selected from Gulf War veterans who did not participate in the registry and did not request a health evaluation by the CCEP. Before operation deployment, 34 out of 718 of the cases (48%) and 116 out of 2233 of the controls (5.2%) tested positive for M. fermentans-specific antibodies. There was no difference in rates of seroconversion between cases and controls (1.1 vs. 1.2%) to M. fermentans during Operation Desert Storm. Thus, there is no serological evidence that suggests infectionby M. fermentans is associated with development of 'Gulf War illness'.

Asian/Pacific Islander women in medical education: personal and professional challenges.

PURPOSE: The purpose of this qualitative study was to identify the complex issues facing Asian/Pacific Islander (API) women students at one Midwestern medical school as they subjectively experience their medical training. Of particular interest was how students navigated family influences, career planning, and ethnic and gender stereotypes. SUMMARY: Sixty-five percent of the students reported that their parents exerted various degrees of encouragement or pressure to enter medicine. The remaining students said that the decision was entirely theirs (20%) or that the decision had been made for them (15%). Many reported the larger Asian "community" as a source of influence. A slight majority of students thought they were perceived by faculty as being "quiet," often too quiet. With only 1 exception, all of the students believed that their cultural identity influenced their specialty choice. Stressors reported by students centered on competition, achievement, and formation of intimate relationships (i.e., dating). CONCLUSIONS: Medical educators who provide personal and professional support for API women students should be keenly aware of the career, gender, and family issues that emerge at the intersection of API and Euro-American cultures. Faculty development should include an educational component on issues of concern to API students, men and women. Faculty also need to wrestle with the cultural values of "modesty, respect for authority, public self-consciousness, and other directness" as they intersect with assertion as a primary value found in Euro-American culture in general and in medical education in particular.

On white coats and professional development: the formal and the hidden curricula.

White coat ceremonies are a recent phenomenon in medical education. Selected as a symbol by the Arnold P. Gold Foundation to impress upon medical students the importance of compassion and humility, the white coat has had a long association with all things medical, scientific, and healing. It is also associated with the attributes of purity and goodness traditionally symbolized by the color white. Thus, its selection as the material focus of the white coat ceremony seems natural. This article situates the white coat ceremony as a curricular event and suggests that, in addition to having the meanings cited above, the white coat has other meanings that fall into the realm of the hidden curriculum--it can symbolize caregiving hierarchies and spheres of practice, the social and economic privilege of physicians, and medicine's well-established practices of determining membership in the profession. Finally, this paper suggests several other ceremonies or rituals that may be better than the white coat ceremony for encouraging compassion and humility in medical students.

Absence of mycoplasmal gene in malignant mammalian cells transformed by chronic persistent infection of mycoplasmas.

Chronic persistent infections by mycoplasmas induced malignant transformation of C3H mouse embryo cells that normally had never been reported to undergo spontaneous transformation. This mycoplasma-mediated oncogenic process had a long latency (more than 7 weeks of continuous mycoplasmal infection) and showed a multistage progression characterized by reversibility (at least up to 11 weeks of mycoplasmal infection) and irreversibility of malignant properties upon removal of the mycoplasma from culture. Further prolonged infections (18 weeks) by Mycoplasma fermentans or M. penetrans resulted in permanent transformation of these C3H cells that no longer required the continued presence of the transformation-inducing mycoplasmas in cultures to retain their malignant properties. Previous studies of viral oncogenesis revealed that virus-transformed cells always had viral gene(s) present. Integration of viral gene(s) apparently played an important role in the process of oncogenesis. In this study, we examined if the continued presence of any mycoplasmal gene(s) in mammalian cells, in whatever form, was also crucial in causing malignant cell transformation. Representational difference analysis (RDA) was a recently developed powerful technique to compare differences between two complex genomes. In the RDA system, subtractive and kinetic enrichment was used to purify and isolate restriction endonuclease gene fragment(s) of mycoplasmal origin, presumably present only in mycoplasma-transformed C3H cells, but not in nonmycoplasma-exposed control C3H cells. After three rounds of subtractive hybridization following PCR enrichment for each of three different restriction enzymes DNA digests, no gene fragment of mycoplasmal origin was amplified or identified in the permanently transformed C3H cells. Differing from tumorigenesis in animal cells induced by most oncogenic viruses or in plant cells induced by Agrobacteria, mycoplasmas evidently did not cause malignant transformation by integrating their gene(s) into the mammalian cell genome.

Immunohistochemical diagnosis of typhus rickettsioses using an anti-lipopolysaccharide monoclonal antibody.

A monoclonal antibody directed against an epitope on the lipopolysaccharide of typhus-group rickettsiae was developed for the purpose of detecting this heat-stable, proteinase-resistant antigen in formalin-fixed, paraffin-embedded tissues. Rickettsia prowazekii organisms were identified in endothelium and macrophages in sections of the brains of three Egyptian men who died of epidemic louse-borne typhus in Cairo during World War II and in the brain from a recent case of typhus fever acquired in Burundi. R. typhi organisms were identified in endothelial cells from a fatal case of murine typhus and in experimentally infected mice. This approach is applicable not only to the study of archival tissues and experimental animal models but also could be used to establish a timely diagnosis of typhus-group rickettsiosis by immunohistochemical examination of cutaneous biopsies of rash lesions during the acute stage of illness.

High-level expression of H-ras and c-myc oncogenes in mycoplasma-mediated malignant cell transformation.

C3H mouse embryo cells, which normally have low inherent spontaneous transformation, underwent malignant transformation while chronically infected with Mycoplasma fermentans or Mycoplasma penetrans. This mycoplasma-mediated oncogenic process had long latency (more than 7 weeks of persistent mycoplasmal infection) and showed multistage progression characterized by reversibility and irreversibility of malignant properties upon removal of M. fermentans from culture. Marked expression of H-ras and c-myc mRNA, but not N-myc, src, N-ras, or p53 mRNA, was found in the mycoplasma-transformed C3H cells that exhibited characteristic malignant properties of morphological changes and uncontrolled cell growth. However, at least up to the eleventh week of persistent mycoplasma infection, the marked expression of H-ras or c-myc mRNA in C3H cells depended on continued presence of the mycoplasma in culture. H-ras or c-myc mRNA rapidly declined to the undetectable low levels of nontransformed parental C3H cells, and all malignant properties of the once-fully-transformed C3H cells quickly reversed, if M. fermentans was eradicated from culture. In comparison, infection with M. penetrans for 7 or 11 weeks also induced a high level of H-ras, but not c-myc, mRNA expression in C3H cells. Despite having prominent amount of steady-state H-ras mRNA, these M. penetrans-infected C3H cells did not show any sign of malignant transformation. Thus, marked expression of H-ras gene alone was not sufficient to effect transformation in C3H cells. Interestingly, after a further prolonged (18 weeks) infection with either M. fermentans or M. penetrans, C3H cells revealed prominent chromosomal changes, expressed constitutively (with or without the presence of the transforming mycoplasmas) at high levels of both H-ras and c-myc mRNA and became permanently transformed. These cells were able to form tumors in animals.

Professional development of medical students: problems and promises.

Observers and critics of the medical profession, both within and without, urge that more attention be paid to the moral sensibilities, the characters, of medical students. Passing on particular moral values and actions to physicians has always been an essential core of medical training, and this call for renewal is not new in modern medicine. Some of the structures and characteristics of modern medical education, however, often work directly against the professionalism that the education espouses. For example, medical students are socialized into a hierarchy that has broad implications for relations among health care professionals, other health care workers, and patients, and academic medicine has not promoted and taught critical reflection about the values and consequences of this hierarchy. Further, behind the formal curriculum lies the "hidden curriculum" of values that are unconsciously or half-consciously passed on from the faculty and older trainees. Two resources for thinking anew about professional development for medical students are feminist standpoint theory and critical multicultural theory, each of which raises important and fundamental questions about defining the role of medicine in society and the role of the physician in medicine. The author discusses these two theories and their implications for medical education, showing how they can be used to move discussions of professional development into analysis of the widespread social consequences of how a society organizes its health care and into critical reflection on the nature of medical knowledge.

Demonstration of Chlamydia trachomatis in inguinal lymphadenitis of lymphogranuloma venereum: a light microscopy, electron microscopy and polymerase chain reaction study.

Intravacuolar organisms in vacuolated macrophages were associated with areas of necrosis and suppuration in 12 patients with suppurative inguinal lymphadenitis. The intravacuolar organisms measured 0.2 to 2.0 micrometers in diameter, stained Gram negative with the Brown-Hopp's tissue Gram stain, faintly blue with hematoxylin and eosin stain, and black with the Warthin-Starry silver impregnation stain. The organisms lined vacuolar membranes and/or clumped in centers of vacuoles. Electron microscopy revealed elementary and reticulate bodies and intermediate forms characteristic of the genus Chlamydia. Cultures of three lymph nodes in McCoy cells grew Chlamydia trachomatis, lymphogranuloma venereum (LGV) serovars. Polymerase chain reaction using primers for chlamydial 16S ribosomal DNA confirmed the organisms as Chlamydia in lymph nodes from nine patients. Recognition of chlamydial organisms by light microscopy in tissue sections of lymph nodes allows a definitive diagnosis of lymphogranuloma venereum.