H U M A N P A T H O L O G Y - - V O L U M E 6, NUMBER 5 September 1975 WOMEN IN ACADEMIC PATHOLOGY T o TIlE EDITOR: I would like to ask the question: W h e r e are the women in academic pathology? At meetings, women are in the audience a n d the panels o f experts on the stage are all men. T h e officials of the various boards, the officers o f the pathology societies, a n d the clmirmen o f d e p a r t m e n t s are almost exclusively male. O f approximately 158 editors a n d members o f the editorial boards of the commonly read pathology j o u r n a l s - i . e . , lluma, l)atholog)", The
Ame)ican Journal of Pa/holog)', The Ame)ica)~ Journal of Clinical Pathology, Cancer-all arc men.
This is a serious p r o b l e m because it means that there are few visible models to guide women planning tJleir medical careers. Worse, it means that women's salaries are lower than men's in the case o f academic appointments, and that when major decisions (on either a national or d e p a r t m e n t a l level) are made, there are few (or no) women present. Thus, the system perpetuates itself. T h e elite ch,b o f politically powerfial pathologists remains inviolate, while wmnen vie with one another at the lower rungs o f the acadenfic ladder. This surely represents a real "patlmlogical" condition among presumably "equal" Immans, and perhaps the O p e n F o r u m o r C u r r e n t Topics in Ihtman Patholog)' might be instrumentally app r o p r i a t e for cvahmting the problem. KA'~"H. WOODROW, M.D. University of California, San Francisco, School of Medicine San Fraucisco, California
THE CORE CURRICULUM T o TIlE EDITOR:
640
Your publication in the November 1974 issue o f lluman Pa/holoLq' o f "A Dcbatc on the Core Curriculunl in l'athology" was o f great interest to me. Ahhougll I am not primarily in acadcmic pathoh)gy, I am a i)racticing pathologist and have been a iDember o f the voluntary pathology faculty o f the University o f Miami School of Mcdicine fi)r the past twenty years, activcly invoh'ed in lecturing to s o p h o m o r e medical and I)h.D.-M.D. students. As a memI)er o f tile ASCP Board of Schools (now N a t i o n a l Accrediting Agency for Clinical Laboratory Sciences) since 1971, I have had reasonable expcri, ence in dealing with and learning about tile educational prgccss per se.
It Ires been my practice over the )'ears to invite medical students to spend their postsopllomore s u m m e r with m e as Fellows in my laboratory and to open o u r autopsy room to s o p h o m o r e medical students to witness our autopsies and participate in clinical-pathological correlations. In these circumstances I Imve observed a markedly increasing degrec of surprise and astonishment on the part o f the students concerning a seemingly "new" world o f knowledge and observable pllcnomena, a world a p p a r e n t l y missed d u r i n g their compressed fornml education in p a t h o l o g y - a u d i o visuals, mcchanisnls o f discase, a n d all. I drink that the debaters, as profound, erudite and expert as they are, have been h a m p e r e d by the words "core curriculum," an ancient, misinterpreted, and poorly u n d e r stood semantic misi~omer, discarded some time ago as valid terminology and concept in curricultml d e v e l o p m e n t by many advanced nonmedical edncators. T h e real issues, in my opinion, are: 1. T h e compression o f a viable and vital body o f incdical knowledge by rcsponsible, accountable, medical educator authorities into an unrecognizable fragmented nmlentity resuhing in the virtual removal f i o m the curricvlum o f an area o f inedical knowledge that permeates and relates to all fields o f lnedical practice. 2. T h e acceptance or even a discussion o f the concept o f "core" o r "essential" curricula, connoting a passive acceptance o f things as tile)" are. "Let us deal efficiently with what they have given us" is not the answer. 3. A reluctance on the part o f many pathology educators to become familiar with the educational process. T h e educational process invoh'es more than brilliant lecttu'ers (with so little time), r e a d i n g assignments in bcautifidly written texts and journals (with so little time to read), the availability (at all times) to the student o f sets o f h u n d r e d s o f K o d a c l u o m c s with con-" venicnt viewers and a national examination (of questionable validity) as lncasurement of competence. T h e educational process involves, among o t h e r things, cooperative plamfing within the institution o f curricula based on an u n d e r standing o f the v a r i o u s facets of cognitive psycllomotor and atfcctive domain; the relative importance, priority, or rank o r d e r i n g of the subject material invoh'ed; the use o f instructional objectives as a means o f tclling the students what is expected o f them and helping the instructor to construct an examination as one pertinent m e a s u r e m e n t tool o f wlmt Ilas o r has not been learned; and the d e v e l o p m e n t o f question pools, item analysis, and so fortll. National a g r e e m e n t on a standard o r even core curriculum will never be achieved, let us hope. I suspect that these a n d other*basic
CORRESPONDENCE
elements o f the education process have not permeated the hallowed balls o f many inedical schools. One positive approach to the problem of the compressed curricuhun is its evaluation b)" pathology education leaders through the joint development of an effective instrument to validate or invalidate the seeming catastrophe in medical education related to the gradual disappearance of pathology as a subject or entity. With all effective instrument, effectively applied and evaluated, patholog)' educators could have the ammuuitiou to effectively blast open the constrictive bands on the In,ge, pulsating, vital, boxed-in mass of knowledge currently kept fi'om the medical student. It is incumbent on our educato,'-leaders in pathology to familiarize themselves and their facuhy with the educatioual process and all that it conuotes. Knowledge is the key to judgment. Good jt, dgment, tile highest level of cognitive domain aud the hall,nark of the good doctor, cannot be achieved without the assemblage of a bod)' of knowledge supple-
mented b}' exposure o f the student to observable pllenomena. This takes time. This basic facet of cognitive domain cannot be achieved by omission, osmosis, gimmicks, and poorly organized, foreshortened curricula. Dr. Jolm Simon's profound comments in your editorial sectiou real[)' provide the alternative keys to the circumlocutions o f the debate, q'here is a cause worth fighting f o r the traditional curricuhun with updated teaching methodologies. Deans and other medical school powers-that-be must be made to understand something like this pat'apllrase of one of D,'. Simou's remarks: Theory, apart from observation, cannot filrnish the student with anything better thau shifting sands for the fot,ndatioll of Iris clinical knowledge. Time must be made available for theory and observation; curricula must be redesigned accordingly. It could be said that a member o f a voluntary facuhy making constructive cominents about an area of medical education that involves the powerful forces of medical school politics is n;u've and t, naware of the problems
Figure i. Trict,spid valve showing conspictzous hemorrhage of anterior cusp. These lesions are usually much smaller and tend to favor tile septal cusp (s~e p. 6-t2).
6 Bx ]
HUMAN PATHOLOGY-VOLUME
6, N U M B E R 5 September 1975
related t o the situation as it exists. Oil the other hand, the nonacademic pathologist is on the firing line. He needs not only the infusion o f fresh blood in his (lepartment in terms of new associates; he also needs to work with a medical and surgical stall" with some understailding of disease processes. In a sense the pathologist, in m o d e r l l day parlance, is a c o n s u m e r of the products o f the medical school. More important than that, the patient is the uhimate consumer. T o subject hiln to tile ministrations o f the "incomplete" physician with little or no knowledge of pathology is a faihlre for which the medical school is responsible and should be accountable. JEROME BENSON, M.D. ,Miami I lcart Institute
Miami Beach, Florida
ENDOCARDIAL HEMORRHAGES OF THE RIGHT HEART CAUSED BY EMBOLIC IMPACT "I'o TIlE EDITOR:
T h e anatomic pathologist, as a trained observer, is boun(I to Inake serendipitous and possibly original observations with tile naked eye o r through the microscope and incorporate t h e m into his teaching. If he is not particularly inclined or adept at formalizing them I))' publication, he ma)' be amazed, amused, or chagrined, d e p e n d i n g on his l)crsonality, to find that after having demoilstratcd these findings to generations o f residents, someone else, equally astute, doculnents these observations in print. It is the p t u p o s c o f this note to record and illustrate a lesion that I have been showing to residents for decades, nil-holy, the focal endocardial henlorrhage caused by tile impact o f thromboeml)oli destined to go to tile hlng. T h e s e lesions are most colnlnon on the septal cusp o f the tricuspid valve but may be seen on tile l)uhnonic vah'e o r the mural e n d o c a r d i u m o f the right atl-iunl o r ventricle. A h h o u g h these h e m o r r h a g e s ace not invariabl)' associated with demonstrable puhnonar)" emboli, they comtnonly are a signpost for their presence (Fig. 1, page 641). Search o f weighty totnes, (;ernaanic, British, and native, has failed to turn up a cotnparal)le description. FRFDERICK G. ZAK, M.D. The Mctho(list Ih)sl)it:tl and Downstate Medical School
642
Brooklyn, New York
THE PATHOLOGY OF CEREBRAL EDEMA T o TIlE EDITOR: In a generally excellent review o f the pathology of cerebral edema, Manz [ H u m a n Pathol., 5:29 I-313, 1974] discusses the concept that astrocytes are "high sodium cells" and may "represent a Tunctional' extraccllular sp,lce" in the brain. In view of recent data concerning the physiology o f these cells, we feel that these concepts ;Ire no longer tenable. T h e size o f tile extracellular COlnpartlnent in the brain can be cstinlated b)' use o f chelnical lnarkers or direct lneasurcment using electron microscop)'. Chclnical nlethods indicated a much larger c o m p a r t m e n t than was obvious flotn the nlorlfllologic data. This discrepancy, as Manz indicated, motivated the original suggestion that astrocytes (and possibl)" o t h e r types o f glial cells) might contain a high intracellular sodit, m concentration and functionally behave as if their cytoplasm wcrc part of the extracellular space3 Subsequelu investigations have seemed to s u p p o r t these ideas3 -s hnplicit in this forlnulation are the notions that glial cells help provide the necessary ionic e,avironlnent for normal n e n i o n a l electrical activity and also serve as a diffusion pathway for sodium and possibly 0 i h e r s n b s t a n c e s . . S u c h cells would necessarily have high relative permeabilities to sodiutn and chloride and low Inelnbrane l)oten rials. Rather than colnment about ahernative interpretations o f previous experilnental work, we would like to summarize more recent work, mailfly electroph)'siological, that is incompatible with these ideas. Elegant exl)erilnents by Kufller and his colleagues n on morlfllologically identified glial cells in the leech have established that these cells contain al)l)roxilnately 10-t ineq. p e r I. of potassiuln and a inaxinaum o f 26 nleq. p e r 1. o f sodiunl. T h e figure for sodium is undoubtedl)' an overestimate, since it assulnes that ;111the measured sodium was contained only in glial cells. These workers also demonstrated that the cells are relatively i m p e r m e a b l e to sodium, have high resting nlcmbl-ane potentials, and arc not part o f a pathway for rapid diffusion o f sodiunl. Similar resnhs were obtained froln experiments on nmnnnalian preparations. 7 Cortical cells, now uneqlfivocally delnonstrated to be gila (nlainly astrocytcs8), have high resting nlclnbrane potentials ( - 6 0 to --90 nw.), which are very sensitive to changes in the cxtracelhtlar potassiuln concentratio,i and are relatively impermeable to sodiunl 9 T h e estimated intracelhflar i)otassium concentration is high and ;halilies that freely diffusible soil;urn mnst necessarily be low to maintain osmotic equilibrit, m ?
Ame)ican Journal of Pa/holog)', The Ame)ica)~ Journal of Clinical Pathology, Cancer-all arc men.
This is a serious p r o b l e m because it means that there are few visible models to guide women planning tJleir medical careers. Worse, it means that women's salaries are lower than men's in the case o f academic appointments, and that when major decisions (on either a national or d e p a r t m e n t a l level) are made, there are few (or no) women present. Thus, the system perpetuates itself. T h e elite ch,b o f politically powerfial pathologists remains inviolate, while wmnen vie with one another at the lower rungs o f the acadenfic ladder. This surely represents a real "patlmlogical" condition among presumably "equal" Immans, and perhaps the O p e n F o r u m o r C u r r e n t Topics in Ihtman Patholog)' might be instrumentally app r o p r i a t e for cvahmting the problem. KA'~"H. WOODROW, M.D. University of California, San Francisco, School of Medicine San Fraucisco, California
THE CORE CURRICULUM T o TIlE EDITOR:
640
Your publication in the November 1974 issue o f lluman Pa/holoLq' o f "A Dcbatc on the Core Curriculunl in l'athology" was o f great interest to me. Ahhougll I am not primarily in acadcmic pathoh)gy, I am a i)racticing pathologist and have been a iDember o f the voluntary pathology faculty o f the University o f Miami School of Mcdicine fi)r the past twenty years, activcly invoh'ed in lecturing to s o p h o m o r e medical and I)h.D.-M.D. students. As a memI)er o f tile ASCP Board of Schools (now N a t i o n a l Accrediting Agency for Clinical Laboratory Sciences) since 1971, I have had reasonable expcri, ence in dealing with and learning about tile educational prgccss per se.
It Ires been my practice over the )'ears to invite medical students to spend their postsopllomore s u m m e r with m e as Fellows in my laboratory and to open o u r autopsy room to s o p h o m o r e medical students to witness our autopsies and participate in clinical-pathological correlations. In these circumstances I Imve observed a markedly increasing degrec of surprise and astonishment on the part o f the students concerning a seemingly "new" world o f knowledge and observable pllcnomena, a world a p p a r e n t l y missed d u r i n g their compressed fornml education in p a t h o l o g y - a u d i o visuals, mcchanisnls o f discase, a n d all. I drink that the debaters, as profound, erudite and expert as they are, have been h a m p e r e d by the words "core curriculum," an ancient, misinterpreted, and poorly u n d e r stood semantic misi~omer, discarded some time ago as valid terminology and concept in curricultml d e v e l o p m e n t by many advanced nonmedical edncators. T h e real issues, in my opinion, are: 1. T h e compression o f a viable and vital body o f incdical knowledge by rcsponsible, accountable, medical educator authorities into an unrecognizable fragmented nmlentity resuhing in the virtual removal f i o m the curricvlum o f an area o f inedical knowledge that permeates and relates to all fields o f lnedical practice. 2. T h e acceptance or even a discussion o f the concept o f "core" o r "essential" curricula, connoting a passive acceptance o f things as tile)" are. "Let us deal efficiently with what they have given us" is not the answer. 3. A reluctance on the part o f many pathology educators to become familiar with the educational process. T h e educational process invoh'es more than brilliant lecttu'ers (with so little time), r e a d i n g assignments in bcautifidly written texts and journals (with so little time to read), the availability (at all times) to the student o f sets o f h u n d r e d s o f K o d a c l u o m c s with con-" venicnt viewers and a national examination (of questionable validity) as lncasurement of competence. T h e educational process involves, among o t h e r things, cooperative plamfing within the institution o f curricula based on an u n d e r standing o f the v a r i o u s facets of cognitive psycllomotor and atfcctive domain; the relative importance, priority, or rank o r d e r i n g of the subject material invoh'ed; the use o f instructional objectives as a means o f tclling the students what is expected o f them and helping the instructor to construct an examination as one pertinent m e a s u r e m e n t tool o f wlmt Ilas o r has not been learned; and the d e v e l o p m e n t o f question pools, item analysis, and so fortll. National a g r e e m e n t on a standard o r even core curriculum will never be achieved, let us hope. I suspect that these a n d other*basic
CORRESPONDENCE
elements o f the education process have not permeated the hallowed balls o f many inedical schools. One positive approach to the problem of the compressed curricuhun is its evaluation b)" pathology education leaders through the joint development of an effective instrument to validate or invalidate the seeming catastrophe in medical education related to the gradual disappearance of pathology as a subject or entity. With all effective instrument, effectively applied and evaluated, patholog)' educators could have the ammuuitiou to effectively blast open the constrictive bands on the In,ge, pulsating, vital, boxed-in mass of knowledge currently kept fi'om the medical student. It is incumbent on our educato,'-leaders in pathology to familiarize themselves and their facuhy with the educatioual process and all that it conuotes. Knowledge is the key to judgment. Good jt, dgment, tile highest level of cognitive domain aud the hall,nark of the good doctor, cannot be achieved without the assemblage of a bod)' of knowledge supple-
mented b}' exposure o f the student to observable pllenomena. This takes time. This basic facet of cognitive domain cannot be achieved by omission, osmosis, gimmicks, and poorly organized, foreshortened curricula. Dr. Jolm Simon's profound comments in your editorial sectiou real[)' provide the alternative keys to the circumlocutions o f the debate, q'here is a cause worth fighting f o r the traditional curricuhun with updated teaching methodologies. Deans and other medical school powers-that-be must be made to understand something like this pat'apllrase of one of D,'. Simou's remarks: Theory, apart from observation, cannot filrnish the student with anything better thau shifting sands for the fot,ndatioll of Iris clinical knowledge. Time must be made available for theory and observation; curricula must be redesigned accordingly. It could be said that a member o f a voluntary facuhy making constructive cominents about an area of medical education that involves the powerful forces of medical school politics is n;u've and t, naware of the problems
Figure i. Trict,spid valve showing conspictzous hemorrhage of anterior cusp. These lesions are usually much smaller and tend to favor tile septal cusp (s~e p. 6-t2).
6 Bx ]
HUMAN PATHOLOGY-VOLUME
6, N U M B E R 5 September 1975
related t o the situation as it exists. Oil the other hand, the nonacademic pathologist is on the firing line. He needs not only the infusion o f fresh blood in his (lepartment in terms of new associates; he also needs to work with a medical and surgical stall" with some understailding of disease processes. In a sense the pathologist, in m o d e r l l day parlance, is a c o n s u m e r of the products o f the medical school. More important than that, the patient is the uhimate consumer. T o subject hiln to tile ministrations o f the "incomplete" physician with little or no knowledge of pathology is a faihlre for which the medical school is responsible and should be accountable. JEROME BENSON, M.D. ,Miami I lcart Institute
Miami Beach, Florida
ENDOCARDIAL HEMORRHAGES OF THE RIGHT HEART CAUSED BY EMBOLIC IMPACT "I'o TIlE EDITOR:
T h e anatomic pathologist, as a trained observer, is boun(I to Inake serendipitous and possibly original observations with tile naked eye o r through the microscope and incorporate t h e m into his teaching. If he is not particularly inclined or adept at formalizing them I))' publication, he ma)' be amazed, amused, or chagrined, d e p e n d i n g on his l)crsonality, to find that after having demoilstratcd these findings to generations o f residents, someone else, equally astute, doculnents these observations in print. It is the p t u p o s c o f this note to record and illustrate a lesion that I have been showing to residents for decades, nil-holy, the focal endocardial henlorrhage caused by tile impact o f thromboeml)oli destined to go to tile hlng. T h e s e lesions are most colnlnon on the septal cusp o f the tricuspid valve but may be seen on tile l)uhnonic vah'e o r the mural e n d o c a r d i u m o f the right atl-iunl o r ventricle. A h h o u g h these h e m o r r h a g e s ace not invariabl)' associated with demonstrable puhnonar)" emboli, they comtnonly are a signpost for their presence (Fig. 1, page 641). Search o f weighty totnes, (;ernaanic, British, and native, has failed to turn up a cotnparal)le description. FRFDERICK G. ZAK, M.D. The Mctho(list Ih)sl)it:tl and Downstate Medical School
642
Brooklyn, New York
THE PATHOLOGY OF CEREBRAL EDEMA T o TIlE EDITOR: In a generally excellent review o f the pathology of cerebral edema, Manz [ H u m a n Pathol., 5:29 I-313, 1974] discusses the concept that astrocytes are "high sodium cells" and may "represent a Tunctional' extraccllular sp,lce" in the brain. In view of recent data concerning the physiology o f these cells, we feel that these concepts ;Ire no longer tenable. T h e size o f tile extracellular COlnpartlnent in the brain can be cstinlated b)' use o f chelnical lnarkers or direct lneasurcment using electron microscop)'. Chclnical nlethods indicated a much larger c o m p a r t m e n t than was obvious flotn the nlorlfllologic data. This discrepancy, as Manz indicated, motivated the original suggestion that astrocytes (and possibl)" o t h e r types o f glial cells) might contain a high intracellular sodit, m concentration and functionally behave as if their cytoplasm wcrc part of the extracellular space3 Subsequelu investigations have seemed to s u p p o r t these ideas3 -s hnplicit in this forlnulation are the notions that glial cells help provide the necessary ionic e,avironlnent for normal n e n i o n a l electrical activity and also serve as a diffusion pathway for sodium and possibly 0 i h e r s n b s t a n c e s . . S u c h cells would necessarily have high relative permeabilities to sodiutn and chloride and low Inelnbrane l)oten rials. Rather than colnment about ahernative interpretations o f previous experilnental work, we would like to summarize more recent work, mailfly electroph)'siological, that is incompatible with these ideas. Elegant exl)erilnents by Kufller and his colleagues n on morlfllologically identified glial cells in the leech have established that these cells contain al)l)roxilnately 10-t ineq. p e r I. of potassiuln and a inaxinaum o f 26 nleq. p e r 1. o f sodiunl. T h e figure for sodium is undoubtedl)' an overestimate, since it assulnes that ;111the measured sodium was contained only in glial cells. These workers also demonstrated that the cells are relatively i m p e r m e a b l e to sodium, have high resting nlcmbl-ane potentials, and arc not part o f a pathway for rapid diffusion o f sodiunl. Similar resnhs were obtained froln experiments on nmnnnalian preparations. 7 Cortical cells, now uneqlfivocally delnonstrated to be gila (nlainly astrocytcs8), have high resting nlclnbrane potentials ( - 6 0 to --90 nw.), which are very sensitive to changes in the cxtracelhtlar potassiuln concentratio,i and are relatively impermeable to sodiunl 9 T h e estimated intracelhflar i)otassium concentration is high and ;halilies that freely diffusible soil;urn mnst necessarily be low to maintain osmotic equilibrit, m ?
