James J. Brokaw

The Teaching of Complementary and Alternative Medicine in U.S. Medical Schools: A Survey of Course Directors.

Purpose The number of U.S. medical schools offering courses in complementary and alternative medicine (CAM) has risen sharply in recent years. This study gauged the current state of CAM instruction by gathering details about the specific topics being taught and the objectives behind the instruction. Method Data were collected from questionnaires mailed to 123 CAM course directors at 74 U.S. medical schools. Results Questionnaires were returned by 73 course directors at 53 schools. The topics most often being taught were acupuncture (76.7%), herbs and botanicals (69.9%), meditation and relaxation (65.8%), spirituality/faith/prayer (64.4%), chiropractic (60.3%), homeopathy (57.5%), and nutrition and diets (50.7%). The amounts of instructional time devoted to individual CAM topics varied widely, but most received about two contact hours. The “typical” CAM course was sponsored by a clinical department as an elective, was most likely to be taught in the first or fourth year of medical school, and had fewer than 20 contact hours of instruction. Most of the courses (78.1%) were taught by individuals identified as being CAM practitioners or prescribes of CAM therapies. Few of the courses (17.8%) emphasized a scientific approach to the evaluation of CAM effectiveness. Conclusion A wide variety of topics are being taught in U.S. medical schools under the umbrella of CAM. For the most part, the instruction appears to be founded on the assumption that unconventional therapies are effective, but little scientific evidence is offered. This approach is questionable, especially since mainstream medicine owes much of its success to a foundation of established scientific principles.

The current status of medical genetics instruction in U.S. and Canadian medical schools

Purpose Relatively little is known about how medical genetics is being taught in the undergraduate medical curriculum and whether educators concur regarding topical priority. This study sought to document the current state of medical genetics education in U.S. and Canadian accredited medical schools. Method In August 2004, surveys were sent from the Indiana University School of Medicine to 149 U.S. and Canadian medical genetics course directors or curricular deans. Returned surveys were collected through June 2005. Participants were asked about material covered, number of contact hours, year in which the course was offered, and what department sponsored the course. Data were collated according to instructional method and course content. Results The response rate was 75.2%. Most respondents (77%) taught medical genetics in the first year of medical school; only half (47%) reported that medical genetics was incorporated into the third and fourth years. About two thirds of respondents (62%) devoted 20 to 40 hours to medical genetics instruction, which was largely concerned with general concepts (86%) rather than practical application (11%). Forty-six percent of respondents reported teaching a stand-alone course versus 54% who integrated medical genetics into another course. Topics most commonly taught were cancer genetics (94.2%), multifactorial inheritance (91.3%), Mendelian disorders (90.3%), clinical cytogenetics (89.3%), and patterns of inheritance (87.4%). Conclusions The findings provide important baseline data relative to guidelines recently established by the Association of American Medical Colleges. Ultimately, improved genetics curricula will help train physicians who are knowledgeable and comfortable discussing and answering questions about genetics with their patients.

Apoptosis in regenerating and denervated, nonregenerating urodele forelimbs

Denervated limbs of larval salamanders fail to regenerate if amputated and, unlike adult limbs, undergo regression. The cellular basis of the tissue loss is poorly understood. We used TUNEL staining of larval axolotl limbs fixed and sectioned at intervals after bilateral amputation and unilateral denervation to investigate the role of apoptosis during normal limb regeneration and denervated limb regression. In the first week after amputation a small percentage of apoptotic cells was found in both innervated and denervated limbs. During the second week the apoptotic index remained low in the mitotically active mesenchymal cells of the regenerating limbs, but increased twofold in the nondividing, dedifferentiated cells of the regressing limbs. TUNEL‐positive cells resembling apoptotic bodies were restricted primarily to the dedifferentiated area beneath the wound epithelium, but were also present within the wound epithelium itself. Macrophages were identified immunohistochemically and were also found in increased numbers in distal areas of the denervated regressing limbs. The results suggest a role for apoptosis in the early phase of normal regeneration and indicate that denervated limb regression involves an increased rate of apoptosis and removal of apoptotic bodies by macrophages and the wound epithelium.

Calcitonin gene-related peptide potentiates substance P-induced plasma extravasation in the rat trachea

Antidromic stimulation of vagal sensory nerves is known to produce plasma extravasation in the rat trachea. This neurogenic inflammation is thought to be mediated by substance P or other tachykinins released from sensory nerve endings. We sought to determine whether calcitonin gene-related peptide (CGRP), which is also released from sensory nerve endings, can potentiate substance P-induced plasma extravasation in the rat trachea. To accomplish this, we measured the amounts of Evans blue dye extravasated into the trachea after intravenous injections of substance P alone and combined with CGRP. We found that when substance P and CGRP were injected together, the amount of plasma extravasation produced in the trachea was substantially greater than the amount produced when substance P was injected alone. This potentiation was critically dependent on the dosage of CGRP and was not observed when relatively high dosages were used. We also found that CGRP had a potent hypotensive effect and speculate that reduced blood pressure may account for the lack of potentiation observed at the higher CGRP dosages. Based on these findings, we conclude that CGRP can potentiate substance P-induced plasma extravasation in the rat trachea and may therefore play a role in modulating neurogenic inflammation of the airways.

Mechanism of platelet activating factor-induced vascular leakage in the rat trachea

Platelet activating factor (PAF) is a phospholipid mediator of inflammation and vascular leakage that may be important in the etiology of asthma. We and others have demonstrated that PAF causes vascular leakage in the rat trachea. In the present study, we attempted to determine how PAF mediates this effect. Vascular leakage was quantitated by measuring the amount of intravascular Evans blue dye extravasated into tracheal tissue. Intravenously administered PAF increased vascular leakage, although Lyso-PAF and Enantio-PAF had no effect. PAF-induced vascular leakage was inhibited in a dose-dependent fashion by the PAF receptor blocker WEB 2086. However, PAF-induced vascular leakage was not inhibited by blockade of cyclooxygenase/lipoxygenase, calmodulin, calcium channels, protein kinase C, histamine receptors, or by destruction of peptidergic sensory nerves. We conclude that PAF causes vascular leakage in the rat trachea by a stereospecific receptor-mediated mechanism that does not depend on arachidonic acid metabolites, calcium, protein kinase C, histamine, or peptidergic sensory nerves.

Differential effects of phosphoramidon and captopril on NK1 receptor-mediated plasma extravasation in the rat trachea.

We sought to confirm the identity of the tachykinin receptor subtype that mediates plasma extravasation in the rat trachea, and assess the respective contributions of neutral endopeptidase (NEP) and angiotensin-converting enzyme (ACE) in regulating this tachykinin-induced response. To achieve these aims, we determined the relative potencies of several natural tachykinins and receptor-selective synthetic agonists, both before and after inhibiting NEP with phosphoramidon and ACE with captopril. We also determined the effects of these peptidase inhibitors, and the NK-1 receptor antagonist L-703,606, on the plasma extravasation produced by capsaicin, which releases tachykinins endogenously from sensory nerve endings. We found that the rank order of potency for producing plasma extravasation in the rat trachea was NK-1 receptor agonist ([Sar9, Met(O2)11] SP)>substance P>neurokinin A> neurokinin B. The NK-2 ([Nle10]NKA (4–10)) and NK-3 ([MePhe7]NKB) receptor agonists were without effect. We observed no change in the relative potencies of these peptides after giving rats phosphoramidon or captopril, which suggests that the different peptide potencies are not simply the consequence of different rates of enzymatic degradation. Nevertheless, the responses to substance P and neurokinin A were clearly potentiated in rats given phosphoramidon, indicating that NEP effectively degrades tachykininsin vivo. No significant potentiation was evident for any peptide in rats given captopril. Similarly, the plasma extravasation produced by capsaicin was potentiated in rats given phosphoramidon, but not in those given captopril. Pretreating rats with L-703,606 abolished the response to capsaicin. We conclude from these observations that NK-1 receptors mediate tachykinin-induced plasma extravasation in the rat trachea, and that NEP regulates this response with little or no contribution from ACE.

Effects of platelet-activating factor on vascular permeability and granulocyte recruitment in the rat trachea

Platelet-activating factor (PAF) is a phospholipid mediator known to produce several features of airway inflammation. We examined the effects of intravenous PAF on vascular permeability and granulocyte recruitment in the rat trachea. To assess vascular permeability, anesthetized rats were given injections of Evans blue dye (30 mg/kg, iv) and PAF (1–10µg/kg, iv), and then their tracheas were removed and assayed spectrophotometrically for dye content. We found that a PAF dosage of 6µg/kg increased the tracheal dye content 7-fold compared to controls. The amount of extravasated dye in the tracheas was significantly increased 1 min after PAF injection, was maximal at 5 min, and had returned to control levels by 10 min. To assess granulocyte recruitment, anesthetized rats were given an injection of PAF (6µg/kg, iv), and then their tracheas were removed and stained to reveal myeloperoxidase-containing neutrophils and eosinophils. We found that the number of neutrophils in the tracheal mucosa was increased 7-fold from controls 5 min after PAF injection, but was not significantly increased 6 h later. The number of eosinophils in the tracheal mucosa was not significantly increased from controls at any time after PAF injection. We conclude that intravenous PAF causes a rapid but transient increase in vascular permeability in the rat trachea, and that intravenous PAF also causes a rapid but transient recruitment of neutrophils into the tracheal mucosa without a similar effect on eosinophils.

Meta-analysis and review of learner performance and preference: virtual versus optical microscopy

Over nearly two decades, a wealth of literature describing the various capabilities, uses and adaptations of virtual microscopy (VM) has been published. Many studies have investigated the effects on and benefits to student learning of VM compared with optical microscopy (OM).

Is Reflective Ability Associated With Professionalism Lapses During Medical School

Purpose Recently, many have argued that learning to reflect on one’s experiences is a critical component of professional identity formation and of professionalism. However, little empirical evidence exists to support this claim. This study explored the association between reflective ability and professionalism lapses among medical students. Method The authors conducted a retrospective case–control study of all students who matriculated at Indiana University School of Medicine from 2001 to 2009. The case group (n = 70) included those students who had been cited for a professionalism lapse during medical school; the students in the control group (n = 230) were randomly selected from the students who had not been cited for a professionalism lapse. Students’ professionalism journal entries were scored using a validated rubric to assess reflective ability. Mean reflection scores were compared across groups using t tests, and logistic regression analysis was used to assess the relationship between reflective ability and professionalism lapses. Results Reflection scores for students in the case group (2.46 ± 1.05) were significantly lower than those for students in the control group (2.82 ± 0.83) (P = .01). A lower reflection score was associated with an increased likelihood that the student had been cited for a professionalism lapse (odds ratio = 1.56; P < .01). Conclusions This study revealed a significant relationship between reflective ability and professionalism, although further study is needed to draw any conclusions regarding causation. These findings provide quantitative evidence to support current anecdotal claims about the relationship between reflection and professionalism.

Impact of a competency-based curriculum on medical student advancement: a ten-year analysis.

Background: In 1999, the Indiana University School of Medicine implemented a new curriculum based on the attainment of core competencies beyond medical knowledge. Purpose: The objective was to document how the Student Promotions Committee (SPC) has adjudicated students’ competency-related deficiencies over the past decade. Methods: Using SPC records, the authors determined the frequency of competency-related deficiencies reported to the SPC over time, the nature of those deficiencies, and how the deficiencies were remediated. For the purposes of this study, traditional knowledge-related deficiencies like course failures were excluded from analysis. Results: From 1999 to 2009, 191 students (138 male, 53 female) were referred to the SPC for competency-related deficiencies in 8 performance domains involving communication, basic clinical skills, lifelong learning, self-awareness, social context, ethics, problem solving, and professionalism. By comparison, 1,090 students were referred to the SPC for knowledge-related deficiencies during this time. Collectively, the 191 students were cited for 317 separate competency-related deficiencies (M ± SD = 1.7 ± 1.3; range = 1–10). Of these 317 deficiencies, the most prevalent were in the competencies of professionalism (29.3%), basic clinical skills (28.4%), and self-awareness (17.7%). Each of the remaining competencies constituted less than 10% of the total. Successful remediation utilized 12 methods ranging from a simple warning letter to repeating the year under close monitoring. Remediation was unsuccessful for 17 students (8.9%) who were dismissed from medical school primarily due to unprofessional behaviors and poor self-awareness. Conclusions: Competency-related deficiencies can be identified and remediated in most cases, but deficiencies in professionalism and self-awareness are especially challenging.