Richard P. Vance

Pure nongestational choriocarcinoma of the ovary report of a case

The authors report a case of pure nongestational choriocarcinoma of the ovary (NGCO) in a prepubertal female patient and emphasize the electron microscopic and immunohistochemical findings. Pure NGCO accounts for 0.6% or less of all ovarian neoplasms. Distinction from gestational choriocarcinoma of the ovary (GCO) is important because of the worse prognosis of NGCO. No distinctive ultrastructural or immunohistochemical differences were found between NGCO and GCO. Cytogenetic studies may be indicated in future cases to investigate potential reasons for the difference in prognosis.

An unintentional irony: The autopsy in modern medicine and society

Autopsy rates continue to decline despite abundant evidence of the autopsys value. Such an extraordinary contradiction requires that we look beyond issues of education to consider our basic moral and political commitments; to consider, in other words, the kind of society in which we live, and the kind of people we are. In a heterogeneous culture, we should not be surprised to find that even our most basic obligations may be in conflict. This essay draws on social and ethical perspectives to examine a peculiar phenomenon: the reluctance of physicians to have autopsies performed on themselves or their family members. Such behavior reflects an unintentional irony, a conflict between our societal commitments to treat dead persons properly and our professional commitments to remain self-critical. The resources needed to resolve medicines unintentional irony are to be found in our traditional language of medicine as a moral praxis, an uncertain but honorable craft devoted to the care of those who suffer. Autopsies remain the best way to learn whether or not clinical judgments are made correctly. Therefore, the autopsy is not an option; it is a professional obligation. We simply cannot hope to maintain our professional integrity as long as we proclaim the value of autopsies for our patients, but deny for ourselves and our families the same privilege.

Recruitment of pathology residents: APC questionnaire results, 1987 and 1988

Our data show a persistent decline of US graduates entering pathology. Moreover, our data indicated that the NRMP provides only a small percentage of the total pathology slots ultimately filled. If the intentions of the 1988 cohort remain consistent, the predictions of Anderson et al concerning a shortage of community-hospital and private-laboratory pathologists seem to be well-founded. This evidence, coupled with the long-acknowledged shortage of academic pathologists, makes improved recruitment an imperative. Recent reports have described several potentially important recruitment tools. However, substantial change in recruitment needs to take place if significant shortages are to be avoided.

Why the Virtues are Not Another Approach to Medical Ethics: Reconceiving the Place of Ethics in Contemporary Medicine

Despite the persistence of some polemical critiques, the virtues seem to have secured a place in the horizon of moral philosophy and theology.1 Precisely what this place will be, however, is still contestable. It would appear that the dominant trend is toward including such topics as a component within a more comprehensive pluralistic ethical method. That is, the ethical method will be one in which there is a relatively independent need for rules, for an assessment of consequences, and for an appreciation of the need for narrative, character, and/or the virtues. This is the strategy that has been adopted by a wide variety of scholars, both in terms of theological ethical method (for example, [8], [45], [63]) and with more specific reference to medical ethics (for example, [2], [19]).

Cultural literacy of medical students

The acrimonious debate over multiculturalism in education has yet to affect directly medical educators [1, 2]. Our undergraduate university curricula, some charge, have been and still are little more than arenas for political indoctrination that discriminate in subtle but powerful ways along lines of race, class, and gender [1-5]. Political correctness has become a watchword for some and a code word for others [6, 7]. For multiculturalists, any expression of sentiment for the traditional curriculum, or for educational programs that teach Western cultural ideas, must be immediately exposed as ideological. For those who understand Western culture to be heterogeneous, self-critical, and tolerably selfcorrecting, multiculturalist attacks are thinly veiled versions of Marxist ideology. The politicization of education threatens, traditionalists argued, to balkanize our campuses and make intercultural, interracial dialogue all but impossible. Whether the current multiculturalism debates are a passing fad or not, no one can say. However, medical educators would do well to reflect on the implications of this debate for their tasks. Indeed, multiculturalism in the university is connected to cultural phenomena. Most physicians face, as we all know, an increasingly pluralistic patient population. Patients from varied cultural backgrounds create complex challenges to effective communication. How patients assess or value pain, suffering, disease, disability, and death depends on the substantive moral, political, and religious traditions of which they are a part. Hence, many problems

Metachronous intracranial neoplasms in an infant

Sir: In the July 1983 issue of this journal, Blewitt et al. reported a case of epithelioid sarcoma studied by means of enzyme histochemistry and immunohistochemistry in addition to light and electron microscopy. The authors affirm that this sarcoma ‘is composed of a single cell type, the myofibroblast’. Since Enzinger’s (1970) first description, the controversial histogenesis has not been clearly defined, but some authors have supported an histiocytic or fibro-histiocytic derivation of the neoplasm. The statement in the paper is based on negative results obtained when tumour cells were investigated for histiocytic markers and conversely on the positive results exhibited for actin. The latter test unfortunately cannot be considered very specific, since, quoting the authors, ‘it was impossible to absorb out staining by prior incubation of antiserum with actin’. Data derived from single case reports are not usually conclusive in the definition of the histogenesis of a neoplasm, even less if in conflict with the results obtained by other workers. We had the opportunity to study six cases of epithelioid sarcoma by means of enzyme histochemistry and immunohistochemistry, one case from our own Institute and five from the files of the Department of Soft Tissue Pathology of the AFIP, Washington. In our case the epithelioid sarcoma cells displayed strong enzymatic activity for acid phosphatase and non-specific esterase; immunoperoxidase staining was also observed when the cells were tested with anti-a-I-antichymotrypsin serum and with the monoclonal antibody anti-Leu M2. In five AFlP cases studied with anti-muramidase and anti carcinoembryonic antigen (CEA), three cases were positive for muramidase and four for CEA (a cross-reacting antigen with monocytes). Our data favour an histiocytic derivation or differentiation of this sarcoma, a view which conflicts with the myofibroblast origin suggested by Blewitt et al. (1983).

The cultural literacy of graduate management students

T he acrimonious debate over multiculturalism in education has not yet begun to directly affect graduate business educators. Our undergraduate university curricula, some charge, have been and still are little more than arenas for political indoctrination that discriminate in subtle but powerful ways along lines of race, class, and gender (see Ravitch 1990, Searle 1990, Sullivan 1990, Hacker 1990, and Stanfield 1985). Political correctness has become a watchword for some, a code word for others. For multiculturalists, any expression of sentiment for the traditional curriculum, or for educational programs that teach Western cultural ideas, must be immediately exposed as ideological. For those who see Western culture and politics as heterogeneous, self-critical, and tolerably self-correcting, multiculturalist attacks are thinly veiled versions of Marxist ideology. Traditionalists argue that the politicization of education threatens to balkanize our campuses and make intercultural, interracial dialogue all but impossible. Whether or not the current multiculturalism debates are a passing fad, management educators would do well to reflect on the implications of this debate for their tasks. Indeed, multiculturalism in the university is connected to cultural phenomena. As we all know, most managers face pluralistic customer and employee populations. Customers and employees from varied cultural backgrounds create complex challenges to effective communication--particularly in todays global economy. Competitiveness often depends on an adequate understanding of cultural value differences. As Philip West has argued (1989), Pacific Rim competitors know even more about American culture than do American businesspeople. This knowledge provides considerable advantage in predicting how Americans will think and behave. Despite the growing social and political tensions facing U.S. business, we know of no empirical research focusing on the broad range of cultural knowledge management students need to respond to the social environment. E.D. Hirschs cultural literacy project (1983, 1987) has called our attention to the serious lack of cultural knowledge among U.S. students. Hirsch and his collaborators used current general circulation newspapers, books, and magazines as their sources. They selected information items that writers did not define, because these items are assumed to be part of the common knowledge readers share with the writer. Consequently, the level of knowledge assumed by Hirsch is far less than that needed for an adequate understanding of Western culture, much less non-Western cultures. The cultural literacy project aimed to define minimal functional literacy for our current social and cultural environment and selected cultural literacy items empirically--on the basis of contemporary use. Hirschs efforts have been aimed at primary education. Only one published report has assessed cultural literacy among professional students. In 1988, Charles King reported that a class of fourth-year medical students at the University of Kansas College of Health Sciences correctly identified only 30.7 percent of 100 basic cultural literacy items. Our study presents briefly the resuits of an expanded and more detailed version

Transfusion medicine: law, ethics, and profession

To the Editor: With the emerging recognition of the vital clinical consultancy role played by the transfusion medicine specialist, important ethical issues are beginning to be addressed.’.* Yet medical ethics is both an extremely important and a persistently confusing field. It is confusing not only because of our social and moral pluralism, but also the heterogeneous methods that modem ethicists use.3 Moreover, the extent to which medical ethicists have been critical of modern medicine may come as a surprise to many physicians. Some ethicists have argued that the very notion of profession is dangerous because it tempts physicians to think that they have some special powers of moral judgment. Unfortunately, ethicists seldom notice the extraordinary diversity of opinion found within their own ranks. Indeed, how can one construct a coherent notion of ethics when the basic constitutive concepts-rights, obligations, persons, etc.-remain confused or confusing? Consequently, many of the most controversial issues in medical ethics are now controlled not by ethical discussions, but by legal debates. Of course, legal considerations do not per se exclude ethical inquiry. Yet, as Dworkin has clearly shown, legal reasoning is far more broad-reaching than the typical ethical a n a l y ~ i s . ~ Similarly, while legal determinations do not exempt physicians from dealing with these difficult matters, they do preempt professional judgment and deliberation. Consider, for example, informed consent. Even though ethicists and physicians have discussed informed consent exhaustively, almost all the important informed-consent issues have been decided in legal circles, either through court decisiom or through legislation.’,2 Similarly, confidentiality issues have been defined largely by legal regulations or proceedings.‘.2 In contrast to modern legal and philosophical ethics, traditional medical ethics insisted that medical practice involved knowledge, experience, and ~ i r t u e . ~ Good medical technique involved knowledge of general medical principles, experience in applying them, and a commitment to the best interests of patients. Therefore, ethics in medicine traditionally focused on the sort of people who practice it, the qualities that make good physicians good, and the commitments that physicians make to their patients. Virtues in medicine are acquired through experience-by watching and imitating especially good practitioners while they work. Competence is the most basic of these virtues. It is, most simply, the ability to apply general principles of knowledge to particular situations. Other historical virtues refer to the way in which competent physicians ought to practice their craft. Diligence describes the persistence with which we attempt to solve difficult medical problems. Trustworthiness expresses the inviolable commitment to patient welfare. Finally, prudence (i.e., practical wisdom, or phronesis) ties all the virtues together and enjoins good physicians to do their job consistently and wisely. By focusing on these virtues, however, we reach a rather surprising conclusion. All those aspects of medical practice that protect us from charges of negligence in our courts-our professional regulations, the AABB standards, all our quality control and quality assessment programs-are really the most available and important ethical aspects of our practices. Therefore, transfusion medicine ethics should he concerned primarily with our definitions of competent, diligent, and prudent practice. If this is right, such problems as clerical errors leading to transfusion reactions are important primarily because of our ethical commitments to patient care and not just because of any legal consequences. Perhaps it is hard for us to recognize that such aspects of technical skill have moral dimensions, because technical excellence is such an everyday concern. Yet ethics is not merely concerned with rare, emotionally wrenching dilemmas. Medical ethics has to do, much more importantly, with the consistent and predictable practice of good medicine. RICHARD P. VANCE, MD Department of Pathology The Bowman Gray School of Medicine Wake Forest University Winston-Salem, NC 27103