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ABOUT THE COVER: The School of Medicine—the first school established by New York Medical College—owes its founding in 1860 to the vision of a group of civic leaders in New York City who believed that medicine should be practiced with greater sensitivity to patients. The cover represents the growth that has been achieved since 1860. It's a sketch of the Tree of Hippocrates whose roots have a long standing history with New York Medical College. The pictures, representing the leaves of the tree, are of students and faculty currently at New York Medical College. – Jordan Whatley, Ramsey Saba, Anna Djougarian
EDITORS IN CHIEF Linda DeMello Navid Shams Gavin Stern SENIOR GRAPHIC DESIGNER Allison Navis
MANAGING EDITORS Amin Esfahani Michael Rahimi WEB COMMUNICATIONS Kevin Cummings
SENIOR WEBMASTER Calley Levine
EXECUTIVE FACULTY ADVISOR Gladys Ayala, MD EDITORIAL BOARD Gladys Ayala, MD Diana Cunningham, MLS Kenneth Lerea, PhD Stephen Moshman, MD Padmini Murthy, MD Ellior Perla, MD Susan Rachlin, MD Sansar Sharma, PhD
Christine Capone Edward Hurley Sean Kivlehan Jenny Lam Annabelle Teng Dennis Toy
Linda DeMello Navid Shams Gavin Stern
Commentary Loren Francis Janet Nguyen David Maerz Amy Reed Vivek Rajasekhar Yiyi Liu Roopa Chari Matthew Duda
International Medicine Stuart Mackenzie Yin Tong Padraic Gerety Justen Elbayar
Research Humera Ahmed Jonathan Drake Meaghan Roche
Poetry & Fiction Marissa Friedman Danielle Masor Alireza Force Audrey Uong
Community Health Chris Ours Sarah Pozniak Maximilian Klein Joshua Davis
ART EDITORS Anna Djougarian Jordan Whatley Ramsey Saba
WEB DESIGN Jordan Whatley Ramsey Saba
Quill & Scope is an annual NYMC student publication dedicated to promoting awareness of the personal, social, economic, and ethical issues confronting the modern physician. It was founded in 2008 by medical students Christine Capone and Sean Kivlehan. The articles selected for publication have been chosen for their literary or artistic merit. They do not necessarily represent the opinions or views of the editors, faculty, or New York Medical College. All rights reserved. No part of this publication may be reproduced, stored in electronic format, or transmitted in any form without the express permission of New York Medical College.
May 2011 Dear Colleagues: This academic year New York Medial College marks its 151st birthday. If my Latin is correct this year is our sesquicentennial plus unum. A number of challenges face medical education as we go into the 21st century. The criticism of our profession is not about the science or technology of modern medicine but about its humanistic role. In A Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care Kenneth Ludmerer worried about medicine fulfilling its social contract as a profession. Abraham Flexner had anticipated this in 1925: Scientific medicine in America – young, vigorous and positivistic – is today sadly deficient in cultural and philosophic background. In 1927 the legendary Francis W. Peabody, first chief resident in medicine at Harvard's Peter Bent Brigham Hospital, added to the discussion: The most common criticism made at present by older practitioners is that young graduates have been taught a great deal about the mechanism of disease, but very little about the practice of medicine – or to put it more bluntly, they are too "scientific" and do not know how to take care of patients… One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is caring for the patient. This continuing concern raises the question of the place of the humanities in medical education. The National Endowment for the Humanities defines them as: … language, both modern and classical; linguistics; literature; history, jurisprudence; philosophy, archaeology, comparative religion, ethics, history, criticism and theory of the arts, those aspects of social sciences which have humanistic content and employ humanistic methods. The humanities, the academic disciplines that study the human condition, can and should play an important role in medical education. I congratulate Navid Shams & Linda DeMello, Editors-in-Chief, the editorial board and all the talented students who have contributed to this 4th edition of Quill & Scope. Your efforts are a reminder to all of us of the need to continue developing the art as well as the science of medicine.
Ralph A. O'Connell, M.D. Provost and Dean, School of Medicine
It is my honor to present to you the fourth annual issue of Quill & Scope, the New York Medical College student medical journal. With all the pressures of medical school—the mastery of tremendous amounts of knowledge, the meeting of responsibilities to family and fellow students, the demands of lab, classroom and clerkship—it's a wonder that students can find the time to eat and sleep, much less produce a literary and artistic compendium such as this one. Yet I hold the firm belief that our students—and in fact, many physicians I know, some of whom number among our faculty and alumni—have exceptional talents that go beyond science and medicine. It seems that the fundamental requirements of a physician— intelligence, compassion, and a desire to heal—often find their way into artistic expression. In these pages you will see evidence of the creativity and natural talent that can be found among our students. Also, for the first time, the editors have included contributions from students at other institutions as well. The results are quite gratifying. You will read essays, commentary, fiction and poetry, and you will see visual artistry as well. May this anthology be an inspiration to the entire community, especially to those who may find in its pages the seed of an idea for their own expression, and will be encouraged to share it with the world. Sincerely,
Karl P. Adler, M.D. President and Chief Executive Officer
Foreward to Quill & Scope, Volume IV I am honored to write a note of introduction for this issue of Quill & Scope. Herein, medical students communicate beautifully about their experiences as physicians in training. They have written reviews, poetry, commentaries, essays, clinical experiences, and scientific papers, and they have presented artwork that speaks thousands of words. I am proud of the work products that are published here. I acknowledge the creative efforts of these students, and wish them great success in the future. Navid Shams and Linda DeMello deserve congratulations for their work as editors of this volume. As well, thanks to Faculty Executive Advisor, Dr. Gladys Ayala. This year, the leadership of this publication decided to invite contributions from students beyond New York Medical College. As such, Quill & Scope becomes a publication that transcends local geography and has the potential to become a publication that is national or even an international in scope. The medical humanities are important for the teaching and learning of medicine. We need the humanities to help us reflect, to create a legacy of how medicine is practiced today, and to create a vision for the medical practice of the future. The medical humanities in general, and the contents of this publication specifically, add to the richness of medicine, capture experiences that have moved us, and leave a legacy for those who follow. We speak about our successes and our failures, about our patients and our teachers, about our hopes and our fears, about what we learn when physicians become patients, about our relationships, about what it means to be a doctor. Thanks to all the students who have shared their work in this journal. Enjoy.
My very best,
Paul M. Wallach, MD Vice Dean for Medical Education
Growth, both professional and personal, is an integral part of medical school. Many of us have experiences that we will never forget and opportunities that we will forever cherish. We conquer obstacles we may never have imagined we would face, from the fears of our first dissection in gross anatomy, to the anxiety of the first time we placed our hands on patients, to the triumph of completing another round of grueling exams. Our lives can be hectic and overwhelming, but we always make time for what we are passionate about, including the arts, humanities, and medicine outside of the lecture hall. In four years of annual publication, Quill & Scope has also transformed itself, growing and changing each year, as we all do. This year, we accepted (amt) submissions, making this our largest issue yet. We opened our doors to the students of New York Medical College as well as students from (6 or "several") schools from across the country. We believe that every medical student should have an outlet to channel his or her insights, ideas, and talents. Within this issue, there are topics from (name some different article topics from the journal make this detailed!). Readers may also find an uncut edition of this journal at our website: http://www.nymc.edu/Clubs/quill_and_scope/index.htm, along with extras about our staff, the history of the journal, and previous editions. Through these works of art, literature, poetry, essays, research, and editorials, we hope our contributors' enthusiasm about medicine and the humanities shines through. Quill & Scope is distributed annually to students, faculty, alumni, deans, and the Board of Trustees. Our staff has expanded to over 30 students, along with our faculty review board of (amt). We are deeply grateful to everyone who participated in bringing this year's edition to fruition, for this publication would not be possible without them. We also thank you, dear reader, for listening to the impassioned voices of medical students from across the country.
Linda DeMello, Navid Shams, Gavin Stern Editors in Chief
CONVERSATION An Interview with Doctor Daniel Peters 1 Jin Packard An up, close and personal interview with Dr. Daniel Peters, retired surgeon, and the current Assistant Professor of Cell Biology and Gross Anatomy at NYMC with appointments in both the Medical School and the School of Health Sciences and Practices.
COMMENTARY A Nutty Approach to Disease Prevention 9 Amin Esfahani Tree nuts are healthy foods with a favourable macro- and micronutrient profile. They are low in saturated fats and high in mono- and polyunsaturated fatty acids. They are also good sources of vegetable protein, fiber, phytosterols, polyphenols, vitamins and minerals. Because of this healthy nutrient profile, it has been postulated that tree nuts may play a significant role in health maintenance and disease prevention. The purpose of this paper is 1) to provide a brief overview of the current scientific evidence on the role of tree nuts in prevention and management of diabetes and heart disease and 2) to outline some of the key challenges for recommending nuts as part of a healthy diet to patients with or at risk of diabetes or heart disease. The Not-so-Sweet Side of Sugars 15 Maximilian Klein Refined sugar is becoming highly scrutinized as a possible explanation for the explosion of diabetes and obesity related health problems in our nation. We are often told by the media that added sugar, high fructose corn syrup (HFCS) in particular, is bad for our health and we should minimize our consumption of it, but scientists and health care providers rarely take the time to explain why the added sugar is detrimental to our health. The research behind sugar metabolism has been well elucidated, and I propose in this article that it is the high level of fructose in the average diet, particularly from table sugar and HFCS, that contributes to many of our nation's pressing health concerns. This article represents my attempt to communicate the science from the research bench in such a way that a general audience can understand why fructose is particularly dangerous. It is my hope that with a better conceptual understanding of the science, individuals will be more willing to reduce the amount of added sugars in their diets. Medical Science and the Serials Crisis: Is Open Access a Viable Solution? Jim Shen This work provides an overview on open access publishing.
A Comparison of Music as a Therapy Before and After the 20th Century in America 21 Chu-En Lin This piece provides a historical overview of the use of music as a therapy in the Unites States, with an emphasis on the changes that have occurred over the past century.
Challenges in Stem Cell Therapy: Bench-To-Bedside 30 Varunkumar G. Pandey & Michael Karsy The article is a review of stem cell research and some of the challenges before the technology can become realizable patient therapy. We tried to make it a general review for individuals from various backgrounds. Hepatocellular Screening Guidelines and Bellevue's High Risk Population 34 Ramoncito David This report has been adapted from a previously published piece in "Clinical Correlations". The current screening modalities for hepatocellular carcinoma are described along with the guidelines for surveillance in at-risk populations. The sensitivity of accepted screening practices is challenged in the context of patients who are at high risk for developing early onset HCC. In particular, the subset of patients with long-standing chronic Hep B infection may benefit from revised screening criteria that include more patients who exhibit certain risk factors for this disease. The Economic Effects of Compulsory Medical Licensing 37 Vivek Rajasekhar Over the past several decades, the United States has witnessed a rise in the demand for medical care, while the supply of doctors providing that care has remained flat. This paper traces the cause of that shortage to the compulsory licensing of physicians and examines alternative to that policy.
COMMUNITY HEALTH Five Years and Counting 45 Mary Breige O' Donnell This paper highlights the vital role of La Casita de la Salud, New York Medical College's studentrun health clinic in East Harlem, as a resource to both the community and medical students. Social Causes of Obesity 47 Gregory Katz Two thirds of our country is overweight and a third is obese. Meanwhile, medical costs continue to rise, largely as a consequence of treating those with chronic disease. And our current medical system seems more focused on treating symptoms of diseases like diabetes, hypertension, and heart disease rather than their root causes. This paper examines the origins of these problems and attempts to determine the role of physicians in reversing these trends.
POETRY & FICTION Yaakov Liss - Mostly White Coat Jordan Teitelbaum - Two Diamantes Marissa Friedman - An Uninvited Visitor Marissa Friedman - Matters of the Heart Jordan Teitelbaum - Tried & Fried Anchit Mehrotra - Here Today, Here Tomorrow Charisse Chin - Sapphire Blew Harry Flaster - R.I.P. Little Tiny Tim
51 52 53 54 57 58 59 60
PERSPECTIVES Mohs Surgery: The Cutting Edge of Dermatalogy 67 Christine Shaver This article describes a technique in the dermatology field known as Mohs surgery. The procedure was created by a medical student, Frederic Mohs, back in the 1930's, yet is still considered a cutting edge treatment for removal of skin cancers. Mohs surgery highlights the interesting combination of skills from various medical fields that a dermatologist will use to result in a highly effective method of tumor excision while minimizing the extent of tissue removal. Private Interest, Ethics, and Sincere Medical Practice 69 Yousuf Sayeed Healthcare providers are held to high standards in society. They are venerated as saintly figures that always mean well, working solely for the benefit of their patients. Upon closer observation, it seems that this is not always the case. With the juxtaposing relationship between private interest and genuine healthcare, patients are beginning to realize that some healthcare providers are more concerned with generating profit rather than treating their patients. Through examining personal experiences, documented studies, and enlightening cases of unethical medical practice, it is evident that work must be done to restore the trust between patients and their healthcare provider. Scope of the Scope 73 Benjamin Cox To many of us the stethoscope is just a diagnostic tool. This essay puts a twist on this idea and demonstrates how a stethoscope can be used as a teaching instrument for sharing information about findings with patients and their families. Complications of PPROM: Preterm, Premature Reality of Medicine 75 Diana Kirschner Medical school is challenging on its own, but life takes a new turn when a parent is diagnosed with cancer. This work describes how coping with both medical school and a parent's illness can help train a more compassionate physician. The Modern Bloodletters 76 Charles Volk When doctors order blood tests to be drawn, the order goes out to a team of people who have made bloodletting the sole focus of their job. Who are these people who have trained to complete this one task? The author shares his experiences drawing blood and what it is like to be ancillary staff at a large medical center. Broken System 82 Holly Foote This touching piece describes a situation where a friend fell through the cracks of the healthcare system. At a Loss for Words: Language Choice in the Doctor's Office 84 Evan Schloss This piece is about language choice among bilingual populations (ie. code-switching and all the deliberations between people when they decide which language to use), and its effects on the doctorpatient relationship.
Informed Consent: A Cultural Dilemma 86 Emily Junck Obtaining informed consent is a process unique to Western medicine. Cultural differences are highlighted and conflict can arise when trying to explain consent to immigrant or ethnic patients. This essay describes an example case and provides suggestions of important points to include in the physician-patient discussion in order to improve understanding. A Polish Grandmother Andrei Kreutzberg A touching tribute to an amazing grandmother.
INTERNATIONAL MEDICINE Thoughts in a Disaster Sean Kivlehan This paper discusses Sean's experiences in Haiti during his psychiatry clerkship.
Writing in Afghanistan 94 Ali-Reza Force This paper represents an analysis of the way in which internet communication by a physician can impact a general audience. Attitudes in Psychiatry in Bangalore, India 98 Akshay Lohitsa An analysis of an international rotation in Bangalore, India where an American medical student was able to compare and contrast attitudes towards psychiatry and mental illness. Many third world countries boast cure rates comparable or better than the U.S. for schizophrenia and other psychiatric diseases, and it remains unclear why this would be. One possible reason of why this trend is occurring is provided.
ORIGINAL FINDINGS Olfactory cleft inflammation present in seasonal allergic rhinitis & intranasal steroids 103 Anita Sivam The purpose of this work was to determine the effect of mometasone furoate on olfactory loss in seasonal allergic rhinitis and to study its effect on inflammation in the olfactory region.
MEDICAL STUDENT RESEARCH FORUM Oral Presentation Winners Poster Presentation Winners
108 109
ART AND PHOTOGRAPHY Katrina Bernardo – A Gatsby Past Sabrina Perrino – Endless Winter Julie Grimes – Untitled Paul Janoian – Central Park Anna Djougarian – Kaleidoscope Anna Djougarian – Embrace Paul Janoian – Tappan Zee Bridge David Maerz – Day Off Calley Levine – Untitled Paul Janoian – Tarrytown Lake Ernest Yushvayev – Hiding Anna Djougarian – Comfort Anna Djougarian – Relentless Paul Janoian – Frozen Pond Paul Janoian – Sunshine Cottage Road Ernest Yushvayev – Waiting David Maerz – Opportunity Luke Selby – Rough Road Sabrina Perrino – Pole Pole (Slowly, slowly) - A State of Mind Alina Djougarian – Floating Away Alina Djougarian – Discovery Calley Levine – Untitled Calley Levine – Untitled Jeremy Shugar – Bottoms Up Paul Janoian – Tarrytown Lake
7 8 28 29 43 44 46 49 50 52 53 55 56 58 58 66 74 81 90 93 100 101 102 107 110
An Interview With Doctor Daniel Peters Jin Packard
The following is an excerpt taken from an interview with Doctor Daniel Peters, conducted by Jin Packard. The content presented here has been edited by Dr. Peters and the staff at the Quill & Scope (with permission). This interview can be accessed in its entirety at: http://www.freshwhitecoat.com/2011/01/interview-dr-daniel-peters.html
JP: Thank you so much for agreeing to this interview. To a person who's never met you, how would you describe yourself? DP: Out of your list of questions, I thought long and hard about this one the most. I tend not to describe myself, period. You know what? Just spend enough time with me and draw your own conclusions. My wife, to this day will say I'm one of the most stubborn people she's ever met. My colleagues and I have joked that I have a surgeon's personality. There is no such thing as a surgeon's personality. At a medical staff meeting in a hospital, surgeons are clearly outnumbered so they tend to stay quiet. You hear this internist or that pediatrician voice their opinions, well - you know what, she's got a surgeon's personality, he's got a surgeon's personality... One of the hardest things with organizing physicians, it's like everybody's a CEO. I have a raging sense of humor which I don't show around you guys, but I fully believe in the liberal use of sarcasm, irony, parody, analogy. It can be pretty funny in my house sometimes. It's probably my most common side, but in this environment, that's not the side you guys should be seeing. You know, so, it's just different. My guess is that you are passionate about religion, family, heritage, hunting, and task-outcomes. Plus you're a doctor. So I'd be surprised if you weren't a mean cook – am I right? I don't hunt. You don't? No actually, I take that back. I hunt very avidly - in Shoprite, in the A&P. Where, you know, you can stalk the meat in the case, and then go over and stalk some dairy products. But, there's no need to hunt. I've taken care of far too many hunting accidents. And there are very strict safety rules that need to be obeyed. Why do it, just because I can? But do you cook? Oh, yeah. My mother's Italian, my father's German and Danish, people look at me and say, "You look Italian, funny that you're not." I say, "Oh really? What do you mean, funny that I'm not?" They say, "But your name is Peters – did it get changed on Ellis Island?" Well as much as they might not believe it, I too have a mother. I used to help her cook because my older brother was out doing something and my younger brother was too young. So, I sort of inherited all the family recipes and have since made many of my own.
Jin Packard: Interview with Dr. Peters
When and why did you decide to go into medicine? It wasn't my first career choice. In 1969, we landed on the moon. Consider, I was in 5th grade in 1969 and graduated high school in '76. The Apollo program was over by the time I graduated from high school, and aerospace engineers were working at McDonald's and Burger King because they'd been laid off. I went into college with a very strong background in mathematics, but I realized at a young age that if I went into aerospace engineering, the future just wasn't there. The aerospace program didn't come back until the 80's. In my naïveté, I figured I'd find something where it's unlikely to be affected by external factors. People are always gonna need help, and I liked helping people, so [medicine] seemed like a natural fit. I remember being in the lobby of the Basic Science Building over here watching the first shuttle landing (1981), because they stopped class and actually televised it on the monitors in the room. By then, I was in med school. Then, what about surgery? Probably the 3rd year of med school. It just seemed to be a natural fit for me. And then I did my surgery rotation and said, "Naahh, this is bananas. This is not for me." And then I did my medicine rotation after surgery, and I finished that I said to myself, "I'm gonna be a surgeon." What everybody does is important. No man is an island. So you naturally select what fits your strengths, because that's what's gonna keep you going the longest, and then develop a circle of people you trust and work together to take care of people. Actually, in my 3rd year the thing I liked the most was Ob/Gyn. But I didn't think that it was the thing for me – I liked the OB but there wasn't enough surgery in the GYN to keep me happy. So I figured, depending on how I choose to practice, I can still have my hand in it and do surgery (I used to help on a lot of C-sections early in my practice). I don't regret making that decision. I tend to think that anybody could do what I did, but not everybody wants to. You're all intelligent people, any one of you guys could become a surgeon. All it takes is the commitment. Some people may have more natural skill than others, some may be smarter, but there is a broad range of individuals who have the ability, but not everyone has the commitment. Can you tell me about the best day you ever had in practice? It's not necessarily what you'd think it would be; because it was something that happened well after the fact. There was a Christmas Eve – more than several years ago – I got a call from a friend who's a gynecologist, and she said "I have a woman in my office who has an incarcerated femoral hernia." Christmas Eve is very important in my family. My wife runs the children's choir at our church, and that mass is at 5PM on Christmas Eve. If you don't get there by at 4, you don't get a seat because it's the mass of the year for people who don't normally show up. It was 10AM and I had already signed out. My answering service gave this gynecologist my home number, and I couldn't say no to this person. For a couple of reasons, not the least of which was that she had someone in her office who had an emergency condition and needed help. I was in a no win situation. I did not want to leave my wife alone with five children on a busy day and we were both justifiably upset. I told my wife I could get it done. The last thing I wanted to do was to go in and leave my family on a big holiday. I wanted to be with THEM! I really had no choice. I knew that if I handled it right, I could get everything done and still make it to Christmas Eve Mass with time to spare. I saw the patient at the GYN's office, then I drove the patient to the hospital in my own car, took her straight up to the O.R., did the hernia repair under local anesthesia, and got home with a half an hour to spare. I didn't rush the operation and I didn't rush the patient – I rushed the logistics of getting to and from thr O.R. That's not the memorable part. Because it would be too easy to blow off that situation – tell the answer2
Jin Packard: Interview with Dr. Peters
ing service to say that you are not there, or say that they couldn't get a hold of you, you know, something. What you have to realize is that everybody you come across has their own life story and YOU have the ability to affect it in either a positive or negative way. About a month later, I get a thank-you card from her kids. Their family picture was on the front, she must have had 10 kids, and the opening was, "Thank you for saving our mother." A pause. Then with a slight tightness in his voice: If I had turned that down, not taken care of that lady, I would have let down 12 people including the lady and her husband. Just the fact that they let me know, that it meant that much to them… The real point is that your most memorable day is rarely the day you would pick and possibly not even one that would stand out in your memory. Case in point, I retired from practice seven years ago. I got a call just the other day, during dinner, from the family of a former patient. Someone that I had consulted on but did not need surgery. The story was that, eight or so years ago, I had carried them through a rough time, a bunch of them were talking about it, about me, and they felt the need to call and say thank you and tell me how much it meant to them. What I was willing to "file away" as "just a consult, no trip to the O.R.," turned out to be a very important day in someone's life and I had a positive impact on it. But I would not know it for over eight years. We don't get to pick our best day, it picks us. So be careful, always be a caring professional, and don't become complacent or jaded. The worst day? There are too many of those to pick, not because you didn't do your best, but because your best was not enough. Did you ever think about doing something in a more challenging environment, like Doctors Without Borders or combat surgeries? I actually had given serious thought to not practicing in the U.S. just because, like I said, money was never a motivation for me. It was always more a matter of who needed my help the most. Because of the legal climate in this country, and a lot of other things, before we had kids I'd say to my wife, "Let's go to Africa, let's go to Southeast Asia, some place that would need my help." She'd counter with, "Well, what about going to Appalachia? What about going to an Indian reservation?" But I had actually looked into that kind of stuff. It's a decision I didn't mind making for myself, and my wife, being who she is, she would have been happy wherever we went, but once we started having kids, those no longer became possibilities. I've also thought over the years about Doctors Without Borders, but the problem with that is that economically, it became extremely unfeasible. You had to provide your own airfare and make a certain time commitment. Being in solo private practice, if you take off more than a week at a time, people forget who you are. I was in a solo, private practice for the extent of my surgical career. So if I had left for a month, I would have left the hospital where I worked without coverage, I would have left my patients without coverage, and by the time I got back, I would have had to re-build my practice. How about educating health staff in a developing country? They often don't have big universities or people who can come down and teach so there's not only a resource deficit, but severe training deficit as well. The prospect has always intrigued me, it's always been more a matter of – and I actually looked into that when I first made the decision to retire – nobody returned my calls. 3
Jin Packard: Interview with Dr. Peters
Case in point: How am I sitting here today? If it wasn't for Dr. Pravetz, if I hadn't graduated from NYMC, if it wasn't the right thing at the right time… I'm sure these humanitarian organizations get inundated with calls. Unless someone ushers you through the maze, even if you offer services for free, they don't know you. Let's switch gears and talk hobbies. Why are you into guns, and does that tie into the surgeon's personality? Most of my hobbies are centered around precision. My father was a machinist. He had an old Indian motorcycle that needed a fuel pump, so he took a block of aluminum and carved it out. I grew up in that kind of environment, working on cars, fixing things. So, precision has always fascinated me. My first love/hobby was always cars, motorcycles, but working on them, you know, just became more difficult as things became more electronic. And guns have always fascinated me. It was something I never really had time for. So when I finally retired, I had the time to devote to such a serious thing. The ability to hit a target – like that bulls eye I showed you, at 100 yards, open-sight – the ability to do that has always fascinated me. My hand-eye coordination has always been good. My wife and I went on a cruise before we had children, I was a first-year surgical resident and on the ship, they had skeet shooting. I was 26 or 27 years old. I had never fired a shotgun off a moving ship before, or for that matter, I had never even picked up a shotgun in my life. I managed to hit 9 out of 10 clays. Do you have a favorite gun? You know, I'm more fascinated with handguns than rifles, which is not something I expected. They're harder to shoot well, so it's more of a challenge. Some students know about your wrist injury from a motorcycle accident. Could you tell us what you went through while healing, evaluating yourself, and coming to a decision to retire from surgical practice? Any sage advice? Nope, never been in a motorcycle accident! I've heard people say you had a lawnmower accident, slipped and fell, etc… Let's set the record straight. Alright. It was a winter day, Wednesday January 10th, 2001. Early in the morning, and I was rushing to get to the hospital for a surgery meeting. On my driveway between my car and the RV there was one patch of ice, I ran in to get something in the house, slipped, fell, and I felt my wrist go. I'm lying on the ice, and I knew I just broke my [left] wrist. I realized that my bone was about to come through the skin, so I partially reset it myself in the driveway. I got up, went in the house, I yelled up the stairs, "I think I need help." And everybody came running because I never ask for help. I told my wife, very matter-of-factly, "I broke my wrist." That's the German side I guess, emotions and pains just don't process the same way in German brains. My friend, who's a physician at the hospital, told me I did myself a favor by partially resetting it. I got my hand in a cast, did my rounds, did a couple of discharges, and went home. It was a comminuted fracture that healed at an odd angle. I know there was some neuropraxia because my hand was numb for a few days afterwards. Distal ulnar nerve injury. It hurt like hell, but I knew it was a different kind of pain. When he finally took the cast off, even the slightest wind blowing across the hair on the back of my hand was extremely painful. And I just ignored it. I was out of work for 3 months. 4
Jin Packard: Interview with Dr. Peters
It hurts to this day, right now. I didn't sleep last night. So if I look tired, that's why. Then what I noticed over the next 3 years, because I didn't retire until 2004, was that I was not happy with my level of skill. Initially, my hand would just cramp after holding forceps all day. The nurse might ask, are you ok, and I'd make excuses like, "Oh the glove's too tight, you know." By the end, in 2004, I was sending cases out. I cut myself in the OR a few times because I only have partial sensation in [my left] hand. I saw several hand specialists. They all said pretty much the same thing, "You already represent a danger to yourself and you should retire before you cause anybody else any problems. Now that you've documented it, if you don't tell your patients then you haven't gotten informed consent and you're gonna get screwed. Don't wait till someone tells you that you need to retire." That was the 2nd time in my life I had heard that. The first time was when I finished my residency, and I said to a surgeon I trusted, "Do you become dangerous, or are people just dangerous when they leave residency?" He said, "That's a good question, but let me tell you this. Regardless of what your skill level is now, you're gonna start doing less and less in variety because of external factors that whittle down what you do. When you get to the point where you know you're uncomfortable, retire before somebody tells you that you need to." Having heard it twice in my life, I decided it was time to bite the bullet and just do it. Was it tough going home, the first week or two? Or did it hit you later? You know, life is funny. It's hard to put into words. It was something I had been thinking about for 3 years, because I was getting worse, gradually. Once I sought help for it, I knew that was the end of the story. It was 2004 when I called up Dr. Pravetz to start working here, and I said "I just worked 24/7 for 20 years, I'm taking a month off." I went to Florida with my family for about 2 weeks, which I think was the first time I ever took a 2-week vacation. I've always been comfortable with the thought of closing my practice, only because I accepted the fact that it was time. You know what, things happen, and frequently we're not in control of the things that happen to us. There is an old expression," don't judge a surgeon by how fast they are, judge them by how they handle their complications." This was me, exercising my best judgement, handling a complication. Back to what you said about disclosure. There was a recent discussion, past month or two, about surgeons having to disclose their sleep status their patients, in order to get fully informed consent. Did you hear about that? Not only did I hear about it, I emailed the doctor at NBC about what disservice he did to the profession. He and I had an email battle on New Year's Day about the fact that I thought he accused surgeons of being mercenaries. The news bit that he did, you had this anchorman who is a complete ass, saying "Well, doctors aren't gonna want to disclose because they'll lose money." And the doctor says to him, "Good point, not only the doctors but the hospitals too." I ripped him as much of a new one as I could. Surgeons are trained for this, there is such a thing as a combat mentality. You know, you're sort of programmed for the long haul to keep your skills as sharp as you can. There are days where I've operated with nothing more than cat naps, and nobody ever suffered as a result, no one was ever at risk. If I felt they were, I would not have performed the surgery. Take this for what it's worth: I did that with no problem. But as soon as my hand started cramping, I retired. The problem is, you can't legislate common sense. The expression we had in surgery was, you can teach a monkey to operate, but you can't teach it to think. Thinking is probably the most important commodity you'll have. 5
Jin Packard: Interview with Dr. Peters
When it comes to someone asking how many hours of sleep did you have, that's irrelevant. How about asking, did you have a fight with your wife last night? Did you get angry with someone in your car today? It's an extremely complex and important issue that can't be legislated. Getting back to an earlier point, you really need to have faith and trust in the people you work with, to be able to say, "I'm too tired to work, can you cover for me?" So, in the end, regardless of what you are doing or talking about, you should be your biggest critic. Never stop thinking, use your common sense. Don't wait for someone to tell you what needs to be done, "Just do it!" Always be honest with yourself, your loved ones, your colleagues, and your patients. Be kind and compassionate, even when you are so tired and worn out that you barely have enough energy to power your next heart beat. When you find yourself saying that you really don't have enough time to do something is really the moment you need to slow down and make the time to do it. Never turn away someone who needs your help. Someday that person will be you. If delayed gratification is all you get, accept it, save it for a rainy day, and move on, don't always look for a pat on the back. That's not what we are here for. And lastly, don't look at medical school as the end. It is really just the beginning. You have a long way to go; look at me. Sure, when I was in your position, I figured residency, family, private practice… but I really had no clue what adventures were about to come my way. Academic medicine? Never. Teaching?! Time goes by all too quickly, and you only get one chance. To borrow a line from one of my favorite philosophers, Harley Davidson, "it's about the ride, not the destination." Enjoy the ride folks, be the best you can be, and don't look back. In conclusion, as if I haven't bored you with enough truisms and five cent psychology, let me share one last story. It was at the final dinner, the "last supper," so to speak, of my surgery residency. It was the farewell to the graduating chief residents and the welcome to the incoming interns. During the cocktail hour I was engaged in conversation with one particular surgeon and mentor I had trained under. We had a mixed history, not liking each other for the first few years of my training. I endured and, right or wrong, voiced my complaints at times. But I made a decision to "just do it." My first day of my fourth year, I was the senior resident on his team. I showed up for AM rounds, bright eyed and bushy tailed, 6:30am, only to be greeted by, "so, I got you?" Over the next four months I worked hard, complained hard, but never lost sight of who I was and never tried to be something or someone I was not. By the end of the four months, I got an apology. "I had you wrong all of these years, I'm sorry." At the beginning of this interview, you asked me how I describe myself and I said," I don't. Spend enough time with me, or anyone else for that matter, and draw your own conclusions." Don't be so quick to judge people, accept them for what they are, know their limitations as well as your own. Give them a chance and focus on the positives. He and I stood there, in an awkward sort of goodbye moment and he asked me if I thought I was ready to go it alone. I don't think he was surprised by my answer, but it might not be what you would think. I responded, in a very calm and matter-of-fact manner, "first, you're never alone," to which he grinned. Then, "I know that I know what I know, and that I can do what I know how to do. But, what really worries me, is how much is out there that I don't even know enough to worry about. How do I do the things that I don't know? It's like finding out not just that you didn't know something, but worse, that you didn't even know that it was something you should have anticipated or even knew how to anticipate." His grin widened, then, a simple response, "you're never alone, and you're ready." Remember, you're never alone. Doctor Daniel Peters is a New York Medical College graduate, and is currently an Assistant Professor of Cell Biology and Gross Anatomy at NYMC with appointments in both the Medical School and the School of Health Sciences and Practices. He is a compassionate and dedicated teacher with an infectious enthusiasm for medicine. We are all indebted to Dr. Peters as a mentor for his professional and patient-centric approach to clinical practice and the basic sciences, which we all stand to learn from as physicians in training. The Quill & Scope extends its most sincere appreciation to Dr. Peters for sharing his story and insight with us. 6
Katrina Bernardo A Gatsby Past
Sabrina, Perrino The Endless Winter La Jolla, California, January 2008
A Nutty Approach to Disease Prevention Amin Esfahani
INTRODUCTION The prevalence of type 2 diabetes has increased dramatically over the past three decades and current estimates predict a further 50% increase worldwide by the year 2030.1 Diabetes is associated with numerous micro- and macrovascular complications including, blindness, kidney failure and limb amputation.2 Furthermore, the presence of diabetes increases the risk of cardiovascular disease (CVD) two to five fold, especially for women.3,4 Alongside the current global obesity epidemic5,6, the increase in prevalence of diabetes is going to further strain the already-overburdened healthcare system of United States and potentially prove catastrophic for nations with limited resources. While there is no available cure for diabetes, studies have shown that primary prevention can be attained through modifications to diet and lifestyle. Unfortunately, with mass media as a vehicle, the general public, for the most part, has been exposed to "fad diets" and "magic bullets" that not only lead to no metabolic benefits but may in fact, in some circumstances, prove harmful by depriving the body of many essential nutrients. These "quick-to-fix" approaches have drawn the attention away from the traditional staples of human diet such as whole grains, fruit, green leafy vegetable, seeds and nuts which have been linked by scientific evidence to a reduced risk of a number of chronic diseases including diabetes and CVD.7 The purpose of this paper is to 1) provide a brief overview of the current evidence linking tree nuts to the risk of diabetes and heart disease and 2) to outline some of the key challenges for recommending nuts as part of a healthy diet to patients with or at risk of diabetes or heart disease. TREE NUTS The term, "nut", encompasses a wide range of seeds that based strictly on botanical definitions are not actually nuts. While hazelnuts meet the botanical definition, almonds, pistachios and walnuts which are all seeds of drupe fruits, do not. Despite this inconsistency, the aforementioned seeds, along with hazelnuts, pine nuts, pecans, cashews, Brazils, and macadamias have been clustered together under the collective term, "tree nuts" by the International Tree Nut Council.8
...tree nuts as a whole are healthy foods because of favorable fatty acid profile… as well as being good sources of protein, fiber, phytosterols, polyphenols, vitamins and minerals."
Until recently, in Western societies, nuts were considered to be high fat and as such, contraindicated in therapeutic diets. However, scientific evidence in the past decade has changed this negative perception. Despite small variations in their micro- and macronutrient profiles, tree nuts as a whole are healthy foods because of their favorable fatty acid profile (low in saturated fats and high in mono- and polyunsaturated fats [MUFAs and PUFAs respectively]). They are also low in available carbohydrate content, as well as being good sources of vegetable protein, fiber, phytosterols, polyphenols, vitamins and minerals. Table 1 summarizes the micro- and macronutrient profile of some commonly consumed nuts. Nuts may therefore be a useful component of a dietary strategy aimed improving the risk factors of diabetes and CVD. 9
Amin Esfahani: Tree Nuts & Disease Prevention
Table 1 Nutritional profile of commonly consumed, whole, natural nuts (per ounce)
19 halves
14 halves
Protein, g
Carbohydrates, by difference, g
Saturated fatty acids, g
Monounsaturated fatty acids, g
75 (8)
31 (3)
28 (2)
1.1 (6)
1.7 (10)
0.7 (4)
1.2 (6)
0.8 (4)
0 (0)
5 (0)
0 (0)
3 (0)
1 (0)
200 (6)
160 (4)
116 (4)
295 (9)
125 (4)
76 (20)
74 (20)
34 (8)
34 (8)
45 (10)
137 (15)
139 (15)
79 (8)
137 (15)
98 (10)
0.9 (6)
1.6 (10)
1.3 (8)
0.6 (4)
0.9 (6)
0.7 (30)
0.2 (10)
1.3 (60)
0.4 (20)
1.0 (50)
0.2 (15)
0.6 (30)
0.3 (15)
0.4 (20)
0.5 (25)
Selenium, mcg
0.7 (0)
3.3 (4)
1.1 (2)
2.6 (4)
1.4 (2)
0.06 (4)
0.06 (4)
0.19 (10)
0.24 (15)
0.1 (6)
0.3 (15)
0.06 (4)
0.04 (2)
0.05 (2)
0.04 (2)
1.0 (4)
0.4 (2)
0.3 (2)
0.4 (2)
0.3 (2)
Vitamin B-6, g
0.04 (2)
0.07 (4)
0.06 (2)
0.36 (20)
0.15 (8)
Folate, total, g
14 (4)
20 (4)
6 (2)
14 (4)
28 (6)
Number of Kernels per Ounce Total Energy, kcal
Fiber, total dietary, g Total Lipids
Polyunsaturated fatty acids, g Cholesterol Minerals, mg* (% DV)
Vitamins, mg* (% DV)
Vitamin E (total tocopherols)
Modified from tables prepared by the International Tree Nut Council8, accessed on January 15, 2011. The values are for unsalted, unroasted nuts (except for cashews and pistachios which were dry roasted)*mg (miligram); %DV = % daily value
Amin Esfahani: Tree Nuts & Disease Prevention
NUTS & HEART DISEASE The protective effect of nuts in relation to the risk of CVD has been demonstrated in a number of cohort studies. A pooled-analysis of the results from four major cohorts9-12 (sample size of over 170,000 individuals) demonstrated that in comparison to little or no nut consumption, the highest intake group for nut consumption (4 or more servings per week) had a statistically significant reduction of approximately 35% in the risk of developing coronary heart disease (CHD).13 Clinical interventions have supported the findings of the aforementioned cohort studies and have shed light on potential mechanisms of action. The dietary interventional studies have shown that nut consumption can reduce the risk of heart disease by improving serum lipid profile, endothelial function, and blood pressure, in addition to lowering oxidative stress, and inflammation.14 Two systematic reviews showed that the intake of 1.5 to 3.5 ounces of nuts, 5 or more times per week, can reduce LDLcholesterol (LDL-C) 3-19% in comparison to Western or lower fat diets.15,16 Meta-analyses of clinical trials involving almonds or walnuts have demonstrated that both are effective in significantly lowering Total-C and LDL-C.17,18 Furthermore, despite the absence of a pooled analysis, the results from 4 clinical trials show that the intake of 2 to 3.5 ounces (approximately 50 kernels/oz) of pistachios per day increased serum HDL-C levels.19-22 The strength of the evidence has prompted the United States Food and Drug Agency (USFDA) to approve a qualified health claim for nuts and serum cholesterol reduction. NUTS AND TYPE 2 DIABETES While the current evidence demonstrates that the frequent intake of nuts is protective against heart disease, the effect of nuts on the risk of developing type 2 diabetes is not as conclusive. Of the two cohort studies on this topic, one showed a 27% reduction in the relative risk of developing diabetes in individuals who consumed nuts five or more times per week compared with those who rarely or never ate nuts23, while the other did not show a link between nut/peanut intake and the risk of type 2 diabetes.24 Despite the inconsistency in the epidemiological evidence, there are a number of plausible mechanisms that suggest a potential protective effect for nuts against the risk of type 2 diabetes. The first relates to the low available carbohydrate content of nuts (Table 1). Adequate glycemic control is crucial for prevention and management of type 2 diabetes.25 A number of acute studies have shown that almonds are capable of improving post-meal glyciemic control through low post-meal glucose and insulin responses.26, 27 Both of these parameters have been linked to improved insulin sensitivity, prevention of hyperinsulinemia and overall, improved glycemic control in patients with type 2 diabetes.28 However, despite plausible evidence it is not clear if improvements in acute glycemia are indicative of long term changes in insulin resistance. Moreover, the limited number of long-term clinical trials in this area have been inconclusive, with some showing benefits in fasting insulin and glucose and others showing no effect.29 Worth noting is that no study to date has shown improvements in HbA1c (established marker of long-term glycemic control). However, these long-term term trials have had a number of limitations, which have been outlined in other publications.14 Several other lesser studied mechanisms for reducing the risk of diabetes include: reduction in inflammation30, which has been linked to the risk of diabetes and heart disease31, or improvement in glycemic control through displacement of carbohydrates with MUFAs (high in nuts)32. Finally, a recent meta-analysis of the prospective studies showed that a 100mg per day increase in dietary magnesium intake reduced the risk of developing diabetes by 14%.33 Nuts are good sources of magnesium (Table 1).
Amin Esfahani: Tree Nuts & Disease Prevention
The current body of scientific research demonstrates that nuts may have a modest beneficial effect on serum lipids and markers of glycemia in subjects with type 2 diabetes.14, 34 Therefore, the moderate use of nuts as a part of a healthy diet and in very high risk populations alongside medication may help better manage diabetes. Furthermore, while the assessment of long-term effect of nuts in prevention and management of diabetes is required, due to the potentially favourable effects on glycemia and inflammation intake of nuts may benefit those at risk of developing diabetes. KEY CHALLENGES There are a number of concerns associated with recommending the intake of nuts to high risk populations (e.g. patients with diabetes). Food allergy is one of these concerns. Currently, 0.4% of the US population are allergic to tree nuts (most prevalent allergies are those to walnuts, cashews and almonds).35 This type of allergy is a major contributor to the overall 100-200 annual deaths that result from food-induced anaphylaxis.36 There are also several important research areas that need to be addressed when assessing the impact of nuts on health outcomes. One is the aforementioned, long term effect on markers of diabetes. Another has to do with the fact that despite similarities, there are still differences in micro- and macronutrient profiles of specific nuts, which may lead to different metabolic effects. Therefore, more trials need to be conducted using the "lesser-studied" tree nuts in order to determine whether they generate comparable metabolic benefits to almonds, walnuts and pistachios (the "more studied" tree nuts). Furthermore, the efficacy of mixed-nut diets should also be examined. Finally, dose-response studies should be conducted, in order to determine the ideal intake levels for maximal metabolic benefits and to also establish detrimental doses. The most common cited concerns with nut consumption are their high fat content and energy density, which some fear will lead to weight gain and consequently, obesity. However, the overall evidence from epidemiological studies not only shows no association between nut intake and weight gain, but it in fact points to an inverse trend.37 Furthermore, evidence suggests that in the context of energy-restricted diets, the addition of nuts generates a more lasting and greater magnitude of weight loss among obese subjects.38 One mechanism of action that has been studied in almonds, suggests that the cell walls of almonds decrease the bioaccessibility of lipids by hindering their availability for digestion.39 However, more clinical trials are required to assess the impact of nuts on weight loss and if applicable, to help determine the potential mechanisms of action. Overall, addressing these key challenges will allow governing agencies to make better recommendations to the general public. CONCLUSION Tree nuts on their own are not "magic bullets" that will prevent chronic diseases. However, the current body of scientific evidence shows that their addition to healthy diets leads to additional metabolic benefits. For instance, the addition of nuts to a vegan-diet rich in plant sterols, vegetable proteins and soluble fiber led to reductions in LDL-C similar to those obtained with starting doses of Statin medication.40 Furthermore, their inclusion in the Mediterranean or weight loss diets has improved the efficacy of these diets in comparison to the currently recommended therapeutic diets.41-43 Overall, the intake of nuts as part of a healthy diet can improve risk factors of heart disease, short-term glycemic control and to a limited extent enhance weight loss. As such, in lieu of their energy density, healthy individuals and those at high risk of type 2 diabetes and/or heart disease will benefit from the inclusion of nuts in their diets.
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Trichopoulou A, Bamia C, and Trichopoulos D. 2009. Anatomy of health effects of Mediterranean diet: Greek EPIC prospective cohort study. BMJ 338: b2337.
Estruch R, Martinez-Gonzalez MA, Corella D, Salas-Salvado J, Ruiz-Gutierrez V, Covas MI, Fiol M, Gomez-Gracia E, Lopez-Sabater MC, Vinyoles E, Aros F, Conde M, Lahoz C, Lapetra J, Saez G, and Ros E. 2006. Effects of a Mediterranean-style diet on cardiovascular risk factors: a randomized trial. Ann Intern Med 145: 1-11.
Jenkins DJ, Wong JM, Kendall CW, Esfahani A, Ng VW, Leong TC, Faulkner DA, Vidgen E, Greaves KA, Paul G, and Singer W. 2009. The effect of a plant-based low-carbohydrate ("Eco-Atkins") diet on body weight and blood lipid concentrations in hyperlipidemic subjects. Arch Intern Med 169: 1046-54.
The Not-so-Sweet Side of Sugars Maximilian Klein
Medical school is funny sometimes. Every now and then in lecture I hear the professor say something that makes me think, "Why was I not told this before" In this light, I feel obligated to expand on one particular experience for the benefit of our population. I was caught off guard the day we covered fructose metabolism in a series of lectures on carbohydrate biochemistry when my professor made the comment, "At one time, fructose was experimentally tested to see if it could be used as a substitute for glucose. It turned out to be very bad for the patients." Very bad for the patients? When did they figure this out? I made sure to see my professor after class to ask him more about this, and he casually told me that scientists have known about the harmful effects in humans of high fructose feeding for quite some time.1,2 I found out that if you force feed fructose into a mouse it will develop diabetes and diabetes related conditions3-6, or as current journals like to put it, "deleterious metabolic effects".7 So often, media health correspondents and public health officials makes hints to stay away from high fructose corn syrup (HFCS), but has anyone ever explained why the public should stay away from large amounts of fructose? Or better yet, why the sugar fructose is particularly bad for our health when compared to other dietary components? As a public health student as well as a medical student I think the science needs to be better communicated from the research bench to the public with more understandable explanations and fewer "just do as I say" rules.
has anyone ever explained why the public should stay away from large amounts of fructose?�
First, I should start out with a little refresher on the basics of sugars. They take on many names and forms but essentially they are all cousins to one another; that is, they are all related to each other by their chemical structure. Two common sugars that we have all heard of are sucrose (table sugar) and lactose (found in dairy products). Sucrose and lactose are what we call disaccharides, meaning that they have two smaller sugar molecules linked together in a chemical bond. In order to transport the sucrose and lactose from our food into our blood stream we have to first break down the disaccharides into their individual units. If we do not break the disaccharides into individual monosaccharides, the bacteria downstream in our intestines quickly do it for us and release copious gas as a byproduct, hence the potentially uncomfortable condition lactose intolerance, which basically results from an individual's inability to break down lactose into its individual sugar units.8 Ok, let's get back to the main story. The two units that make up sucrose are glucose and fructose. Ah-hah! Sucrose is a 50/50 ratio of glucose and fructose. So what is the big deal about HFCS since the commercial form is usually 55% fructose and 45% glucose? Well if you will take my word for now that fructose is dangerous, then HFCS has a 5% increase in danger which theoretically is less good. But back to the central question, "Why is fructose so bad?" To answer this question the science behind how fructose is metabolized needs to be explored. 15
Maximilian Klein: The Not-so-sweet Side of Sugars
Let us consider glucose first. When glucose enters your bloodstream (whether from the 50% component of your table sugar, your morning cereal, or your sandwich bread) your blood sugar (i.e. blood glucose) will raise above the normal, healthy level. The raise in blood sugar will then cause your pancreas to respond like a good watchdog and secrete the hormone insulin which will then lower your blood sugar back to the normal, healthy range. Easy enough, right? Well, fructose is different. If glucose could represent cars driving throughout the highway of your bloodstream, fructose would be like an ambulance roaring through the traffic, going around all the other cars until it arrives at its destination (the liver). Once in the liver, fructose has a front-of-the-line pass to be metabolized no matter how much was actually ingested. In biochemical terms, this type of event is described as "unregulated." What is the end result of this unregulated metabolism? The fructose that you eat puts an enormous strain on your liver by ravaging its energy supply in order for the fructose to be metabolized as quickly as possible, and this has serious health consequences. In reality there are many diseases (pathologies) that can be attributed to the fact that fructose metabolism is unregulated. The effects of consuming large amounts of fructose through foods and drinks such as sugar-sweetened beverages are well linked to conditions such as non-alcoholic fatty liver disease (NAFLD), increased fat storage (making you fatter), decreased fat burning (keeping you fat), high blood pressure, muscle insulin resistance (impaired ability for muscle to lower your blood sugar when it is too high), kidney stones, and gout (painful buildup of uric acid in joints) -- just to name a few.7, 10-14 The increased cardiovascular risk from fructose consumption is evident in people of all ages too, especially in regards to adolescents and sugar-sweetened beverage consumption.15 In addition, there is evidence suggesting that over time large fructose consumption leads to an overall increased hunger level. This point about hunger seems counter-intuitive. Normally after we eat our hunger goes away, but fructose seems to contribute to chronic elevated insulin levels, which results in a continual state of hunger or a so -called state of sugar addiction.12 One of the authors of the above journal review, a pediatrician and neuroendocrinologist named Robert Lustig, coined a memorable phrase, saying that fructose is like "alcohol without the buzz".16 If I have managed to convince you that fructose is dangerous, now you might ask the question, "How do I avoid fructose?" One of the most important things you can take away from this article is the fact that fructose makes up half of table sugar and over half of HFCS. Fruit and honey are the only major dietary sources of fructose found in nature, which is a very narrow scope, and based on the biochemistry, sources of dietary fructose should be kept to just that. Of course it is nearly impossible to eliminate sucrose altogether from our diets, but the fact is that your body is not well-equipped to handle the high levels of fructose that are found in many processed and packaged foods. Things like rice and potatoes are essentially giant LEGOÂŽ block creations of glucose, but not any fructose.
From a historical perspective fructose was virtually absent from our diet just a few hundred years ago.�
From a historical perspective fructose was virtually absent from our diet just a few hundred years ago.10 Until industrialization and the rise of corn production, the sources of fructose in our diet were limited to mainly honey and fruit. Please understand too that the amount of fructose in fruit is small compared to sugar-sweetened soda, for instance, and therefore should not be of much concern (Table 1).7,10 Many people ask "Why is HFCS used so much more than say, regular corn syrup or sucrose?" The answer has several parts, but what I want you to know is that fructose tastes sweeter than glucose. So, if a 50/50 mixture of glucose and fructose is converted to a new ratio of say 45% glucose and 55% 16
Maximilian Klein: The Not-so-sweet Side of Sugars
fructose, which is the standard in HFCS, the end product tastes better to most people. Clever, right? Sounds like more of a killer-filler to me. It pays off tremendously to know exactly what your food is made of (for instance, that table sugar is 50% fructose), and I believe that having a conceptual understanding of why certain foods are hazardous to your health is crucial for making the necessary steps to achieve better dietary habits. If fructose is really as bad as it is thought to be, our public health campaigns should be targeted to all fructosecontaining sugars. REFERENCES [1]
Beck-Nielsen H, Pedersen O, & Lindskov HO. 1980. Impaired cellular insulin binding and insulin sensitivity induced by high-fructose fee ing in normal subjects. American Journal of Clinical Nutrition. 33, p. 273-278.
Hung CT. 1989. Effects of high-fructose (90%) corn syrup on plasma glucose, insulin, and C-peptide in non-insulindependent diabetes mellitus and normal subjects. Journal of the Formosan Medical Association. 88(9), p. 883-885.
Cohen, A. M., Teitelbaum, A., & Rosenman, E. 1977. Diabetes induced by a high fructose diet. Metabolism. 26(1), p. 17 -24.
Tobey TA, Mondon CE., Zavaroni I, & Reaven GM. 1982. Mechanism of insulin resistance in fructose-fed rats. Metabolism. 31, p. 608-612.
Fukuda H, Iritani N, & Tanaka T. 1983. Effects of high-fructose diet on lipogenic enzymes and their substrate and effector levels in diabetic rats. Journal of Nutritional Science and Vitaminology. 29(6), p. 691-699.
Hwang IS, Ho H, Hoffman BB., & Reaven GM. 1987. Fructose-induced insulin resistance and hypertension in rats. Hypertension. 10, p. 512-516.
Tappy L & LĂŞ KA. 2010. Metabolic effects of fructose and the worldwide increase in obesity. Physiology Reviews. 90 (1), p. 23-46.
Wilt TJ, Shaukat A, Shamliyan T, Taylor BC, MacDonald R, Tacklind J et al. 2010. Lactose Intolerance and Health. Evdience report/Technology assessment. 192, p. 1-410.
Basciano H, Lisa F, & Adeli K. 2005. Fructose, insulin resistance, and metabolic dyslipidemia. Nutrition & Metabolism. 2(5).
Bantle JP. 2009. Dietary fructose and metabolic syndrome and diabetes. The Journal of Nutrition. 139(6), p. 1263-1268.
Johnson RK et al. 2009. Dietary sugars intake and cardiovascular health. Circulation. 120, p. 1011-1020.
Lim JS, Mietus-Snyder M, Valente A, Schwarz JM, & Lustig RH. 2010. The role of fructose in the pathogenesis of NAFLD and the metabolic syndrome. Nature reviews: Gastroenterology & hepatology. 7(5), p.251-264.
Choi HK, Willett W, & Curhan G. 2010. Fructose-rich beverages and risk of gout in women. Journal of the American Medical Association. 304(20), p. 2270-2278.
Brown CM, Dulloo AG, Yepuri G, & Montani JP. 2007. Fructose ingestion acutely elevates blood pressure in healthy young humans. American Journal of Physiology: Regulatory, integrative and comparative physiology. 294(3), p.730737.
Welsh JA, Sharma A, Cunningham SA, & Vos, MB. 2011. Consumption of added sugars and indicators of cardiovascular disease risk among US adolescents. Circulation. 123, p. 249-257.
Lustig RH. 2010. Fructose: metabolic, hedonic, and societal parallels with ethanol. Journal of the American Dietetic Association. 110, p.1307-1321.
USDA Agricultural Research Service. 2010. Nutrient data laboratory. Retrieved March 26, 2011, from http:// www.nal.usda.gov/fnic/foodcomp/search/
The Coca-Cola Company. 2009. Nutrition connection. Retrieved March 26, 2011, from http://productnutrition.thecocacolacompany.com/welcome
Pepsi-Cola Company 2011. Pepsi product information. Retrieved March 26, 2011, from http://
Medical Science and the Serials Crisis: Is Open Access a Viable Solution? Jim Shen
Introduction n 2002 and 2003, several manuscripts were posted to arXiv (pronounced "archive") which laid out the solution to the then nearly century-old mathematical problem known as the Poincaré conjecture. arXiv hosts hundreds of thousands of preprints, or manuscripts not yet published in a peer-reviewed journal, from the fields of physics, computer science, quantitative biology, quantitative finance, statistics, and mathematics. Anyone in the world may access it, free of charge. Thus, in an instant, the solution to one of the most prestigious unsolved problems in mathematics was made freely available to all. Such easy access to information is not the norm in medicine. In medicine as well as many other fields, access to most of the primary scientific literature is paid for by the audience. A scientist would produce a paper, submit it to a journal for peer-review and publication, and upon publication access would be given only to the audience that has paid the journal's subscription fees. Thus, an informationseeking physician or patient must pass through financial barriers in order to access the latest clinical trials on her disease. Most would agree that unencumbered access to the latest science is extremely important for both physicians and patients, so why has it not become a reality? The answer requires an understanding of the role of the serials crisis. The serials crisis refers to the rising subscription costs of academic journals and the financial difficulties it poses for subscribers, especially academic libraries. Profit motives on the part of publishing companies, market consolidation due to merging of such companies, and high demand for access among university faculty have led to upwardly spiraling journal prices that are taxing the budgets of the university libraries that subscribe to them., Between 1986 and 2003, the price of scholarly journals increased 215% while the Consumer Price Index, which measures the changes in the price level of consumer goods and services, rose only 68%. For example, the University of North Carolina at Chapel Hill reported that it paid $10,924 for its 2004 subscription to the Journal of the American Medical Association. It has always been in a scientist's interest for her work to see widespread exposure. Thus as publishers began imposing an increasing financial barrier to access their work, some scientists began to look for an alternative way to distribute their papers.
access to the latest science is extremely important for both physicians and patients, so why has it not become a reality?"
An Array of Open Access Models Emerge In response to the serials crisis, several models of open access science publishing emerged and the Internet proved to be a natural medium on which these models could grow. The aforementioned arXiv was an early example in which preprints, early drafts of papers to be submitted to traditional peerreviewed journals, were hosted on the Internet to be freely accessed by all. Since its establishment at Cornell University in 1991, around 600,000 preprints in physics, mathematics, and computer science have now become available for download. In 1994, Steven Harnad issued his "subversive proposal" that scientists self-archive their papers on the Internet, reasoning that this would allow wider dissemination 18
Jim Shen: Medical Science and the Serials Crisis
of their work than publication in increasingly costly subscriber access-only journals. In medicine the efforts of Harold Varmus, co-recipient of the 1989 Nobel Prize in Physiology or Medicine, former director of the National Institutes of Health, and current director of the National Cancer Institute, to create a medicine-specific version of arXiv resulted in the birth of PubMed Central, a free repository of electronic peer-reviewed scientific literature. Open access efforts to date fall roughly into one of two camps, known as "green" and "gold" open access. Green open access, currently the more popular of the two, refers to the practice of publishing an article in a non-open access journal that grants the author permission to self-archive, or upload the article to some sort of open access archive, be it an institutional-specific or third party-administered archive. Gold open access, on the other hand, refers to the direct publishing of an article in an open access journal. BioMed Central is an example of a gold open access publisher of electronic journals, funded not by the traditional subscription fees but by payments from the authors of submitted articles. In recent years, open access publishing has gained momentum and is now a significant contributor to scientific literature. A recent study estimated that 21.7% of academic medical journal articles were published in either green or gold open access form. While many publishers have been willing to grant authors the permission to self-archive, not all are fans of open access. Publishing companies, working with trade groups such as the Partnership for Research Integrity in Science and Medicine (PRISM), have voiced objections to this movement. Among the main criticisms is the claim that open access publishing results in inadequate peer review, diminishing the quality of the published science. Without charging for subscription, traditional journals argue that it will be difficult to pay the costs required to support a robust peer review infrastructure. Open access efforts have attempted to work around this problem either by publishing preprints or using nontraditional methods of peer review. Articles submitted to the Harold Varmus-founded open access journal PLoS ONE undergo an abbreviated initial peer review process and are then reviewed by readers after publication – a system known as "open peer review." A few years ago, the prestigious journal Nature experimented with open peer review but encountered weak reader participation in the review of posted articles. Nature eventually chose not to adopt open peer review. However, it did not end its foray into open access entirely. On January 6, 2011, Nature issued a press release announcing the creation of a gold open access journal, Scientific Reports, which will not rely on an open peer review process. Instead, it will use a modified version of the traditional peer review system in which there are no in-house editors. An Editorial Board Member either conducts the review herself or sends the paper to one or more referees for peer review. In order to establish which papers are most important, the most frequently downloaded, blogged, or emailed papers will be listed on the Scientific Reports website – a feature reminiscent of the reader-driven participation crucial to open peer review. Proponents of preprint servers such as arXiv note that "amateur postings" are "surprisingly rare." Open access advocates argue that open access and peer review can coexist and even suggest that open access journals may be better able to adopt improved peer review methods than traditional journals. Responding to fears of financial viability, open access proponents point out that a multitude of open access journals, including those published by BioMed Central, are supported by fees paid by authors, not subscribers. In addition, they argue that open access articles are cited more often than non-open access articles, although there is disagreement as to whether this is due to a statistical bias wherein higher quality papers tend to be available on an open access basis compared to lower quality papers. Conclusion The combination of the serials crisis and the emergence of the Internet convinced many scientists of the necessity and viability of open access science publishing. Despite the strides made in recent decades, progress towards universal open access has been and continues to be characterized by mixed success. A 19
Jim Shen: Medical Science and the Serials Crisis
variety of open access schemes are in play and evolving due to financial and logistical pressures as well as pushback from traditional publishers and groups like PRISM. The opportunity to create new publications has also given publishers a chance to overhaul the peer review process. Time will tell which scheme, if any, will prevail. REFERENCES [1]
Case MM. Information access alliance: challenging anticompetitive behavior in academic publishing. Coll Res Libr News 2004 Jun;65(6):1.
Albert KM. Open access: implications for scholarly publishing and medical libraries. J Med Libr Assoc. 2006 July; 94 (3): 253–262.
Kyrillidou M, Young M. ARL statistics 2002–2003. [Web document]. Association of Research Libraries, 2004. [cited 21 Dec 2004]. _http://www.arl.org/stats/pubpdf/arlstat03.pdf_.
Panitch JM, Michalak S. The Serials Crisis: A White Paper for the UNC-Chapel Hill Scholarly Communications Convocation, January, 2005.
Pfeiffer A. Universities use social media to connect. New York Times. 2010 Mar 30. Accessed 29 Dec 2010.
Poynder R. Ten years after. Info Today 2004 Oct;21(9):1,23-4,44. (Available from: <http://www.infotoday.com/it/oct04/ poynder.shtml>. [cited 29 Dec 2010].)
Harnad S, Brody T, Vallieres F, Carr L, Hitchcock S, Gingras Y, Oppenheim C, Stamerjohanns H, & Hilf E. (2004) The Access/Impact Problem and the Green and Gold Roads to Open Access. http://dx.doi.org/10.1016/j.serrev.2004.09.013 Serials Review 30 (4) 2004.
Poynder R. Ten years after. Info Today 2004 Oct;21(9):1,23–4,44. (Available from: <http://www.infotoday.com/it/ oct04/poynder.shtml>. [cited 29 Dec 2010].)
Björk B-C, Welling P, Laakso M, Majlender P, Hedlund T, et al. (2010) Open Access to the Scientific Journal Literature: Situation 2009. PLoS ONE 5(6): e11273. doi:10.1371/journal.pone.0011273
Falagas ME. Peer review in open access scientific journals. Open Med. 2007 Apr 14;1(1):e49-51.
Overview: Nature's peer review trial. Nature (2006). doi:10.1038/nature05535.
Announcing Scientific Reports, a new open access publication. Press release from Nature Publishing Group. 6 Jan 2011. (Available from: <http://www.nature.com/press_releases/scientificreports.html> [cited 23 Jan 2011].)
Scientific Reports – Guide to Referees. (Available from: <http://www.nature.com/srep/referees/index.html> [cited 23 Jan 2011].)
Announcing Scientific Reports, a new open access publication. Press release from Nature Publishing Group. 6 Jan 2011. (Available from: <http://www.nature.com/press_releases/scientificreports.html> [cited 23 Jan 2011].)
Jackson, Allyn (2002). From Preprints to E-prints: The Rise of Electronic Preprint Servers in Mathematics. Notices of the American Mathematical Society 49 (1): 23–32.
Falagas ME. Peer review in open access scientific journals. Open Med. 2007 Apr 14;1(1):e49-51.
Harnad, S., Brody, T., Vallieres, F., Carr, L., Hitchcock, S., Gingras, Y, Oppenheim, C., Stamerjohanns, H., & Hilf, E. (2004)The Access/Impact Problem and the Green and Gold Roads to Open Access. http://dx.doi.org/10.1016/ j.serrev.2004.09.013 Serials Review 30 (4) 2004.
[18] Gargouri Y, Hajjem C, Larivière V, Gingras Y, Carr L, Brody T, Harnad S. Self-selected or mandated, open access increases citation impact for higher quality research. PLoS One. 2010 Oct 18;5(10):e13636. [19] Davis PM, Lewenstein BV, Simon DH, Booth JG, Connolly MJ. Open access publishing, article downloads, and citations: randomised controlled trial. BMJ. 2008 Jul 31;337:a568. doi: 10.1136/bmj.a568. 20
A Comparison of Music as a Therapy Before and After the 20th Century in America Chu-En Lin
"Music has Charms to sooth a savage Breast, To soften Rocks, or bend a knotted Oak." 1 -William Congreve (The Mourning Bride, 1697) Ancient history is replete with the idea that music can be used as a therapeutic agent. In the latter part of the sixth century B.C.E., Pythagoras and his followers discovered that the pleasant effects of music came from musical consonances that stemmed from ratios of the fourth, fifth, and octave intervals created by the pounding of different-sized hammers. The idea was similar to dividing a string into segments that have ratios of 2:1 (octave), 3:2 (fifth), and 4:3 (fourth).2 In the fourth century B.C.E., Aristoxenus wrote that the Pythagoreans "used medicine for purifying the body, music for purifying the soul." At around 400 B.C.E., Plato championed that "the intelligent man [should use] music to heal himself when he recognizes that his soul-circuits are out of kilter," such as when one gets angry.3 In the second century A.D., Celsus mentioned in his eight books on medicine that in order to treat depression, "symphoniae et cymbala strepitusque," or loud noise and cymbals, should be used.3 And in the Old Testament of the Bible, David the armor bearer was described as calming the mind of King Saul with his harp whenever the king was troubled by a distressing spirit.4 The above examples demonstrate that for thousands of years, music has been used to alleviate anxiety; nevertheless, its incorporation into a healthcare setting is comparatively new, at least in America.5 An examination of the history of music therapy in the United States reveals a major disparity in the periods before and after the twentieth century, in terms of the number and quality of publications in the field, the extent of the use of music in hospitals, as well as the prominence of music therapy in the undergraduate curriculum. An analysis of each of the three factors reveals how the growth of each correlates with both the growth of the remaining two factors, as well as the societal acceptance of music as a therapy. Perhaps the notion of music as therapy would be met with less resistance if the medical community had an appreciation for the historically established therapeutic benefits of music therapy, as well as its proposed role as adjunctive therapy—with no intention of replacing conventional therapies. Before the twentieth century, only a handful of publications exists on music therapy. Worthy of note is the fact that in the entirety of the eighteenth century, only two articles on music therapy were published in the United States. One was published in the same month in which President George Washington was first elected, and the other a month before the end of his second term.6 Furthermore, there was a total of only nine publications on music therapy during the nineteenth century.7 As a result, the majority of the sources that include information on the history of music as a therapeutic agent are generally cited from the twentieth century. Late eighteenth century music therapy can be described as the "expository" stage, or "a time of floating ideas.6 An anonymous first article was published in the same month President Washington was elected in his first term in February. Titled "Music Physically Considered," the article first referred to Rene Descartes in order to contrast the nonmaterial mind with the mechanistic body, and to further the idea that the mind's influence on the body is reciprocal. It then referred to Drs. Hermann Boehaave (1668-1738) and William Cullen (1710-90), both physicians who were heavily influenced by Descartes, to expound upon this idea. Even though neither physician made the claim that the mind-body relationship should be applied to medical treatments, the article maintained that music could help balance the healthy state by exciting or relieving emotions. Perhaps the most convincing evidence for the therapeutic effects of music in the article was a case study in which music was used to treat "severe 21
Chu-En Lin: Music Therapy
and debilitating depression of a dancing teacher." 6,8 The study, however, was marred by a lack of adequate references. The article ended with a quote from poet John Armstrong's (1717-95) "The Art of Preserving Health:" Music exalts each joy, allays each grief, Expels diseases, softens every pain, Subdues the rage of poison and the plague; And hence the wise of ancient days ador'd One power of physic, melody and song.9 Quotes from sources that do not contain much scientific evidence such as the preceding example are not uncommon in works from the eighteenth and nineteenth centuries, as the first scientific journal for music therapy, the Journal of Music Therapy, was founded a century later, in 1964.10 In fact, the first nineteenth century essay on music therapy entitled, An Inaugural Essay on the Influence of Music in the Cure of Diseases, contained the same Armstrong quotation in its closing.6,11 Perhaps not surprisingly, Edwin Atlee, the author of the essay, asserted that music was most therapeutic in its treatment of mania, which he thought was "the consequences of a delirious or mistaken idea." The comment on mania was perhaps itself a mistaken idea by today's medical definitions.6,11 Two years after Atlee published his essay, his colleague Samuel J. Mathews wrote a dissertation, On the Effects of Music in Curing and Palliating Diseases, and included another quote from Armstrong's "The Art of Preserving Health" in addition to quotes from Shakespeare and Pope.7,12 Between 1840 and 1841, a series of three articles, each entitled "Medical Powers of Music," was published; all three contained numerous sources from classical Greco-Roman writers to support music as a cure, yet little scientific evidence was provided.6,29,30,31 Even in the late-nineteenth century, an article titled "The Medical Uses of Music," written by George Beardsley and published in the New England Medical Monthly, gave only vague and previously documented stories of music treating illnesses.7,13 The articles published in the eighteenth and nineteenth centuries, however, were not entirely without merit. A month before President Washington's Farewell Address, an anonymous second article entitled "Remarkable Cure of a Fever by Music: An Attested Fact," was published in the New York Weekly Magazine. The article was essentially a case study detailing the disappearance of symptoms of delirium while a musician performed in concert, with symptoms returning immediately after the concert had ended.6,14 The study had serious credibility issues if analyzed by modern standards; nevertheless, it is important to understand that during this time the republic was in its formative years, "hospitals were medieval death houses," and that health-related publications had to compete for limited space in the popular press.6 Thus, even though there was an eight-year gap between the publishing of the first and second article in the eighteenth century, these two articles still reflected the interests of the general public in music as a therapeutic agent. In the nineteenth century, a period in which only nine articles regarding music therapy were published, Atlee's three personal narratives on music therapy in the essay previously mentioned, An Inaugural Essay on the Influence of Music in the Cure of Diseases, may have been, according to Professor William Davis at Colorado State University, "the initial first-hand reports of music therapy in the United States." 7 Finally, Mathews' dissertation, On the Effects of Music in Curing and Palliating Diseases, provided the basis for what modern music therapists refer to as the "iso" principle, or the idea of musical entrainment or "accommoda[tion] to the patient's mind." 6,12 Stronger support for music therapy came in the late nineteenth century in mental health reformer George Alder Blumer's paper, "Music in its Relation to the Mind," and in the establishment of adaptive music therapy in institutional settings in the early to mid-nineteenth century.6,7,15 Convinced that many of the articles written in both eighteenth and nineteenth century America had suspect claims, Blumer instead searched for first-hand reports, mainly from European and British sources on music therapy, and psychology publications for his paper. He concluded that music, along with other activities such as 22
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reading, is effective in treating mental illnesses.6,7 In addition to publishing one of nine papers on music therapy in the nineteenth century, Blumer also contributed to the use of live musical performances in hospitals and by establishing the first "ongoing music program in an American hospital." In this respect he is considered a "pioneer in the music therapy movement" in the United States.7 The introduction of music therapy in an institutional setting, however, occurred earlier in The Perkins School for the Blind in South Boston in 1832.6 From the modern perspective, music therapy is divided into two forms, palliative and adaptive. Adaptive music therapy generally involves therapists working with educators from special institutions in order to aid handicaps in learning, while palliative music therapists generally assist other healthcare professionals in treating patients.6 The first establishment of music therapy in an institution occurred in a school for the blind and was considered adaptive; the success of using music in this setting spurred the development of a similar program at the American Asylum for the Deaf in Hartford, Connecticut. Conversely, significant attention toward palliative music therapy occurred only after World War II.6 In regards to music therapy prior to the twentieth century, only eleven articles were published. Secondly, although adaptive music therapy was used in special institution settings, the use of music in hospitals was limited to the latter quarter of the nineteenth century. Thirdly, the first music therapy course was offered early in the twentieth century, while the undergraduate curriculum in music therapy was nonexistent prior to 1952.16 Altogether, the slow progression of music therapy may be due to the fact that there was no political force to "complement its historical, philosophical, and 6 experimental efforts." Compounding this absence are the dearth of quality articles published and the few demonstrations done on music as a therapy. By the midtwentieth century, however, after the phonograph was invented and the National Association for Music Therapy was established, the field began to experience significant growth.6
...in 1914 the American Medical Association (AMA) first acknowledged the possible benefits of music in hospital treatments…"
Edison's invention of the phonograph in 1877 and the introduction of disc records in 1896 spurred renewed interest in hospitals' use of music. Not only did experiments with animals and humans demonstrate the physiological effects of music in the twentieth century, in 1914 the American Medical Association (AMA) first acknowledged the possible benefits of music in hospital treatments through Dr. Evan O'Neill Kane's letter in the Journal of the American Medical Association. Kane's letter recorded the successful phonograph use in the operating room in order to calm patients before general and local anesthesia prior to operation.17,18 Three years later, the founder of the National Therapeutic Society of New York City, Eva Vescelius, predicted that music could one day be as necessary as "air, water, and food" when its therapeutic value is understood. In 1918, roughly one year after her prediction, Columbia University introduced the first course on music therapy, entitled "Musicotherapy." 16,19 Margaret Anderton and Isa Maud Ilsen, the instructors of the course, had both been involved in treating Canadian soldiers suffering from war-neurosis with music, and together they recommended criteria for future therapists; the qualifications included the use of trained musical professionals who also had knowledge of physics, psychology, anatomy, and physiology.16
Chu-En Lin: Music Therapy
Other successful accounts of the use of music in general hospitals included Dr. Esther L. Gatewood's thorough report in 1920, which included a possible mechanism through which music might work. Her idea was that the stimuli originating from music may bar negative stimuli, such as pain, from "entering into consciousness"—rendering music effective in concert with anesthesia.18,20 This idea was refined by dentist E.S. Best fifteen years later.18,21 A study closely followed Gatewood's report in 1924, when Ida L. Hyde from the State University of Kansas concluded after studying music's effect on cardiovascular systems of fifteen subjects, that "those selections of music... that exert a favorable reflex-action on the cardiovascular system, have also a favorable influence upon the muscle tone, working power, digestion, secretions and other functions of the body." 18,22 The formation of the National Association for Music in Hospitals by Ilsen was a major step forward in the field, and in 1929, the construction of Duke University Hospital marked the first commitment to hospital music—all recovery rooms and bed patients received radio reception through earphones or speakers. According to Dale Taylor, the director of music therapy at the University of Wisconsin, "increased music therapy research and application, improved technology and publications describing music in hospitals [allowed interests for music therapy to spread] from the operating room to other treatment areas [such as] in obstetrics and gynecology." 18 A paper published in 1930 concluded that not only was music not a hindrance in the operating room, but music provided a great means of alleviating patient's fear and objections against chemical agents.18,23 Similar studies investigating music's effects in pediatric and orthopedic divisions of the hospital have also shown positive findings.18 Worthy of note is the fact that during this time, palliative music therapy was provided as a complementary or adjunct therapy, not a replacement for conventional therapies—thus diminishing the posed threat against mainstream medicine. During the 1940s, additional universities began to offer training in music therapy. Affiliations were generally established between hospital officials and the faculty of music colleges, and students were required to perform in wards during their practicum training.16 During the same period, Esther Goetz Gilliland, a pioneer of music education and therapy, began to publish numerous scientific articles in an attempt to organize and establish music therapy as a profession. And in 1944, Kenneth Pickrell, a plastic surgeon from Duke University School of Medicine and Duke Hospital, initiated a project of including music in "the patient's room, the anesthesia room, the operating room, and the recovery room [in order to] simplif[y] the task of the surgeon, the house officers, the nurses, and…the patient." 18,24 It became evident that the role of music therapy in the twentieth century had benefited from course expansions, numerous scientific publications, and its extensive use in hospital wards. Furthermore, the wording used by Pickrell indicated that music was used to "simplify" the task of surgeons and to provide a congenial therapeutic environment for the patients; the phrase "to be offered as a replacement for surgery" was never used. Music was thus viewed as an adjunct or complementary therapy instead of an alternative that holds the same status as conventional medicine. Not only was music incorporated into hospitals during the mid-twentieth century, in order to meet hospital demands during the late 1940s when there were ample veterans from World War II, hospital officials began their own programs for training music therapists; these programs were established in both Iowa and California.16 At the same time, Music Department chairman Roy Underwood at Michigan State College established the first bachelor's degree program in music therapy. Dr. Shannon de l'Etoile, a professor of music therapy at Colorado State University, commented that "the structure of higher education during the 1940s allowed for department chairs to make significant decisions without input from committees, thus expediting what could have been a lengthy and time-consuming process." 16 In 1950, the formation of the National Association for Music Therapy (NAMT), an organization dedicated to the "presentation and publication of music therapy applications" greatly increased the number of studies published in the next ten years.18 The driving force for the NAMT formation came from members of the Music Teacher's National Association; the main objective was to advance the use of music in medi24
Chu-En Lin: Music Therapy
cine, and also to develop standards for music therapy education.16 Fourteen years later, the Journal of Music Therapy was first issued.10 The development of the undergraduate curriculum in music therapy often depended on clinical practices at the time. For example, during the early-twentieth century, music was mainly used in hospitals for entertainment purposes; the primary qualification was thus technical instrumental skills. As music became increasingly incorporated into palliative care, however, training began to focus on maximizing the scientifically establish benefits of music.16 The shift from mere entertainment to science -backed therapeutic practices was mainly due to the realization that the field's acceptance depended on its establishment as an organization, its development of a science and skill-based curriculum, and the quality and quantity of evidence-based publications related to music as a therapy. The latter factor has especially transformed clinical practices recently after studies have shown that music's rhythm entrainment aids movement recovery of patients with stroke, Parkinson's disease, cerebral palsy, and traumatic brain injury.25 Furthermore, a historical review of music therapy journals from their infancy to 2001 entitled "A History of Music Therapy Journal Articles Published in the English Language" revealed that each of the nine major journals on music therapy began with a heavy clinical emphasis. As each journal became more established, historical, philosophical, and qualitative articles were subsequently added.10 Furthermore, when the nine journals were considered as a whole, the amount of quantitative and clinical research studies predominated other types of studies. Dr. Darlene Brooks, the author of the paper, raised an interesting point when she commented on the low number of historical, philosophical, and qualitative research articles published in these journals: "is it possible that researchers are not certain that these types of articles foster the growth of the profession and provide the recognition that music therapy is seeking from accrediting agencies?" 10 Other than the quantity and quality of the journals published, perhaps the fact that music's therapeutic effects, however minor, have been accepted throughout Western civilization has allowed for a smoother transition into a hospital setting, as compared to other complementary and alternative modalities. Of interest are the written reflections from eighteenth and nineteenth century European composers that reveal a belief in music's effects on depression. After being informed of his incurable deafness, Beethoven contemplated suicide, writing "I would have ended my life—it was only my art that held me back…Oh Providence—grant me at last but one day of pure joy—it is so long since real joy echoed in my heart." 2,26 Even though Beethoven was deaf at the time, welltrained composers have the ability to listen to music just by reading the score. In fact, Beethoven's ninth symphony, perhaps the greatest musical composition ever written, was composed when he was deaf.2
...studies have shown that music's rhythm entrainment aids movement recovery of patients with stroke, Parkinson's disease, cerebral palsy, and traumatic brain injury…"
Music, similarly, had an effect on depression as William Styron, after listening to Brahms' Alto Rhapsody, also decided against committing suicide:
Chu-En Lin: Music Therapy
This sound, which like all music—indeed, like all pleasure…pierced my heart like a dagger, and in a flood of swift recollection I thought of all the joys the house had known: the children who had rushed through its rooms, the festivals, the love and work, the honestly earned slumber, the voices and the nimble commotion, the perennial tribe of cats and dogs and bird… All this I realized was more than I could ever abandon.27 Similarly, after Franz Liszt's concert, an attendee commented on his performance as quoted by Williams: In my young soul there awakened for the first time the awareness that music, 'basic form of all the arts'; is more than mere entertainment or earning a living; that God has given it for the lifting up of hearts, for the bringing of comfort and consolation; and that the musician's profession is service to mankind's affirmation of life and joy in life.28 This description about music as a profession may sound strikingly similar to that of medicine as a profession; more importantly, however, these comments represent the fact that, aside from ancient sources, European composers and members of the audience from the eighteenth and nineteenth centuries were able to provide information concerning music's therapeutic effects. Together, modern and ancient sources confirm Western civilization's belief of music as a therapy. An examination of the history of music therapy in America reveals a major disparity in terms of the quantity and quality of music therapy publications, the extent of music's use in hospitals, and the status the therapeutic field holds in the undergraduate curriculum from the periods before and after the twentieth century. An inspection of these three factors reveals how the growth of each contributes to the development and acceptance of music therapy as a whole. Additionally, the fact that music has already been documented and received throughout Western civilization as some form of therapeutic agent, and the notion that music functions mainly as an adjunct therapy, not a replacement for conventional therapies allow its use and acceptance to be met with less resistance by the medical community. Finally, a comparison of music therapy from the periods before and after the twentieth century should lend further interests into the depth, breadth, and mechanisms of music's effects on people—both past and present.
Congreve W. The Works of Mr. Congreve: Volume 2. Containing: The Mourning Bride; The Way of the World; The Judgment of Paris; Semele; and Poems on Several Occasions. London: Adamant Media Corporation, 2005; Pages 1.
Grout DJ, Palisca CV. A History of Western Music. London: W.W. Norton & Company; 2001. Pages 515.
Horden P. Music as Medicine. Burlington, Vermont: Ashgate Publishing Company; 2001. Pages 58-62.
The Holy Bible. Nashville: Thomas Nelson Publishers; 1985. Pages 333.
Watkins GR. Music Therapy: Proposed Physiological Mechanisms and Clinical Implications. Clinical Nurse Specialist. 1997;11(2):43-50.
Heller GN. Ideas, Initiatives, and Implementations: Music Therapy in America, 1789-1848. Journal of Music Therapy. 1987;24(1):35-46.
Davis WB. Music Therapy in 19th Century America. Journal of Music Therapy. 1987;24(2):76-87.
[Anonymous] Music Physically Considered. Columbian Magazine. 1789;111:90-93.
Armstrong J. The Art of Preserving Health. Edinburgh: James Nichol; 1858. Pages 65-66.
Chu-En Lin: Music Therapy [10] Brooks D. A History of Music Therapy Journal Articles Published in the English Language. Journal of Music Therapy. 2003;40(2):151-168. [11] Atlee E. An Inaugural Essay on the Influence of Music in the Cure of Diseases. New York: B. Graves, Printer; 1804. Pages 1. [12] Mathews SJ. On the Effects of music in curing and palliating diseases. Philadelphia: P.K. Wagner; 1806. Pages 1. [13] Beardsley GL. The Medical Uses of Music. New England Medical Monthly. 1882;2:214-216. [14] [Anonymous] Remarkable Cure of a Fever by Music: An Attested Fact. New York Weekly Magazine. 1796;11:14. [15] Blumer GA. Music in its relation to the mind. American Journal of Insanity. 1891;50:350-364. [16] L'Etoile SD. The History of the Undergraduate Curriculum in Music Therapy. Journal of Music Therapy. 2000;37(1):51-71. [17] Kane EO. Phonograph in the Operating Room. Journal of the American Medical Association. 1914;62:1829. [18] Taylor DB. Music in General Hospital Treatment from 1900 to 1950. Journal of Music Therapy. 1981;18 (2):62-73. [19] Vescelius E. Music and Health. Music Quarterly. 1918;4:376-400. [20] Gatewood EL. The Psychology of Music in Relation to Anesthesia. American Journal of Surgery, Anesthesia Supplement. 1921;35:47-50. [21] Best ES. The Psychology of Pain Control. Journal of the American Dental Association. 1935;22:256-267. [22] Hyde IH. Effects of Music Upon Electrocardiograms and Blood Pressure. Journal of Experimental Psychology. 1924;7:213-214. [23] McGlinn JA. Music in the Operating Room. American Journal of Obstetrics and Gynecology. 1930;20:678683. [24] Pickrell KL, Metzger JT, Wilde JN, Broadbent RR, Edwards BF. The Use and Therapeutic Value of Music in the Hospital and Operating Room. Plastic and Reconstructive Surgery. 1950;6:142-152. [25] Thaut MH. The Future of Music in Therapy and Medicine. Annals New York Academy of Sciences. 2005;1060:303-308. [26] Jonas-Simpson C. Musical Expressions of Life: A Look at the 18th and 19th Century from a Human Becoming Perspective. Nursing Science Quarterly. 2004:17:330. [27] Styron W. Darkness Visible: A Memoir of Madness. New York: Vintage Books; 1990. Pages 66-67. [28] Williams A. Portrait of Liszt: By Himself and His Contemporaries. Oxford: Clarendon Press; 1990. Pages 563-564. [29] Medical Powers of Music. The Musical Magazine; or, Repository of Musical Science, Literature and Intelligence. 1840;52:423. [30] Medical Powers of Music. The Musical Magazine; or, Repository of Musical Science, Literature and Intelligence. 1841;54:31. [31] Medical Powers of Music. The Musical Magazine; or, Repository of Musical Science, Literature and Intelligence. 1841;55:45-47.
Julie Grimes Untitled
Paul Janoian Central Park
Challenges in Stem Cell Therapy: Bench-To-Bedside Varunkumar G. Pandey & Michael Karsy
Since, the isolation of human embryonic stem (hESCs) cells by Thomson et al. in 1998, stem cell research has been recognized as the most promising component of the regenerative medicine.1 Stem cells are capable of differentiating into any cell type of the body and this pluripotency allows for limitless therapeutic potential. However, the utility of hESCs is restricted because of pertinent ethical issues, limited availability of human blastocysts, and possible allograft rejection. Furthermore, our understanding of cellular differentiation and epigenetic regulation are still in the primitive stages and pose major hurdles in stem cell research. Before stem cell therapy can become a clinical reality, it is imperative that we address critical issues relating to programming efficiency, tumor susceptibility, and graft survival and rejection. Nonetheless, commendable milestones have been already achieved in the study of stem cells by a number of research groups, and regenerative medicine is gradually inching towards a plausible reality of stem cell therapy. The FDA has recently approved the usage of a hESCbased therapy in 2010 where clinical trials have been initiated by Geron Corporation for patients with spinal cord injury. In this article, we appreciate the recent advancements in stem cell research and discuss current challenges faced by various research groups in stem cell research. The discovery of induced pluripotent stem cells (iPSCs) has paved a new paradigm in stem cell research. The exemplary ingenuity of Shinya Yamanaka in developing a cellular reprogramming technology that facilitates production of iPSCs from somatic cells provided a major breakthrough in stem cell research2. Yamanaka hypothesize that transcription factors playing important roles in the maintenance of hESC identity also have pivotal roles in the induction of pluripotency in somatic cells. The research group identified numerous factors that are differentially expressed in hESCs in comparison to adult stem cells. By performing detailed comparative analysis, they defined four key transcription factors, namely Oct3/4, Sox2, c-Myc, and Klf4, that are essential to the reprogramming of somatic cells. This landmark finding lead to the realization of a long awaited scientific dream that adult somatic cells can be reprogrammed into induced stem cells and perhaps be used for therapeutic purposes. Despite the efforts of Yamanaka in pioneering iPSC technology, several limitations immediately became apparent3. The transgenes used for reprogramming were based on retroviral vectors with random insertion into the host genome, allowing for possible interference with the endogenous gene structure that could result in undesirable insertional mutations. Furthermore, the lack of complete control of transgene expression could result in tumorigenesis. Several solutions have been explored to address these issues including the use of cell-penetrating recombinant proteins for reprogramming cells.4,5 Initial studies exploring cellular reprogramming with Oct3/4, Sox2, c-Myc, and Klf4, have led way to the discovery of a multitude of additional transcription factors that can reprogram iPSCs and in some cases alter the eventual differentiation of cells.6,7 Alterations in chromatin structure affecting epigenetic regulation are important, dynamic regulators of global genetic expression in iPSCs but remain an uncharted territory8 Disruption of tumor suppressor p53 or cell-cycle checkpoint inhibitors (e.g. p14/ ARF, p21) can improve iPSC generation, however are also involved in carcinogenesis.9-12 Human iPSCs have been generated from fibroblasts, keratinocytes and CD34+ human peripheral blood cells13,14. Recent studies have indicated that cell type and culture environment can affect iPSC generation. While certain cell types may prove to be easier to extract cells from, such as fibroblasts from a skin biopsy, other cell types may be more effective for tissue development. Development of iPSCs from keratinocytes show lower rates of transgene retroviral insertion than fibroblasts thus allowing for more regulated control of cell genetics.13 The low efficacy of iPSC generation in vitro also 30
Pandey & Karsy: Challenges in Stem Cell Therapy
remains an important challenge for the generation of significant tissue yields. Evaluation of generated iPSCs for therapeutic efficacy and tumor formation is necessary prior to implantation in patients. In this regard, animal models will be important to assess germline transmission of iPSCs and cell incorporation into patient tissue. Furthermore, animal models prior to clinical development will be important to screen for the formation of teratoma tumor masses from undifferentiated iPSCs and patient immune reaction from iPSCs containing foreign antigens15. The microenvironment of stem cell plays an important role in the regulation of quiescence and differentiation. However, animal models do not fully encompass human microenvironments and evaluation of a biological mechanism for iPSCs engrafted for disease treatment will be important to determine therapeutic efficacy.
Generation and application of iPSCs to human disease Cellular delivery of iPSCs to patients remains a crucial technical limitation, which has driven investigation into tissue engineering technologies. While certain therapies will suffice with single, direct implantation of iPSCs (e.g. Parkinson's disease), other approaches may require multi-site cell delivery (e.g. spinal cord injury). Ex vivo tissue engineering has emerged as a potential solution for artificial tissue formation and organogenesis16. Extracellular matrices (ECM) composed of biocompatible materials in combination with pluripotent cells and specific culturing conditions have been suggested as scaffolds for organogenesis. Technologies such as inkjet printing of collagen matrices, individual live cells, or stem cell growth factor have been used to pattern and generate custom 3D tissues.17-19 Decellularization of endogenous cells from tissues in order to leave an ECM template where iPSCs can be added to regenerate cells has also been pursued in various organs including, heart, liver, kidney, pancreas, and intestine.20,21 The role of hypoxia in regulating stem cells has emerged as an important facet of pluripotency and is actively being investigated.22 Explanted microvasculature beds serving as scaffolds for large tissue formation have also been explored to overcome hypoxic environments limiting iPSC engraftment.23 31
Pandey & Karsy: Challenges in Stem Cell Therapy
A plethora of applications for iPSCs has been suggested, including tissue regeneration for a congenital malformations, degenerative disorders, traumas, and genetic defects. Therapeutic efficacy of hESCs has been demonstrated experimentally in animal models of spinal cord injury24, retinal disease25, Parkinson's disease.26 In addition, the first FDA-approved stem cell therapy in humans was recently approved for spinal cord injury.27 Sponsored by Geron, Phase I trials for complete thoracic injury will be performed using hESCs and have recruited the first patients in October 2010. Disease-specific iPSCs generated from patient tissues can provide new insights into the pathophysiology of various complex human diseases that currently lack effective models. Although extensive literature supports the development of stem cell therapies, results should be scrutinized diligently in order to provide the best quality of patient care. Despite the remarkable potential for iPSCs, and the emergence of this exciting and rapidly expanding field, a variety of technical challenges remain. Historical evidence has suggested that biotechnology takes approximately 10-15 years until the development of realizable therapies.28 While genetic engineering methods were discovered in the 1970s, FDA approval of insulin came in 1982 and was not widely available until the 1990s. Advancements in iPSC technologies will continue to develop with effort from a cadre of new researchers, challenge grants, and national initiatives. It is foreseeable that physicians in the near future will utilize stem cell therapies to treat many of the deleterious diseases currently incurable. REFERENCES [1]
Thomson JA, Itskovitz-Eldor J, Shapiro SS, Waknitz MA, Swiergiel JJ, Marshall VS, Jones JM: Embryonic stem cell lines derived from human blastocysts. Science 282:1145-1147, 1998
Takahashi K, Yamanaka S: Induction of pluripotent stem cells from mouse embryonic and adult fibroblast cultures by defined factors. Cell 126:663-676, 2006
Yamanaka S: A fresh look at iPS cells. Cell 137:13-17, 2009
Kim D, Kim CH, Moon JI, Chung YG, Chang MY, Han BS, Ko S, Yang E, Cha KY, Lanza R, Kim KS: Generation of human induced pluripotent stem cells by direct delivery of reprogramming proteins. Cell Stem Cell 4:472-476, 2009
Zhou H, Wu S, Joo JY, Zhu S, Han DW, Lin T, Trauger S, Bien G, Yao S, Zhu Y, Siuzdak G, Scholer HR, Duan L, Ding S: Generation of induced pluripotent stem cells using recombinant proteins. Cell Stem Cell 4:381-384, 2009
Yamanaka S, Zhang XY, Maeda M, Miura K, Wang S, Farese RV, Jr., Iwao H, Innerarity TL: Essential role of NAT1/p97/DAP5 in embryonic differentiation and the retinoic acid pathway. EMBO J 19:5533-5541, 2000
Yamanaka S, Blau HM: Nuclear reprogramming to a pluripotent state by three approaches. Nature 465:704712, 2010
Hanna JH, Saha K, Jaenisch R: Pluripotency and cellular reprogramming: facts, hypotheses, unresolved issues. Cell 143:508-525, 2010
[9] Kawamura T, Suzuki J, Wang YV, Menendez S, Morera LB, Raya A, Wahl GM, Belmonte JC: Linking the p53 tumour suppressor pathway to somatic cell reprogramming. Nature 460:1140-1144, 2009 [10] Li H, Collado M, Villasante A, Strati K, Ortega S, Canamero M, Blasco MA, Serrano M: The Ink4/Arf locus is a barrier for iPS cell reprogramming. Nature 460:1136-1139, 2009 [11] Marion RM, Strati K, Li H, Murga M, Blanco R, Ortega S, Fernandez-Capetillo O, Serrano M, Blasco MA: A p53-mediated DNA damage response limits reprogramming to ensure iPS cell genomic integrity. Nature 460:1149-1153, 2009 32
Pandey & Karsy: Challenges in Stem Cell Therapy [12] Utikal J, Polo JM, Stadtfeld M, Maherali N, Kulalert W, Walsh RM, Khalil A, Rheinwald JG, Hochedlinger K: Immortalization eliminates a roadblock during cellular reprogramming into iPS cells. Nature 460:11451148, 2009 [13] Aasen T, Raya A, Barrero MJ, Garreta E, Consiglio A, Gonzalez F, Vassena R, Bilic J, Pekarik V, Tiscornia G, Edel M, Boue S, Izpisua Belmonte JC: Efficient and rapid generation of induced pluripotent stem cells from human keratinocytes. Nat Biotechnol 26:1276-1284, 2008 [14] Loh YH, Agarwal S, Park IH, Urbach A, Huo H, Heffner GC, Kim K, Miller JD, Ng K, Daley GQ: Generation of induced pluripotent stem cells from human blood. Blood 113:5476-5479, 2009 [15] Li JY, Christophersen NS, Hall V, Soulet D, Brundin P: Critical issues of clinical human embryonic stem cell therapy for brain repair. Trends Neurosci 31:146-153, 2008 [16] Rustad KC, Sorkin M, Levi B, Longaker MT, Gurtner GC: Strategies for organ level tissue engineering. Organogenesis 6:151-157, 2010 [17] Boland T, Xu T, Damon B, Cui X: Application of inkjet printing to tissue engineering. Biotechnol J 1:910917, 2006 [18] Ilkhanizadeh S, Teixeira AI, Hermanson O: Inkjet printing of macromolecules on hydrogels to steer neural stem cell differentiation. Biomaterials 28:3936-3943, 2007 [19] Nakamura M, Kobayashi A, Takagi F, Watanabe A, Hiruma Y, Ohuchi K, Iwasaki Y, Horie M, Morita I, Takatani S: Biocompatible inkjet printing technique for designed seeding of individual living cells. Tissue Eng 11:1658-1666, 2005 [20] Baptista PM, Orlando G, Mirmalek-Sani SH, Siddiqui M, Atala A, Soker S: Whole organ decellularization a tool for bioscaffold fabrication and organ bioengineering. Conf Proc IEEE Eng Med Biol Soc 2009:65266529, 2009 [21] Ott HC, Matthiesen TS, Goh SK, Black LD, Kren SM, Netoff TI, Taylor DA: Perfusion-decellularized matrix: using nature's platform to engineer a bioartificial heart. Nat Med 14:213-221, 2008 [22] Ma T, Grayson WL, Frohlich M, Vunjak-Novakovic G: Hypoxia and stem cell-based engineering of mesenchymal tissues. Biotechnol Prog 25:32-42, 2009 [23] Chang EI, Bonillas RG, El ftesi S, Chang EI, Ceradini DJ, Vial IN, Chan DA, Michaels J, Gurtner GC: Tissue engineering using autologous microcirculatory beds as vascularized bioscaffolds. FASEB J 23:906-915, 2009 [24] Keirstead HS, Nistor G, Bernal G, Totoiu M, Cloutier F, Sharp K, Steward O: Human embryonic stem cellderived oligodendrocyte progenitor cell transplants remyelinate and restore locomotion after spinal cord injury. J Neurosci 25:4694-4705, 2005 [25] Lamba DA, Gust J, Reh TA: Transplantation of human embryonic stem cell-derived photoreceptors restores some visual function in Crx-deficient mice. Cell Stem Cell 4:73-79, 2009 [26] Yang D, Zhang ZJ, Oldenburg M, Ayala M, Zhang SC: Human embryonic stem cell-derived dopaminergic neurons reverse functional deficit in parkinsonian rats. Stem Cells 26:55-63, 2008 [27] Wadman M: Stem cells ready for prime time. Nature 457:516, 2009 [28] Daley GQ: Stem cells: roadmap to the clinic. J Clin Invest 120:8-10, 2010
Hepatocellular Screening Guidelines and Bellevue's High Risk Population Ramoncito David
Hepatocellular carcinoma (HCC) is the third leading cause of cancer-related death in the world.1 The prevalence of this fatal disease greatly varies among different nations, due to the fact that almost 80% of cases are secondary to hepatitis B or C.2 The implementation of an effective vaccine against the hepatitis B virus (HBV) has reduced the prevalence of HBV carriers in North America to 0.1-2%; however, hepatitis B remains a global public health problem due its high prevalence in Asia and Africa, where 10-20% of the general population are carriers.3 Hepatitis C in the United States is more prevalent in urban areas with higher populations of immigrants and intravenous drug users. Bellevue's patient population is at high risk for hepatocellular carcinoma because of our many Asian, African, and IV-drug-using patients and our relatively high rates of hepatitis B and C. According to the American Association for the Study of Liver Diseases (AASLD), patients at high risk for developing HCC should be entered into a surveillance program that screens them at regular intervals to check for new lesions in the liver. By examining current guidelines and looking at how they are applied at Bellevue, we can shed some light on the question of whether we are screening too many patients or too few. The updated AASLD guidelines published in 2010 state that high-risk groups should be screened with ultrasonography every 6 months.4 Ultrasound as a screening test for HCC has a sensitivity that ranges from 65% to 80% and a specificity greater than 90%. The main disadvantage of this test is that it is operator-dependent; hence the wide range in sensitivity.5 In addition, lesions in the liver are more difficult to detect sonographically in obese and cirrhotic patients, further decreasing the sensitivity. However, due to its cost-effectiveness, safety, and efficacy, ultrasonography is the preferred HCC screening and surveillance modality. Alpha-fetoprotein (AFP) is a serum marker that can be elevated in patients with primary liver cancer. The optimal threshold for elevated AFP levels in HCC screening tests was found to be 20 ng/mL, but even then a screening test employing this cut-off would have a sensitivity of only 60% and a positive predictive value of only 41.5% when the prevalence of HCC is assumed to be 5%, as seen in most liver clinics.6 Some institutions use a combination of ultrasonography and AFP levels for screening, which results in increased sensitivity at the cost of a higher false positive rate.7 However, screening with AFP alone is not recommended, since it was shown in the Hepatitis C Antiviral Long-term Treatment Against Cirrhosis (HALT-C) Trial to be ineffective.8 Interestingly, studies imply that AFP is even less sensitive for the diagnosis of HCC in African-Americans with cirrhosis due to hepatitis C.9 Some have suggested triple-phase CT scanning or MRI as alternative imaging options, but their use has not been studied in non-biased populations where there has not already been suspicion for HCC.10 Moreover, given that the suggested interval time for screening is 6 months, CT scanning would expose the patient to high levels of radiation. Serial MRIs and triple-phase CTs would also accrue significant costs. However, given the availability of resources at some institutions and the lack of contrastenhanced ultrasonography in the United States11, CT scanning may be the best option for screening since it has been shown to have high sensitivity for finding lesions and is not as user-dependent as ultrasonography. At Bellevue, surveillance for HCC in at-risk patients is done by CT scan or MRI every 6 months, which is typically the length of time it takes for tumor size to double. 34
Ramoncito David: Hepatocellular Screening Guidelines
Limiting screening to high-risk patients makes sense because of the potential harm involved: false positives can lead to further unnecessary testing and IV contrast can harm patients with renal insufficiency. The many risk factors for developing HCC include race, male gender, hepatitis B carrier state, chronic hepatitis C infection, hereditary hemochromatosis, cirrhosis, non-alcoholic fatty liver disease, diabetes, alpha-1-antitrypsin deficiency, exposure to environmental toxins (aflatoxin, contaminated drinking water), smoking, and alcohol abuse.12-15 For non-cirrhotic hepatitis B patients, the AASLD guidelines suggest screening all Asian males over the age of 40, Asian females over the age of 50, patients with a positive family history of HCC, and Africans over the age of 20, regardless of carrier status or viral load. They also recommend screening all patients with cirrhosis of any etiology.16 Using the subset of Asian HBV carriers as a study group, we can look more closely at the impact that screening has on mortality. A 2004 trial based in Shanghai, randomized 18,816 Chinese patients between the ages of 35 to 59 with chronic hepatitis B to an active surveillance group followed with an AFP level and ultrasound every 6 months or to an observation group to be followed for up to 20 years. After 5 years they found that mortality due to HCC was significantly lower in the surveillance group compared to the observation group (83 per 100,000 vs. 132 per 100,000, mortality rate ratio 0.63, 95% CI 0.41-0.98).17 The 37% decrease in mortality was attributed to detection of the lesions at an earlier stage in the surveillance group. The number needed to treat (NNT) for this sample was 2,041. Since the treatment offered in the study was resection, it is important to note that in the setting of chronic hepatitis B, HCC may arise prior to the development of cirrhosis, thus improving the prognosis for non-cirrhotic patients undergoing resection. Given the demonstrated benefit of early detection of HCC through screening, it is important to examine whether we healthcare providers are using screening to its full potential. Cost-effectiveness is one way to assess this, and it is generally accepted that surveillance is cost-effective in cirrhotics who have an expected annual incidence of HCC greater than 1.5% per year. Since the incidence of HCC in cirrhotic liver disease of any etiology typically ranges from 3% to 8% per year, it is clear that screening for these high-risk groups is cost-effective and potentially life-saving, given the high mortality rate associated with HCC.18,19 In terms of the actual costs of screening tests, one study performed a cost-utility analysis comparing the incremental costs of four of the most commonly used screening modalities vs. no screening: AFP level alone, abdominal ultrasound and AFP, abdominal triple-phase CT and AFP, and abdominal MRI and AFP. Utilizing Medicare reimbursement data as a standard of cost, they found that screening with ultrasonography and AFP level had an incremental cost-utility ratio of $26,689 per quality-adjusted life year, while abdominal CT and AFP was associated with an incremental cost-utility ratio of $25,232 per quality-adjusted life year. AFP alone is not a viable option due to lack of efficacy, and MRI with AFP had a significantly higher cost-utility ratio of $118,000 per quality-adjusted life year.20 According to this data, abdominal CT with AFP level appears to be the most cost-effective screening modality. More inclusive criteria for screening with CT and AFP would inevitably result in a marginal increase in financial burden, with the incremental costs being dependent on the number of new patients meeting the revised criteria. Before considering a change in the criteria for screening, it is important to evaluate how well the current guidelines work when implemented at a hospital with a high volume of at-risk patients. Here at Bellevue we see many patients with chronic hepatitis B, most of whom are immigrants from China who likely acquired the viral infection by vertical transmission during birth. These patients have had a longer course of infection compared to patients who acquired HBV at a later age. They can develop HCC earlier in their lives, prior to reaching the age at which screening is recommended according to the AASLD guidelines. When there is no family history and no clinical finding of cirrhosis prompting us to screen these patients, they are often not diagnosed unless the lesion is found incidentally or the disease 35
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reaches an advanced stage and becomes symptomatic. Ironically, these young patients with non-cirrhotic livers are also the ones who would benefit most from early detection and subsequent resection. Unfortunately, they are not usually screened since they do not meet the criteria under the current guidelines. Thus it would be helpful to establish more sensitive criteria for identifying patients who are at higher risk for developing early onset hepatocellular carcinoma. One study has shown that in young HBV patients, smoking and cirrhosis were significant risk factors for developing HCC.21 In order for clinicians to implement the tool of screening in a more cost-effective and efficacious manner, further studies need to be done to elucidate important risk factors such as those that can be incorporated into a targeted algorithm for screening that includes those patients at highest risk for developing HCC at a young age. REFERENCES [1]
Parkin DM, Bray F, Ferlay J, Pisani P. Global cancer statistics, 2002. CA Cancer J Clin. 2005; 55(2):74-108.
Perz JF, Armstrong GL, Farrington LA, Hutin YJ, Bell BP. The contributions of hepatitis B virus and hepatitis C virus infections to cirrhosis and primary liver cancer worldwide. J Hepatol. 2006;45(4):529-538.
Maynard JE. Hepatitis B: global importance and need for control. Vaccine. 1990;8(Suppl):S18- S20.
Bruix J, Sherman M. Management of hepatocellular carcinoma: An update. Hepatology. July 2010:1 35.
Bolondi L, Sofia S, Siringo S, et al. Surveillance programme of cirrhotic patients for early diagnosis and treatment of hepatocellular carcinoma: a cost-effectiveness analysis. Gut. 2001;48(2):251-259.
Trevisani F, D'Intino PE, Morselli-Labate AM, et al. Serum alpha-fetoprotein for diagnosis of hepatocellular carcinoma in patients with chronic liver disease: influence of HBsAg and anti-HCV status. J Hepatol. 2001;34(4):570-575.
Zhang B, Yang B. Combined alpha fetoprotein testing and ultrasonography as a screening test for primary liver cancer. J Med Screen. 1999;6(2):108-110.
Lok AS, Sterling RK, Everhart JE, et al. Des-gamma-carboxy prothrombin and alpha-fetoprotein as biomarkers for the early detection of hepatocellular carcinoma. Gastroenterology. 2010;138(2):493–502.
Nguyen MH, Garcia RT, Simpson PW, Wright TL, Keeffe EB. Racial differences in effectiveness of alpha-fetoprotein for diagnosis of hepatocellular carcinoma in hepatitis C virus cirrhosis. Hepatology. 2002;36(2):410–417.
Bartolozzi C, Lencioni R, eds. Liver Malignancies: Diagnostic and Interventional Radiology. Berlin: Springer Verlag; 1999:71-94.
Wilson SR, Greenbaum LD, Goldberg BB. Contrast-enhanced ultrasound: what is the evidence and what are the obstacles? AJR Am J Roentgenol. 2009;193(1):55-60.
Davila JA, Morgan RO, Shaib Y, McGlynn KA, El-Serag HB. Hepatitis C infection and the increasing incidence of hepatocellular carcinoma: a population-based study. Gastroenterology. 2004;127(5):1372-1380.
Chen CJ, Wang LY, Lu SN, et al. Elevated aflatoxin exposure and increased risk of hepatocellular carcinoma. Hepatology. 1996;24(1):3842.
Kuper H, Tzonou A, Kaklamani E, et al. Tobacco smoking, alcohol consumption and their interaction in the causation of hepatocellular carcinoma. Int J Cancer. 2000;85(4):498-502.
1 Yu MC, Tong MJ, Govindarajan S, Henderson BE. Nonviral risk factors for hepatocellular carcinoma in a low-risk population, the nonAsians of Los Angeles County, California. J Natl Cancer Inst. 1991;83(24):1820-1826.
Bruix J, Sherman M; Practice Guidelines Committee, American Association for the Study of Liver hepatocellular carcinoma. Hepatology. 2005;42(5):1208–1236.
Zhang BH, Yang BH, Tang ZY. Randomized controlled trial of screening for hepatocellular carcinoma. J Cancer Res Clin Oncol. 2004;130(7):417-422.
Wong GL, Wong VW, Tan GM, et al. Surveillance programme for hepatocellular carcinoma improves the survival of patients with chronic viral hepatitis. Liver Int. 2008;28(1):79-87.
Sarasin FP, Giostra E, Hadengue A. Cost-effectiveness of screening for detection of small hepatocellular carcinoma in western patients with Child-Pugh class A cirrhosis. Am J Med. 1996; 101(4):422-434.
Arguedas MR, Chen VK, Eloubeidi MA, et al. Screening for hepatocellular carcinoma in patients with hepatitis C cirrhosis: a cost-utility analysis. Am J Gastroenterol. 2003;98(3):679-690.
Diseases. Management of
The Economic Effects of Compulsory Medical Licensing Vivek Rajasekhar
Too Many Patients, Too Few Doctors Kamela Christara, a 47-year-old single mother with Lyme disease in western Massachusetts can't find a personal physician. After calling three dozen practices, she has resorted to the emergency room at Cooley Dickinson hospital in Northampton when health problems arise. Christara is not alone in her difficulties. Since that state's landmark health care reform was signed into law in 2006 by then-Governor Mitt Romney, Massachusetts has suffered acute doctor shortages in ten specialties, ranging from primary care to neurologists.1 A flood of previously uninsured residents now threatens the fragile network of health care providers. A study by the Massachusetts Medical Society found "critical" shortages in family practice and internal medicine, while a recent NPR story revealed that Holyoke Health Center in Holyoke, MA has over 1,600 newly-insured persons on its waiting list.2 The average waiting time for a new appointment stretches to 53 days, the longest it has been in 6 years. Although the situation in Massachusetts is particularly severe, the state is not alone in facing chronic doctor shortages. "The country needs to train 3,000 to 10,000 more physicians a year — up from the current 25,000 — to meet the growing medical needs of an aging, wealthy nation" says a recent article in USA Today. "Because it takes 10 years to train a doctor, the nation will have a shortage of 85,000 to 200,000 doctors in 2020 unless action is taken soon."3 While journalistic inquiry into the cause of this shortage usually attributes the problem to the usual suspects- disparities in reimbursement rates set by insurance companies, Medicare, and Medicaid, administrative work burdening physicians- the root cause of persistent shortages of qualified medical professionals remains unexamined. The supply of physicians in the United States does not respond to market forces, but rather, to political considerations. To practice within a state, clinicians must obtain certification from that state's licensing board. One view of this is that it maintains quality within the health care system by ensuring that only qualified doctors may treat patients. In reality, licensure represents a barrier to entry that physicians interest groups have erected in order to restrict competition within the field. The economic effects are predictable- a decrease in supply of physicians and a drastic increase in their median wages. Meanwhile, the policy fails to protect consumers from incompetent doctors, and by raising the marginal cost of care, reduces the affordability of quality care and restricts patients' access to treatment. The Shortage Nobel Prize-winning economist George Stigler outlines in his Theory of Economic Regulation,4 "[the state], with its power to prohibit or compel... can and does help or hurt a vast number of industries.... regulation, as a rule, is acquired by the industry and is designed and operated primarily for its benefit." Mandatory medical licensing is a prime example of a regulation demanded by an industry (doctors) for their personal benefit (higher wages), and falls into the traditional framework of occupational licensing. At present, some states regulate over 500 professions in this manner, ranging from hairdressers to lawyers. While some rules simply require the individual's name on a list, others demand an extensive process of testing, evaluation, and oversight. Medicine tends toward the latter. As the European Institute of Business Administration Professor S. David Young points out, "indeed, it appears that every organized occupational group in America has tried at one time or another to acquire state licensure for its members. Today at least a fifth, and perhaps as much as a third of the work force is directly affected by licensing laws."5 The argument in favor of licensing laws is that it protects the general public from shoddy workers- the "incompetents, charlatans, and quacks." In truth, licensing acts as a barrier to entry, the term used by economists to signify an obstacle that exists in entering a market. By placing on37
Vivek Rajasekhar: Economic Effects of Compulsory Medical Licensing
erous requirements on the education of aspiring professionals (at great expense to them), and due to the limitations on the licensing boards' willingness to hand out certification, this form of regulation can effectively create a shortage, where prior to, none would exist. In the case of the manufacturing a doctor shortage, the American Medical Association is the primary promoter and enforcer of compulsory medical licensing. Despite only representing 19% of American doctors, the AMA is considered one of the most powerful trade unions in the world. At the time of the country's founding, America's medical system contained a variety of healers, such as herbalists and hydrotherapists, in addition to the modern allopaths and osteopaths. Beginning in 1847, the American Medical Association began organizing to represent the interests of allopaths. At its founding convention in Philadelphia that year, one of the primary objectives outlined was the "upgrading of medical education and concomitant reduction in the number of physicians."6 Nevertheless, Census data indicates that in 1860, the United States possessed over 55,000 physicians, or roughly 175 per 100,000 citizens, one of the highest percentages in the world. Over the course of the next two decades, the AMA became more focused with regard to its ultimate goal. At a meeting in Cincinnati in 1867, the organization endorsed a resolution urging members to "use all their influence in securing such immediate and positive legislation as will require all persons, whether graduates or not, desiring to practice medicine, to be examined by a State Board of Medical Examiners, in order to become licensed for that purpose." Thus began, in earnest, efforts to use medical examining boards as a conduit for entry into the profession. The first attempt at setting up these institutions came in 1874, when the State of Kentucky instituted the Kentucky Board of Medical Licensure. The AMA's efforts culminated with the production of the Flexner report in 1910, which sanctioned allopathic medical schools and condemned homeopathic ones.7 Flexner pushed for the licensing of doctors and hospitals and government subsidies for medical research, with Congress and state governments acting swiftly on these recommendations. By 1915, only Alabama, Colorado, and New Mexico did not require a diploma in medicine nor an examination of applicants as a prerequisite for practice. The number of medical schools began to precipitously drop. In 1910, before the publication of the Flexner report, there were 130 medical schools in the United States. By 1944, there were just 69. The effect on doctors' income was just as swift and remarkable, albeit in the opposite direction. Dale Streinrich points out,8 "While physician incomes and prestige dramatically increased, so did the caregiving workload. Wolinsky and Brune (1994) report that doctors were firmly in the lower middle class at the time of the AMA's founding and made about $600 per year. This rose to about $1,000 around 1900. After Flexner, incomes began to skyrocket such that a 1928 AMA study found average annual incomes reached a whopping (for the time) $6,354. Even during the Great Depression, physicians earned four times what average workers did. A 2009 survey put family-practice doctors (on the low end of the physician income range) at a median of $197,655 and spine surgeons (at the high end) at a median of $641,728. These figures are mind boggling to ordinary Americans, even in good economic times. In addition, the cyclical unemployment that throws workers out of jobs in almost all other industries with the arrival of recessions or depressions became nonexistent among physicians after Flexner." The shortage in doctors and number of medical schools has persisted until today. Only one new medical school was established during the 1980s and 90s.9 During this period, the population of the United States increased 29%, from 238 million to 308 million. As University of Michigan economics professor Mark Perry summarizes, "the supply of medical school graduates has remained basically flat for the last 30 years. At the same time, the demand for physicians' services has increased over time because of a population that is both increasing and aging (fig. 1)."10 38
Vivek Rajasekhar: Economic Effects of Compulsory Medical Licensing
Consequences and Solutions The traditional justification given for strict medical licensing, as with other forms of occupational licensing, has been to keep poor-quality clinicians out of practice. In theory, only practitioners that meet some threshold of capabilities can obtain their license. Since this argument is uncomplicated and can be communicated to laymen with ease and clarity, there is little to no opposition by society. Moreover, because the monetary benefits of licensing are concentrated in such a small group that lobbies heavily in its favor, but the policy's costs are spread out amongst the relatively uninformed general public, occupational licensing is politically very difficult to oppose. However, contrary to conventional wisdom, there is little empirical evidence that medical licensing actually improves the quality of care, or even that it prevents bad practitioners from continuing treatment. State medical boards often rely on private organizations to perform many of the background checks and testing functions, organizations that could continue to provide credentialing services in a private capacity even in the event of the board's termination. Medical boards also have a poor record at disciplining errant providers. Often, colleagues do not report if they know a physician has committed a serious medical error, and if they do, they did not necessarily report them to the state medical board, but instead to their employer. Because establishing proof of substandard care is an expensive affair, requiring expert testimony, lawyers, and witnesses, licensing boards do not investigate a large number of claims. A study of Florida physicians with malpractice payouts found that only 16% were sanctioned by that state's medical board.11 Another report looking at doctors with ten or more malpractice payments between 1990 and 2005 found that only one-third had even been disciplined by their supervising licensing board.12 To make matters worse, there is a pattern of reluctance at reporting negative outcomes to the public. The Federation of State Medical Boards' records show that, in more than 65% of cases, the medical board and the offending physician reached an agreement without the physician being found guilty, thus denying consumers an important record of lowquality physicians to avoid.13 Further, medical licensing commissions have justified their existence by requiring clinicians to obtain higher and higher levels of education to perform the same functions, even if there is little evidence that more degrees actually improves patient care. For example, in 2012, California will begin requiring audiologists to obtain a doctorate (Au.D.), a requirement the Sacramento Bee has called an "extraordinary and costly mandate."14 "The relationship between educational inputs and better health outcomes," California State University- Northridge economics professor Shirley Svorny says, "is not that straightforward. It is not clear that those excluded by these high barrier to entry would not be competent practitioners." Mandating increasingly high levels of education to perform the same functions restricts employers, such as hospitals and clinics, from choosing among a wide range of education and training options. By limiting entry into the medical profession, onerous educational requirements can result in worse outcomes. These policies have also helped drive domestic health care costs skyward over the past several decades. As the Kaiser Family Foundation notes, U.S. health care spending was $7,681 per resident in 2008, amounting to 16.2% of the nation's GDP, the highest percent among industrialized countries. Health care expenditures were $2.3 trillion in 2008, over eight times the amount spent three decades ago.15 As one of the primary inputs into the production of health care, physicians' wages are a significant portion of that inflation. The price of the extra years of mandated schooling, both in terms of its direct cost (tuition) as well as the opportunity cost of the lost wages during those years, is factored into the final price charged to the ultimate consumer of health care, the patient. Unfortunately, the persistent shortage of physicians also manifests itself in other ways. Waiting lists have become commonplace in medicine as a form of rationing the limited supply of health care services. In 1993, the average wait time from when a patient receives a referral to when they can see a specialist was 9.3 weeks. By 1997, that period was up to 11.7 weeks, and currently sits at 17.3 weeks.16 With the recent passage of the Patient Protection and Affordable Care Act, bringing an expected 36 million new patients into the health care system, these wait times are only expected to be further lengthened. Other 39
Vivek Rajasekhar: Economic Effects of Compulsory Medical Licensing
consequences of doctor shortages and wait lists is the reduced time busy physicians can spend with any given patient, as well as the impinged health of patients that must go without a primary care physician. One of the major counterarguments to an unrestricted market for medical professionals is that it opens the door to "quack" doctors. However, according to Svorny, "medical licensing is ineffective and inefficient, and patients would be better served by relying on brand recognition when choosing their doctors."17 Individuals searching for a physician or surgeon could use referral, word-of-mouth, or simply visit a reputable group practice or hospital. Patients could also evaluate health professionals on the basis of price and quality, much as they do when purchasing a car or eating at a restaurant. To this end, many economists have suggested making publicly available doctors' qualifications- the degrees they hold, number of years experience, statistics on patient outcomes- and allowing patients to decide which practitioners to visit based on this information. Also, medical malpractice serves a useful function with regard to eliminating incompetent doctors. An effective tort system for medical malpractice will accrue heavy costs on irresponsible doctors, driving them from the marketplace. Further, malpractice insurers offer discounts to physician groups that successfully reduce medical errors, or alternatively, penalizing physicians that engage in "negligence-prone behavior" with higher premiums.18 On the other hand, hospitals tend to self-insure, and thus have a strong incentive to monitor the performance of their clinicians over time. It is difficult to predict precisely what regulatory features would develop in the absence of official government licensing. Yet, as one of the the most influential economists of the 20th century, Milton Friedman, explains, "the great argument for the market is its tolerance of diversity…. It renders special groups impotent to prevent experimentation and permits the customers and not the producers to decide what will serve the customers best."19 Perhaps the most simple and direct route is to allow private credentialing in medicine- competing degrees, such as M.D.'s, D.O.'s, and whatever alternatives new organizations design. Individuals can choose what combination of education and licensing they prefer, and likewise, patients can choose what brand of physician they are most comfortable with. The accounting industry is one example of how medical licensure should operate. While any person can call themselves an "accountant" and open practice, numerous standards of certification exist to prove professional competency. These include, among many others, the Certified Internal Auditor (CIA), the Accredited Business Accountant (ABA), and the most widely-recognized, the Certified Public Accountant (CPA).20 Conclusion While proponents of medical licensing state that these policies were instituted as a mechanism to protect patients, the evidence suggests that they have not helped to remove incompetent doctors from practice, but rather, have created an acute shortage of doctors throughout the American health care system. Consequently, patient treatment has become more expensive and of lower quality. This form of occupation licensing is deliberate policy of organizations, including the American Medical Association, which use government regulation as a mechanism to raise the wages of the special interest group they represent, American doctors. A better system exists- one that balances safety with cost and access. This requires relying on the market forces to control the supply of doctors, utilizing the "invisible hand" that Adam Smith wrote about over two centuries ago. It means allowing consumers to choose physicians with competing standards of certification and forms of education, in order maximize innovation and efficiency. Based on the failure of the status quo, patients have little to lose, but much to gain from eliminating mandatory medical licensing.
Vivek Rajasekhar: Economic Effects of Compulsory Medical Licensing
Figure 1 demonstrates the empirical effects of medical licensing on doctor quantity and wages. Because licensing boards are only apt to hand out a fixed number of licenses for practice (a number that is now also restricted because of the limited number of medical schools), the supply for physicians shifts to a perfectly inelastic position (SL). The result is that the quantity of doctors under licensure falls to QL and their equilibrium wage rises to WL.
"Study: Mass. has critical shortage of doctors." NECN. October 20, 2010. http://www.necn.com/10/20/10/ Study-Mass-has-critical-shortage-of-doct/landing_health.html?blockID=335019&feedID=4210 [2] "Mass. Health Care Reform Reveals Doctor Shortage." NPR. January 17, 2011. http://www.npr.org/ templates/story/story.php?storyId=97620520 [3] "Medical miscalculation creates doctor shortage." USA Today. March 2, 2005. http://www.usatoday.com/ news/health/2005-03-02-doctor-shortage_x.htm [4] George J. Stigler. "The Theory of Economic Regulation," Bell Journal of Economics and Management Science. (1971):3. http://www.jstor.org/pss/3003160 [5] S. David Young, "Occupational Licensing." The Concise Encyclopedia of Economics. 1993. Library of Economics and Liberty. 17 January 2011. <http://www.econlib.org/library/Enc1/OccupationalLicensing.html>. [6] Ronald Hamowy. "The Early Development of Medical Licensing Laws in the United States, 1875-1900." http://mises.org/journals/jls/3_1/3_1_5.pdf [7] Lawrence D. Wilson. "The Case against Medical Licensing." (1994). http://www.fff.org/freedom/0194d.asp [8] Dale Steinrich. "100 Years of US Medical Fascism." April 16, 2010. http://mises.org/daily/4276#note20 [9] "Expecting a Surge in US Medical Schools." New York Times. February 14, 2010. http:// www.nytimes.com/2010/02/15/education/15medschools.html [10] "Med School Grads Haven't Increased Since 1980; Nurses Can Help, But the AMA Protects Its Turf." April 17, 2010. http://mjperry.blogspot.com/2010/04/medical-school-grads-have-been-flat.html 41
Vivek Rajasekhar: Economic Effects of Compulsory Medical Licensing [11] Gary M. Fournier and Melayne Morgan McInnes, "Medical Board Regulation of Physician Licensure: Is Excessive Malpractice Sanctioned?" Journal of Regulatory Economics 12, no. 2 (1997): 113–26. [12] Seth Oldmixon, "TheGreatMedicalMalpractice Hoax: NPDB Data Continues to Show Medical Liability System Produces Rational Outcomes," Public Citizen's Congress Watch, http://www.citizen.org/ publications/release.cfm?ID=7497. [13] Darren Grant and Kelly C. Alfred, "Sanctions and Recidivism: An Evaluation of Physician Discipline by State Medical Boards," Journal of Health Politics, Policy and Law 32, no. 5 (2007): 867–85; Don Colburn and Steve Woodward, "Few Doctors Lose Licenses for Missteps," TheOregonian, April 19, 2005 [14] "Say What? Can You Hear the Sound of Money?" Sacramento Bee, April 20, 2005. [15] "U.S. Health Care Costs: Background Brief." Kaiser Family Health Foundation. http://www.kaiseredu.org/ Issue-Modules/US-Health-Care-Costs/Background-Brief.aspx [16] Dick Morris. "Rationing, Waiting Lists, Lower-Quality Care." November 17, 2009. http:// www.realclearpolitics.com/articles/2009/11/07/rationing_waiting_lists_lower-quality_care_99053.html [17] Svorny, Shirley. "Medical Licensing: An Obstacle to Affordable, Quality Care." The Cato Institute. September 17, 2008. 17 Jan 2011 <http://www.cato.org/pub_display.php?pub_id=9640> [18] U.S. General Accounting Office, "Medical Malpractice Insurance: Multiple Factors Have Contributed to Increased Premium Rates," GAO-030702, June 2003, p. 38, http://www.gao.govnew.items/d03702.pdf. [19] Friedman, Milton. Capitalism and Freedom. Chicago: The University of Chicago Press, 2002. [20] "Licenses and Designations in the Accounting Field." July 10, 2010. http://www.helpaboutcollege.com/ accounting-careers/licenses-and-designations-in-the-accounting-field
Anna Djougarian Kaleidoscope
Anna Djougarian Embrace
Five Years and Counting Mary Breige O'Donnell
La Casita de la Salud, "the little house of health," was no little idea. New York Medical College's student-run health clinic was proposed in 2003 by three medical students and came to fruition with the opening of its doors on September 24, 2005. Located in East Harlem, in affiliation with Metropolitan Hospital, the clinic began by hosting three clinic days dates in its inaugural year. La Casita de la Salud celebrated its fifth anniversary in September during a very successful 2010-2011 year. Here is a look back at what that idea has grown into over five short years and a look forward at what the future holds. Today, we strive to keep the clinic open every weekend and have nearly one hundred medical student volunteers. We began the 2010-2011 academic year with only two physician preceptors, but were able to recruit four additional volunteer preceptors. We also expanded our team by adding two paid preceptors, who work at the clinic twice a month. With a total of six volunteer and two paid preceptors to treat patients and mentor student volunteers, we have been able to hold clinic nearly every Saturday. In addition to needing a sufficient number of preceptors to oversee clinic operations, La Casita relies heavily on fundraising. This has always been of significant importance but became a primary goal for the 2010-2011 executive board. From 2007 to 2009, the clinic raised approximately $9,165. The current fundraising committee and executive board, with the help of family, friends, colleagues, faculty and alumni, have successfully raised over $9,700 during the 2010-2011 year alone. This will certainly contribute to maintaining clinic operations regularly over the next academic year. La Casita de la Salud is an integral part of the East Harlem community. The patient population of the clinic reports a mean household annual income of $17,701. Because the majority is Spanish speaking, an interpreter is present on all clinic days. In an effort to continue to meet the needs of the community, expanding clinic services is always at the forefront of clinic operations. The 2010-2011 year saw the implementation of a mental health screening and expansion of patient education and community resources available at La Casita. In addition to adding these resources, La Casita de la Salud's Women's Health Clinic opened this past November. This clinic provides well-woman exams and routine gynecological care for women in the community and held its fifth clinic date on March 26th.
…[La Casita de la Salud] serves a vital role in the community of East Harlem [and] serves as an amazing educational opportunity for all medical students at NYMC. "
While the clinic serves a vital role in the community of East Harlem, it also serves as an amazing educational opportunity for all medical students at NYMC's. Having the ability to participate in the student-run clinic as a preclinical medical student offers early exposure not only to the clinical environment, but also to the field of primary care. This opportunity has been shown to be an important consideration for prospective medical students. The 2010 NYMC Interviewee Survey of MD applicants (c/o 2014) showed that 90% stated that having a clinic is "very important" in their choice of a medical school. Also, among those interviewees, 98% stated they would want to participate in La Casita, if accepted to NYMC.
Mary Breige O'Donnell: Five Years and Counting
Third and fourth year medical students continue to actively participate in La Casita by volunteering and remaining as senior executive board members. By continuing to volunteer with the clinic, these students are afforded the opportunity to foster a positive learning experience for their peers through teaching and leading by example, all while treating patients. A great deal has been accomplished over the past five years and La Casita de la Salud has become a successful installation in the community of East Harlem. However, challenges continue to arise and must be overcome to continue to provide services that meet the needs of not only the local community, but also the New York City community at large. The 2011-2012 executive board strives to expand community resources available to the patient population, as well as to continue reaching out to organizations in the community that will benefit from La Casita. We believe it is essential for those serving the community in other capacities to know what we provide so that we can work together and reach out to those in need. We plan to continue the successful fundraising efforts of our predecessors and to add to the growing fund of resources that will aid in expanding the clinic and enhancing services. We are very proud of the five years of amazing work that has been accomplished. We can only hope that we will add to the success of those who have paved the way for us by continuing to provide quality and culturally competent care to the people of East Harlem and surrounding communities. For more information about La Casita de la Salud, please visit us on the web at: www.nymc.edu/student_clinic/
Paul Janoian Tappan Zee Bridge
Social Causes of Obesity Gregory Katz
Crystal smiled broadly as she walked into the exam room for her annual well child visit. At seven years old, she was developing appropriately and in the home stretch of second grade. She had no medical complaints, got along with her peers, and performed well in school. But her weight was in the 95th percentile for her height, and a few questions about the family revealed a worrisome pattern. Mom was obese with type 2 diabetes, and Crystal's 18 month-old sister was sitting in her stroller sipping on a bottle filled with juice. The physical exam revealed multiple decaying teeth, and her mouth was already shiny from several dental fillings. I asked her mother about what the family ate. It was the standard diet for many of our country's poorest citizens: fast food, juice, soda, a paucity of fruits and vegetables. Was this always they way they ate? Pretty much. Crystal and her sister were both picky eaters, fresh food is expensive, and Mom worked full time. She'd been lectured by doctors on previous visits about this already, and I thought she was annoyed with me for bringing up this tired topic. But as the conversation progressed, I realized this frustration was due to her resignation that the changes she needed to make were almost impossible. Mom was troubled by the situation; her family's health was important to her, but there is only so much that one woman can do with limited time and finite financial resources. We live in an age where obesity, hypertension, coronary artery disease, and type 2 diabetes are epidemic in our society. Two thirds of Americans are overweight and a third are obese.1 Meanwhile, we spend more than $1.7 trillion annually on the medical care of people with chronic diseases and almost half of all Americans fall into this group.2 This is largely a product of the modern world and the Western diet; obesity is a major driving force in the development and exacerbation of our health problems.3 We are eating ourselves to death and bankrupting our health care system in the process. But how did we get here? Beginning in the 1970's, the United States Department of Agriculture engineered farm subsidies that encouraged the overproduction of commodity crops like corn and soybeans and made them cheaply available. These policies were enacted with seemingly benevolent intentions: the price of food had spiked and President Nixon wanted to make eating more affordable. As a consequence, the government's agricultural policy goals shifted from trying to support prices for farmers to increasing yield in order to keep food costs low.4 Low-cost corn provides the feed for big agribusinesses to raise cows, chickens, and pigs more quickly, and enables commercial food companies to inexpensively manufacture the high fructose corn syrup that has become ubiquitous in everything from soft drinks to whole wheat bread.4 These cost savings are passed on to consumers, who can now purchase a 390 calorie double cheeseburger and a 150 calorie small Coke from McDonald's for the wallet-busting total of $2.5 Unfortunately, the same economies of scale do not exist for leafy green vegetables. And even if they did, a Big Mac will always be quicker, cheaper, and tastier than a serving of roasted broccoli and a skinless, boneless organic chicken breast. As the costs of energy dense foods have plummeted due to oversupply in the marketplace, the income gap between the rich and the poor has dramatically increased. For many low income families, it's impossible for Mom to wake up at five, work all day, and still have the time and energy to cook a healthy dinner. That's before we even get to the fact that it's cheaper to head to the drive-through, and don't forget that even the pickiest eaters love French fries. It's easy to see how fast food has become a culinary staple for the impoverished. Children are constantly bombarded by cartoon characters in advertisements telling them to eat chicken nuggets and sugary cereal. School lunches are composed of pizza and cheeseburgers and vending machines at school sell cheap potato chips and Yoo-hoo. We have no nutritional education in many of our nation's classrooms, and physical education budgets are being cut 47
Gregory Katz: Social Causes of Obesity
every year. As a consequence, obesity rates among poor children continue to increase, causing a concomitant rise in their lifelong risk of obesity and its myriad complications.6 In the clinic, we lecture patients repeatedly about feeding themselves and their children healthier food. But trying to make healthier choices isn't enough because food manufacturers exploit people who attempt to do the right thing for their families. When a bottle of Heinz ketchup touts the health benefits of lycopene, how can Crystal's mom be expected to know that the sodium and high fructose corn syrup decrease – if not totally negate – the condiment's healthfulness? A box of Honey Nut Cheerioes brags about being packed with fiber to help lower cholesterol, practically screaming, "Eat me. I'm healthy!"7 Forgive them for not also boasting about the 9 grams of sugar – from three different sources – per serving. Welch's is eager to tell you that its grape juice is packed with vitamin C and heart healthy antioxidants. But they aren't quite as eager to report the 38 grams (almost ten teaspoons!) of sugar in each eight ounce glass.8 Motivation to make better choices is necessary but not sufficient; we must also arm our patients with the skills necessary to decipher deceptive and manipulative food labels. When the discussion of a physician's responsibilities inevitably comes around to the importance of preventative medicine, it is crucial that we remember that prevention means more than just increasing the availability of primary care doctors. It also means more than just providing the lip service of lifestyle counseling and the generic advice of telling Mom to give her children less soda and feed them more fruits and vegetables. Patient education and dietary counseling are more than boxes to be checked on the never ending to-do-list that makes up a doctor's day. Just going through the motions will not suffice. But sincere, personalized counseling is time consuming and difficult, and it doesn't always have a tangible impact on health outcomes. And for patients like Crystal, limited resources like time and money mitigate the potential for change. The reality of the situation is that these complicated problems just don't have simple solutions. The medical profession exists at the intersection of public policy, economics, cultural values, personal decision-making, and education. The way we practice needs to take this into account, because chronic disease has a multifactorial etiology. We need to impress upon parents the stark reality that the choices they make today will affect their children for the rest of their lives. We need to educate children from an early age about nutritious eating and developing a healthy lifestyle. At the same time, it is imperative to change the economics of agribusiness to reflect the true price of our food; the real cost of that double cheeseburger is not just one dollar if eating it leads to diabetes and heart disease. Parents must take ownership of their families' lifestyles while physicians need to focus on more than just treating the symptoms of disease and giving generic dietary lectures. And medical education cannot continue neglecting the intimate relationship between diet and health. As a member of the American Medical Association, I receive daily emails detailing new advances in research, changes in policy, and advice on how to navigate the infinitely complex web of health care payments and incentives. Often, these emails encourage me to lobby Congress in an effort to prevent Medicare reimbursements from being cut. Not once have I been pushed to advocate cutting farm subsidies or increasing funding for school lunches and physical education programs. We have a responsibility to look out for more than just our own financial interests; it is our duty as physicians to advocate for our patients' health at every possible level – from discussions with parents to negotiations with hospital administrators to our efforts to lobby Congress. Improving health care cannot be limited merely to expanding health insurance coverage and access to doctors. Health must be more than a peripheral issue in the way we debate policy. At the same time, physicians and patients do not need to await a governmental consensus before changing some of our own behaviors. To adequately tackle a problem of this magnitude and importance, we must expand the scope of our thinking.
Gregory Katz: Social Causes of Obesity REFERENCES [1] Katherine M. Flegal; Margaret D. Carroll; Cynthia L. Ogden; Lester R. Curtin . Prevalence and trends in obesity among US adults. JAMA. 2010;303(3):235-241. [2] Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, National Health Care Expenditures Data, January 2010. [3] Malnick SD, Knobler H. The medical complications of obesity. QJM. 2006;99(9):565–579 [4] Pollan, M. The Omnivore's Dilemma. New York : Penguin Press, 2006. [5] McDonald's Nutrition Facts. http://nutrition.mcdonalds.com/nutritionexchange/nutritionfacts.pdf [6] National Center for Health Statistics, Health United States, 2005 (Hyattsville, MD: Government Printing Office, 2005), accessed online at www.cdc.gov/nchs, on July 1, 2006. [7] Cheerios Nutrition Facts. http://www.cheerios.com/ourcereals/honeynutcheerios/honeynutcheerios.aspx [8] Welch's Nutrition Facts. juices/100-percent-grape-juice
David Maerz Day Off
Mostly White Coat Yaakov Liss
I might have been a segment of hospital wallpaper A drab cream easily ignored But for that coffee stain on the left sternal border Of my short length medical skin Announcing my sleeplessness and clumsiness I've attempted cover-up with my stethoscope bell But could not escape judging eyes during auscultation Concealment with a Blackberry But found myself frightened to Google… Even obscuration with a fortress of pens Positioned in a row Ruined by my bowing Sending me to the ground to gather the debris I should really stop by the dry cleaner. Where on my way, I happened upon a vagrant-- unkempt, malodorous Who screamed, "I like your coat, doctor." I should really stop by the dry cleaner, But I probably never will.
Two Diamantes Jordan Teitelbaum
Life bright, brief breathing, growing, thinking awareness, movement, obstruction, decline falling, failing, leaving silent, permanent Death ———— Hurting electric, intense burning, piercing, mutating sickness, slowness, rebound, reversal collaborating, flowing, functioning fixed, soothed Healing
Paul Janoian Tarrytown Lake 52
An Uninvited Visitor Marissa Friedman
He almost always comes unannounced, but absolutely uninvited. He lingers in the bedroom, and soon spreads into the living room, dining room, and kitchen. He lurks in the dark corners of the house. Always on our minds even when out of sight. He pervades our conversations, causes arguments between family members; fills us with sadness and fear. We ask the questions, "Why is he here?" and, "How can we get rid of him?" So, we take the curtains off the windows, Let the rays of sun burn down on him. We lace his meals with toxins. Gather up as much of his things as we can And throw them out. For the lucky ones, he leaves. But the dread of his return remains. For the unlucky, he takes a loved one with him, And the memory of his visit haunts us forever.
Ernest Yushvayev SUNY Downstate Hiding
Matters of the Heart Marissa Friedman
We can repair a patent foramen ovale, and give nitroglycerin for angina. We can solve the problems of congenital anomaly, or try complementary and alternative medicine from China. We can place a percutaneous stent. Do triple coronary artery bypasses, or quadruples. We can even perform a transplant, only done according to the appropriate scruples. Yes, modern medicine brings a plethora of methods anew, but sometimes it's the heart's most common pathology that leaves us feeling like we don't know what to do. So alone we face the true last frontier of cardiology. For even with all the things surgeons can put together and take apart, there will never be the right medical treatment to cure the broken heart.
Anna Djougarian Comfort
Anna Djougarian Relentless San Diego, Summer 2010
Tried and Fried Jordan Teitelbaum
palpitations, irritations, insufflation, excavation eradication, reparation, interrogation, information, proliferation, generation intubation, extubation, urination, defecation For the patient by the patient said the patient, quoted, noted, diagnostically devoted and rarely sugar-coated training without complaining sometimes looking at dots but not the painting but that's because there's not enough time to the days to navigate crazy mazes we need answers and solutions to cure the body's confusion, it's collusion intruding on increasingly few worry free sprees so please bend at the knees and recite me your ABC's that wart we can just freeze or if you prefer, burn off medical minds which never turn off brains stuffed, buff ready to call the bluff raring to get rough, to get tough to tell disease enough's enough to cure, to heal to secure what's real To healthiness, To happiness To never too much "too" of either of the above 57
Paul Janoian Frozen Pond at NYMC
Here Today, Here Tomorrow Anchit Mehrotra
Twenty Eleven, A-M-P. Here next year? Ask Doctor Lerea.
Paul Janoian Sunshine Cottage Road
Sapphire Blew Charisse Chin
I trusted and defended you and now you stand before me With angry, questioning eyes Eyes so full of hate The flush of blood invading my cheeks betrays the outer confidence I try to invoke "Sapphire, let me get someone who can help you" I am just a medical student— LET ME GET THE HELL OUT OF THIS ROOM!! Before you can finish berating me, I open the door You and your stroller propel past me And barely miss my toes My heart is racing. I just survived my first angry patient My aversion to conflict has been challenged I'm glad to have gone through this as a 2nd year medical student Grateful to start the indoctrination process early H O W E V E R… Part of me wonders if she'll come after me, As I've just become the target of all her frustrations Boy, am I glad to have a house alarm. When I speak to experienced medical professionals it seems like N O
…just part of the job Bizarre patient encounters make me question this.
R.I.P. Little Tiny Tim Harry Flaster
When Kim Young, a third year medical student at Stafford, first saw the ghost, he felt nervous because he was not sure he could correctly recall the SPGP, the Stafford Pediatric Ghost Protocol. The ghost was a young boy, dressed in a hospital gown, standing with one arm on an IV pole for support, looking out the window of the 4th floor Pediatric ICU, watching the rain splatter and run down the panes, the rain drops disappearing into the mist rising from the street below. Gathering his composure, Mr. Young struggled to remember what he had first been taught in lecture, then read about in textbooks, then tested on exams, reenacted in role-plays, and then tested on exams again. Like everything else in medicine, dealing with a ghost had a proper protocol, based on empirical evidence, which he had been required to memorize. He felt nervous because he was not sure if he could remember the protocol now. He struggled to recall the relevant lecture. "Remember, when you first see a ghost, do not panic. Remain calm. Remember that you have been prepared for this situation, and that you can easily call on the experiences of your colleagues and the resources of the hospital, should you need help…" He could not recall what the Professor had said next, and he had no desire to wake up a Resident to ask for help. It was bad enough that he consistently pestered the Residents with questions about the management of living patients, that he should wake them up to help him manage the dead. Frowning, he stared at his own murky reflection cast by the window, scattered by raindrops but still recognizable. His white coat, ID, stethoscope, small books and notes bulging in his pockets stared back at him. Fortunately, at this distance, the blood shot eyes accentuated by dark circles from lack of sleep were not visible, and he felt slightly more confident. The professional uniform and tools were reassuring to Mr. Young, a sign that at least he didn't look as unprepared for clinical medicine as he knew he was. The ghost, of course, did not have a reflection. Nor did it breathe. Most relevant, it was clearly the same boy that his team had treated yesterday, a ten-year-old with Duchenne Muscular Dystrophy (DMD), an X-linked disorder that leads to muscle wasting and physical deterioration such that most children are wheelchair dependent by 10 to 12 years of age. This was a particularly severe case of DMD. Along with the more prominent muscles necessary for walking, the muscles needed for respiration also were severely weakened. Even the cardiac muscle had begun to be replaced by fat and connective tissue. This boy…his name was Eduardo Martinez, he forcefully recalled…had acquired pneumonia perhaps because his respiratory muscles could no longer completely inflate his lungs…and then yesterday he had a heart attack. My. Young had participated in the Code, and before he watched him die, a Resident had given him the opportunity to practice chest compressions on his small, fragile body. During the chest compressions, he had broken one of Eduardo's ribs. Straddling his small body, he had felt and heard a snapping, like a small branch giving way underfoot in a forest. This was not unexpected. It meant he was doing the chest compressions the right way, hard enough to force blood to Eduardo's brain. Now Eduardo was back and Mr. Young could not recall the ghost protocol. It was 12:30am. He stared at Eduardo's back. The small boy, standing, was now suddenly more real to him in death than he
Harry Flaster: R.I.P. Little Tiny Tim
had been in life. Minutes passed, but they could have been hours, with the dull hum of respirators, the sound of the rain on the glass, and sheer exhaustion combining to make Mr. Young feel as if he had stopped breathing also. Maybe, for a few seconds too long, he did stop breathing. It was hard for him to tell. Then, with a start, it started to come back to him. Some neuron, somewhere, had started firing with the right frequency to recruit others. The lecture returned, in a haze, but recognizable, the Professor droning on in his memory… "Most ghosts are innocuous and temporary. Studies have shown that 75% of ghosts will disappear within 24 hours of the first sighting, and that 95% of all ghosts will be gone within the first week. Most of the time, it will be sufficient and best to do nothing, and wait for the ghost to leave on its own… However, please recall that you have been taught the proper protocol, developed at this University, to hasten the departure of a ghost. It may help to remember 'R.I.P. Little Tiny Tim.'" He stared at Eduardo, trying to recall the meaning behind the acronym. Again, his tired mind fired blankly, but then came through, like an old car rumbling to life after the ignition had been turned several times. "I think R stands for…Reason…What are possible reasons for the ghost to return? I – Introspection – What were your feelings about the person before they died? and P is for…Plan – What is the proper protocol to hasten the departure of the ghost? Little is for Location – Where the ghost first appears is significant, also, to whom it manifests… Tiny – What Type of ghost is it? The protocol differs depending on the age, appearance and behavior of the ghost, and Tim – Timing. When did the ghost appear? How long after death?" There, that was it. R.I.P. Little Tiny Tim. He felt a mild sense of triumph, when the mnemonic worked. He felt less nervous now. There was still the problem of the ghost, but since 75% of ghosts disappear within 24 hours, he thought he would take his chances with this one. There was no requirement to report a ghost unless it – oh shit – what was it again? There was no requirement to report a ghost unless it…interferes with patient care…or is present for over a week. This ghost had done neither, so Kim was not required to report it. This meant he had less paperwork to complete, and the trip to Revenant Affairs across the hospital was not required. He paused, watching Eduardo before turning to leave. He was not bothered much by the apparition, though the lack of reflection was a bit eerie. He thought about saying goodnight to Eduardo before he left. Too weird, he decided. What if Eduardo turned around? Better to keep a low profile. It was time to get some sleep.
Five Days Later Five days later, and Eduardo was still hanging around the 4th floor pediatric ICU. This time, he appears on morning rounds while Mr. Young was presenting one of his patients to the team, an 8-year-old girl with cystic fibrosis and community-acquired pneumonia, resistant to first-line antibiotics. She was now struggling on a ventilator and they had just started a new course of antibiotics. He felt he was getting the hang of his pediatric rotation, and so when he began to present, it was with confidence, and he was finally loud enough so the entire team could hear him (one attending, two residents, two medical students, and one nurse). He felt prepared for interruptions and questions from 61
Harry Flaster: R.I.P. Little Tiny Tim
the physicians. "Jessica Parker is an 8-year-old girl with cystic fibrosis exacerbated by a community-acquired pneumonia who…" His voice trails off because Eduardo is back, again, and this time is walking beneath the white coat of an attractive, young female Resident and staring up beneath her skirt, smiling, then looking at Mr. Young and laughing. The team looks at him, as he pauses, mid-sentence, and there is a moment of awkward silence before he recovers and continues: "…failed empiric therapy of cephalexin started at Lakewood Community Hospital three days ago. Cultures are pending and she is now receiving IV antibiotics with Tobramycin with ceftazidime…" While Mr. Young struggles on, Eduardo has stopped looking up the Resident's skirt and has walked over to the computer, mounted on a table with wheels, adjacent to Mr. Young. Mr. Young tries to ignore him and continue with the presentation, but Eduardo has started to push the computer over at Mr. Young. Mr. Young attempts to casually rest his hand on the computer, to stop it from rolling, while he continues to stammer through his presentation. He forgets to report Jessica's past medical history. Eduardo has given up pushing the computer, but is now reaching for Mr. Young's notes. He struggles to continue with the presentation, but he is waving his notes in the air to keep them away from Eduardo. Finally, his attending interrupts him. "What the hell is going on?" asks Dr. Linda Rosen. Mr. Young is startled by her voice, normally sweet when talking to patients and their parents, now suddenly stern and direct. He hopes that he does not show his nervousness when he responds. "I am being interrupted by the ghost of Eduardo Martinez, a patient on this floor who died last week—" "When did you first see Eduardo?" "Last week." "And did you report it? Do you have someone from Revenant Affairs on the case?" "No, because I thought according to hospital protocol ghosts should only be reported if they interfere with patient care or after they have been around for a week… In a voice less stern, Dr. Rosen responds: "A good teaching point. You are right, that is the protocol that physicians follow. But medical students are required to report all cases immediately to Revenant Affairs. I thought that they would have taught you that before you started your rotations. Anyway, please remember the protocol from now on, R.I.P Little Tiny Tim. The R stands for…" Kim half-listened as she explained the protocol, frustrated, because he knew it but still had managed
Harry Flaster: R.I.P. Little Tiny Tim
to screw it up. He was angry with himself for forgetting this very important detail and angry with Eduardo for interrupting his case presentation. Dr. Rosen finished, finally. "OK Kim, after we examine Jessica, I want you to go to Revenant Affairs right away and report this case. Tomorrow, I want you to report on your progress with Eduardo before you present any new cases."
Revenant Affairs Revenant Affairs was on the other side of the hospital, in an older wing, built during the 1970s, during an architectural era that aspired to produce unadorned buildings composed of raw concrete and steel, in a style appropriately called "Brutalism." This name was accurate, as one had the impression of entering a prison, with few and narrow windows, and with the rust stains on the rough concrete, the only color or break from the uniform, angular, hallways and rooms. Mr. Young, as he walked down the halls, had the vague impression that he was being punished, sent to detention because of an apparition that he could not control. Somewhere, in this building, was Father Edwards, a Jesuit and a physician and the chief of Revenant Affairs. Father Edwards' administrative assistant had told Mr. Young to go down the corridor, turn right, then knock on room 166, and to be patient, because sometimes Father Edwards took a while to open the door. "He's there, don't worry". She had said. Mr. Young muttered something in response. It was meant to be a "thank you" but it came out inaudibly. She smiled. "Medical student?" she asked. "Yes". "Don't worry, we get a lot of you around here," she smiled. He reached room 166 and knocked. No response. He knocked again. A minute went by and then the door opened. Some smoke drifted out. Marijuana, Mr. Young recognized by the smell. A large man with a red face and erratic, gray hair appeared through the haze. He had bushy eyebrows, a prominent chin and mouth, eyes slightly red but still bright, as if glazed by tears. He wore a priest's collar around the neck, black and white, a black shirt and coat, black pants. "So, Mr. Young, what can I do for you today?" The voiced boomed, jovial, as Father Edwards extended a hand, smiling. Mr. Young felt enveloped by the large man, his black clothes a stark contrast with his warm, almost boyish demeanor, as they shook hands and exchanged pleasantries. How did he know his name? It took a second for him to recall that he was wearing his hospital ID. "Please, take a seat." Mr. Young sat, absorbing his surroundings, which were unfamiliar. He did not smoke marijuana, and was completely unaccustomed to an authority figure smoking it. Hanging on the wall were many pictures of medical school classes of years past, several different framed degrees, the text in Latin, and a
Harry Flaster: R.I.P. Little Tiny Tim
crucifix, adorned with "IHS" and the symbol of the Jesuit order. To compliment it all, a human skull was on the corner of Father Edwards' desk. "I believe you have a bit of a problem with a former patient that is seeking your attention?" Before Mr. Young could respond, Father Edwards continued: "Before we get to that, a few things about me, and this office. First, despite the crucifix, the skull and the priestly garb, I am a trained physician, and this office is not used for exorcisms, but for the appropriate, compassionate and scientific departure of revenants. Second, the marijuana is for medicinal purposes. This job does take its toll." His voice was deep, but light, and he displayed a brief, mischievous smile at the last statement. "Now, tell me about your ghost." Mr. Young began to describe Eduardo the patient, and then Eduardo the ghost, culminating in his disrupted presentation that morning. Father Edwards listened, occasionally asking a question, but mostly he sat nodding his head, encouraging Mr. Young to continue. When Mr. Young finished, he felt relieved. There were a few moments of silence, as Father Edwards sat, thinking. Mr. Young, for the first time in a long while, felt relaxed. He was in no rush to leave this strange man and his strange office. Perhaps the residual marijuana smoke was having an effect. Finally Father Edwards spoke. His voice was distant, and he was staring, not at Mr. Young, but at something else, not in the room. "What you have experienced is normal, and is something that everyone who practices medicine will experience at some point in their career. You have not seen Eduardo because you made a mistake, or because there is anything wrong with you. As Doctors, we try our best to heal the living, but we all, in one way or another, live with the dead. A ghost, or a revenant, is but a manifestation of a reality that most people outside of our profession have the luxury of living without. There are many ghosts in this hospital, and most, as I know you have learned, do not cause us much trouble. They disappear on their own. There are, of course, some who stay. I am sure they have made you memorize, R.I.P. Little Tiny Tim." Father Edwards smiles and looks at Kim. Mr. Young manages to smile back. "Yes". "That wonderful acronym is a bit dated, actually. I came up with it, but I've been a little too preoccupied with my work to update it based on the latest research," Father Edwards chuckled. "Now, we have ways of dealing with ghosts without having to interact with them. That is one option available to you. We could take care of little Eduardo just by using a simple, ingenious device, the EMR, which would put his spirit to rest. If you are interested in the science behind it, we should talk. I am always looking for new medical students to help with my research." "But that is for another time. For now, I will advise you what I recommend most students, or young physicians, who see their first ghost, to do. This ghost, it seems to me, is not malicious. Contrary to popular belief, most are not. In fact, it is my hunch that this ghost is sticking around to help you in some way. So you have two options: you can talk to the ghost, have a conversation, and listen to what it has to say, or I can employ one of my EMRs to silence his spirit. The choice is yours. However, I recommend to all my students and young doctors to do it old school. By that, I mean speak to Eduardo. From my biased perspective, this will make you a better physician, and you will be prepared to practice 64
Harry Flaster: R.I.P. Little Tiny Tim
in settings where EMRs are unavailable." Father Edwards allowed for a pause. "So, young Dr. Kim, what's it to be? A conversation with a ghost or silence with a machine?" Father Edwards smiled and waited patiently as Mr. Young considered his options. "I'll give talking a try, if that doesn't work, then the EMR." "Ok, great. I admire your decision. It isn't easy, to talk with a ghost. When you feel ready – which ideally will be soon, because the longer you wait the more difficult the conversation becomes – make sure that there aren't a lot of distractions or people in the ICU. Ghosts can be distracted, just like everyone else. Also, it helps not to have others watching who cannot see the apparition. To avoid unnecessary awkwardness. Any questions?" A pause. "What do you think the ghost will have to say?" Father Edwards smiled. "Always hard to say, though in this case I think you will be glad you spoke to Eduardo. If no other questions, then, good luck! You know where to find me if you run into trouble. Here is my pager number, feel free to page me at anytime if you need my help. I mean that." "Now go. Conquer the afterworld. Don't sweat it. Just part of becoming a Doctor." Father Edwards smiled.
Eduardo Martinez Mr. Young returned to the pediatrics ICU, and finished with his other responsibilities. He did not know how to best prepare for his conversation with Eduardo, so he did not try. Eduardo, in the meantime, seemed less interested in Mr. Young, and was watching a baseball game on TV. Evening fell, and the ICU quieted down, until the only sounds came from the hisses and clicks of the respirators and the beeps from the heart monitors. Mr. Young went to a small conference room, and waited. He passed the time by reviewing for his upcoming shelf exam. Taking a break, he looks up. Eduardo is there, staring right at him. Mr. Young does not know what to do, or say. Feeling foolish, he offers a seat to a ghost. Eduardo, despite Mr. Young's self-consciousness, sits down. Not knowing where or how to begin, Mr. Young tries to remember something about Eduardo other than his illness. He remembers, with a flash of guilt, that he had been so busy, so concerned with gathering data and clinical history, that they hadn't spoken much at all. The only thing he could remember is that Eduardo liked baseball. "Who is your favorite baseball player?" Kim asks, finally.
Harry Flaster: R.I.P. Little Tiny Tim
"Pedro Martinez!" Eduardo replies, immediately. "He is the best picture in beisball, and he is from the Dominican Republic, like me, and he is going to make 17 million dollars in the next six years, so he is going to be really rich, and he plays for the Red Sox, which is the best team in all of beisball, and he will probably win the World Series." The words mix and tumble joyfully. "And, my Dad says that his Dad was a janitor, and my Dad is also a Janitor, which means that even I could grow up like Pedro Martinez. And we have the same last name." They talk about baseball, and his family, and the nurses in the hospital, the ones he likes and the ones he thinks are mean. Then abruptly, like any ten-year-old boy, Eduardo gets bored, and says goodbye, and rushes out of the room. The next evening, Mr. Young is finishing his work and preparing to go home when he crosses paths with Dr. Rosen. She asks him about Eduardo. "We talked about baseball, and his family," Kim said. "I have not seen him since we talked." Dr. Rosen gave him a smile she normally reserves for her patients and their families. "Glad to hear it". And she walks away. The sun is setting, casting its dying rays towards the windows, seeking its way through blinds and curtains to where the patients lie.
Ernest Yushvayev SUNY Downstate Waiting 66
Mohs Surgery: The Cutting Edge of Dermatology Christine Shaver
Recently, my friend noticed a small bump on his scalp, well hidden in his hair, which did not seem to be going away. Having heard public service announcements about skin cancer, the fact that the small bump would occasionally bleed, scab over, but never really heal seemed worrisome. A trip to a dermatologist led to a biopsy and a diagnosis of basal cell carcinoma. Fortunately, the prognosis is excellent for a patient if the basal cell carcinoma is removed. While there are multiple methods for removing carcinomas, a technique called Mohs surgery was used in this case, and this article will explain more about the procedure. Mohs surgery highlights the interesting combination of skills that a dermatologist will use in an office setting to result in a highly effective method of tumor excision while minimizing the extent of tissue removal. The Mohs surgical technique was actually discovered by a medical student, Frederic Mohs, in 1938 at the University of Wisconsin-Madison, yet it is still cutting edge in the realm of skin cancer treatment in 2011. Of course, changes have been made over the years to the original technique, but the same principles apply. Essentially, the goal of Mohs surgery is to excise a cancer in its entirety while minimizing removal of uninvolved skin at the tumor margin. The whole procedure will occur with a patient under local anesthetic in the physician's office. The Mohs procedure can be simplified into a process with a few main steps (figure 1), each of which draws upon knowledge from a different field of medicine, thus requiring the Mohs surgeon to be medically well rounded. First, the Mohs surgeon will use skills in surgical oncology to excise the visible tumor while leaving a border of uninvolved skin of approximately 1mm (a standard skin cancer excision would remove a 5-6mm border around the tumor). The patient remains in a waiting room while the specimen is then prepared, cut on a cryostat into thin slices, stained with hematoxylin and eosin, and visualized under the microscope with an eye that is trained in neoplastic dermatopathology. The surgeon makes a "tumor map" where he diagrams the excised specimen and marks the areas where cancerous cells are observed. In areas containing cancerous cells that extend to the border, more slivers of skin must be removed from the patient and further examined microscopically for neoplastic change. The tumor map is modified and the procedure continues until the Mohs surgeon no longer finds tumor cells in areas removed from the neoplasm's margin. Finally, knowledge of reconstructive surgery is needed to repair the skin defect and allow for proper wound healing. Thus, the physician performing Mohs surgery uses broad medical skills, as he utilizes the fields of pathology, surgical oncology, dermatology, and reconstructive surgery all at once. The cure rate when using Mohs surgery for basal cell carcinoma, the 67
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most common skin cancer, is in the range of 97-99.8%, which is extremely encouraging. When asked about his procedural creation, Dr. Frederic Mohs replied, "The crucial idea of excising the cancerous site layer by layer and systematically examining the undersurface of each excised layer under the microscope by means of frozen sections is so logical that it is surprising that it was not thought of a century ago."1 Many agree that the idea is straightforward, but the knowledge needed to perform the procedure can be challenging to find within a single physician. While Mohs surgeons who perform all aspects of the procedure exist, other physicians have opted to take on a team approach to the technique. Some doctor's offices elect to assemble a small team consisting of a surgical dermatologist, histotechnician, and pathologist, but the team must be well-integrated and all members must work together for the team to operate smoothly. So how does one become a qualified Mohs surgeon? Currently, Mohs is a subspecialty of dermatology, and those applying for training must complete a dermatology residency. However, this is not what Frederic Mohs envisioned for the future training of Mohs surgeons. Rather, he believed people from all aspects of the medical realm should be able to receive Mohs training, since most of the time dermatologists are often not involved in primary recognition of early cancerous skin lesions. When writing his first book on the technique, Dr. Mohs said, "The book should be useful to physicians who may be called on to treat or advise regarding treatment of skin cancers and other conditions that are described. This includes dermatologists, surgeons, plastic surgeons, otolaryngologists, gynecologists, urologists, proctologists, pathologists, internists, and general practitioners."2 While knowledge of the Mohs surgical procedure is useful for any physician to have, unfortunately, if one desires to become a Mohs surgeon, it is still necessary to obtain certification in dermatology. REFERENCES [1]
Mohs FE. 1978. Chemosurgery: a microscopically controlled surgery for skin cancer – past, present and future. J Dermatol Surg Oncol; 4:41.
Mohs, FE. 1956. Chemosurgery in cancer, gangrene and infections: featuring a new method for the microscopically controlled excision of cancer. Springfield, Ill: Thomas. p.vii.
Private Interest, Ethics, and Sincere Medical Practice Yousuf Sayeed
Why do people go to healthcare professionals? Generally speaking, the experience is costly, can be extremely intrusive, and professionals are often difficult to get a hold of. That being said, people still find the justification to look past these flaws and cancel all of their plans, leave their country, give up any sense of privacy, and go into massive debt all in order to receive the services of these professionals. Individuals endure these sacrifices because they believe their intentions are shared by the healthcare provider, a provider that has the knowledge to actively work towards a common goal – to fulfill the medical desires of the patient. In an ideal world, these individuals would always be right. Unfortunately, this is not always the case and neither intentions nor the goals are always shared. For as long as I can remember, I have understood that healthcare providers can work for their own benefit. They have just as much of a right to pursue their own interests as anyone else. The true gravity of this understanding, however, did not become as apparent until lately. After a recent visit to an optometrist for a spare set of glasses, I found my experience to be quite "eye-opening," to say the least. The first thing I noticed was the way in which the optometric technician offered an optional eye test. "For just fifteen dollars more, we can test you to check for signs of diabetes and other health problems," she said. Although it seemed like a harmless question and I aloofly agreed to get the exam, in hindsight, it felt more like I was hearing a sales pitch rather than any sort of medical recommendation. After that exam, my sight was further evaluated by the optometrist. The doctor suggested that I should look into having my lenses compressed so they look less bulky. This is a process in which the lenses are made thinner and lighter. She had not stated any sort of medical benefit the procedure would provide, yet she emphasized the aesthetic aspect of compressed lenses. When I politely told her that I had no preference for how the glasses looked because I was going to be using them as a spare set, she appeared to take it personally, as if I was indirectly disappointing her. Later, as another technician was charging me for their services, he insisted that I have my lenses compressed. At one point, he even claimed that they would not be able to fit my lenses in the frame I chose if they were not compressed. I told him my vision had not changed a great deal from my last exam and I did not think that I needed to have my lenses compressed. After that, he showed me a chart of permissible prescriptions that did not need to be compressed. To his dismay, my prescription was clearly within the limit. This agitated me because it made me think that I was doing something wrong for not wanting compressed lenses. I did not go to the optometrist to question my sense of fashion or self-image – I simply wanted an extra pair of glasses. Looking back, I can honestly say it felt more like I was dealing with salesmen and women than healthcare professionals. It was not only in the words they used but also in the nuances of their tone, the way they were upset when I decided against their offer. Having worked in sales, I can understand where they were coming from and why they were being so pushy. They had numbers to meet, commissions to earn, bosses to please, etc. On the other hand, they reminded me of why I quit my sales job and made me question my perception of the goals of healthcare. I feel that this type of behavior should be frowned upon in the medical community. Not only did it tarnish my opinion of the optometrist, it made me, the patient, feel more like a customer. Had I been more naïve, I would have bought whatever they felt I should buy. I even wonder if they cared about whether customers had the type of money to pay for their unnecessary services. With this in mind, I lost 69
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a great deal of trust in the optometrist and found myself analyzing the dualistic nature of a healthcare provider's recommendations. Much of the culture currently practiced in American society emphasizes monetary value and private interest. This emphasis undoubtedly carries over to the healthcare industry, as Bradford Gray writes, "Pressures on the physician to consider interests other than the patient's are increasing. Qualitative, financial, and organizational changes are taking place that may affect whether physicians behave as if responsible, first and foremost, to meeting the needs of their patients."1 Indeed, physicians are vulnerable to the same motivations as the rest of us. With a surplus of options for treating patients and a subjective method of practice, it is not uncommon for physicians to choose a specific procedure or product over another if it provides the physician a personal benefit too. One particular instance of such behavior occurred in Louisiana State University Health Sciences Center in Shreveport, Louisiana. As Mahar writes, "[Hospital officials] say that they were startled to discover that Sulzer Medical had agreed to pay Dr. William Overdyke, an assistant professor at the center who oversaw knee replacements, $75,000 a year to consult on product design while also 'promoting and educating surgeons' on the virtues of Sulzer products."2 Interestingly, it was later noted that Dr. Overdyke and his residents used only Wright Medical Technology products prior to 2000, right around the time when he made a deal with Sulzer. He was found guilty of violating Louisiana state ethics laws and was charged $100,000 for his actions. As a supposedly unbiased employee of the state, the actions of Dr. Overdyke were clearly immoral. Recent events have made the financial aims of some healthcare entities much more transparent. There is a growing trend in hospitals in which asking for payment prior to administering a procedure on an individual is becoming increasingly customary. In fact, "In 2004, Atlanta's Grady Health System, Georgia's largest public hospital, put a new billing system in place: patients scheduled for procedures are called in advance and informed of their co-pay, among other charges."2 On the other end of the spectrum, Mahar goes on to state how the not-for-profit Carle Foundation Hospital, the primary teaching hospital for University of Illinois, condones the arrest of patients that cannot afford to pay their healthcare bills after treatment. From a hospital's perspective, it is understandable why they would want to ensure their patients can pay before they operate on them. Also, one can see why hospitals go to great lengths to receive payment for their services. Still, there is something inherently wrong about refusing to treat patients with life-threatening illness or arresting former patients that could not pay their medical bills. In the study "Insurance Status and Access to Urgent Ambulatory Care Follow-up Appointments," Asplin and other researchers hired graduate students at the University of Chicago to schedule follow-up appointments with clinics in 9 cities throughout America. These students pretended to have either pneumonia, asymptotic accelerated hypertension, or a possible ectopic pregnancy. They attempted to seek care through the clinic within one week of the phone-call. The researchers found that 64.4 percent of the students that claimed to have private insurance could receive treatment within one week while only 34.2 percent of students claiming to have Medicaid were offered appointments. Sadly, only 25.1 percent of the students offering $20 and inquiring about a payment plan were able to see a physician within a week while an astounding 66.3 percent of students offering to pay for services in cash up front were given appointments for the following week. Asplin's study best illustrates the self-serving attitudes prevalent in healthcare. Those that hold private insurance or are able pay completely are clearly held to a different standard than individuals on Medicaid or no insurance.3 In terms of day-to-day practice, there are other factors that can influence the motivations of healthcare providers. When it comes to writing prescriptions, pharmaceutical companies do everything in their power to convince physicians to choose their brand. By offering vacations under the clause of a 70
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minor lecture, office equipment like pens and pads, and free lunches, they are essentially buying the physician's opinion. Katherine Greider asks, "Ultimately, it's a matter of common sense: If all these meals and lectures and gifts had no effect, then what possible motive could the drug companies have for providing them?"4 It is costly to provide all these services to physicians and profit-seeking companies understand that the return is greater than the investment. While some physicians actively prescribe specific medications because they enjoy all the gifts the pharmaceutical companies provide for them, others may be doing it subconsciously because they see the name of a company on the very pen and pad they are using. Some may argue that these trends in medicine are beneficial. Many tout that the capitalistic nature of American medicine, based on improvement through competition and potential fiscal gain, is the reason why we are superior in medical practice in comparison to the rest of the world. Surprisingly, researchers found that this is not necessarily true. While American medicine is undoubtedly advanced, private interest can often times get in the way of providing quality healthcare. According to the study, "Use of Cardiac Procedures and Outcomes in Elderly Patients with Myocardial Infarction in the United States and Canada," in 1991, American physicians were over 6 times more likely to conduct a coronary angiography and nearly 8 times more likely to perform a percutaneous transluminal coronary angioplasty or a coronary-artery bypass surgery after the first 30 days of a myocardial infarction than their Canadian neighbors. One would think that patients would fare much better after undergoing these procedures. On the contrary, the mortality rate for American patients was 21.4 percent while the rate is 22.3 percent for Canadian patients after the first month of surgery during that year. A year after the surgery, the mortality rate rises to 34.3 percent in the US and 34.4 percent in Canada.5 When looking at the tremendous cost of surgeries such as these commonly performed in America, along with the devastating amount of debt families go under, it is difficult to justify the difference between these mortality rates and still claim that we are so much better off than other nations. In fact, during 2007, 62.1 percent of personal bankruptcies in America were primarily due to medical issues.6 This highlights the need for efficient healthcare that considers the holistic needs of the patient rather than what procedures generate the most revenue. Considering these issues, one has to ask, is any of it ethical? Is it justifiable for a dentist to deny a patient that cannot afford to pay them? How about an optometrist that requests a costly test procedure for no relevant purpose? And a physician prescribes the brand name drug when they know the cheaper generic one works just as well? I am not going to pretend to know the answer to these questions. Under the current economic system, both hospitals and the healthcare provider have every right to seek profit. Moreover, the media glamorizes the roles of physicians, dentists, and other healthcare providers as lucrative authorities in American culture and indirectly encourages them to seek profit in efforts to keep up with the image they established. That being said, I believe private interests should never be attained at the cost of the patient. Once the healthcare provider begins to treat the patient, they should ignore all personal incentive and place the patient's goals ahead of their own. Offering honest treatment is critical for long-term success in any healthcare professional's career and may be one of the most rewarding experiences in medicine. If the physician genuinely believes that a more expensive pill will better serve the patient's needs, then that should the only justification required to prescribe it. Admittedly, there are gray areas in which physicians must use their best judgment to determine the rationale behind their decisions. As an example, many would argue that conducting an expensive MRI provides a more accurate representation of the patient's condition than a CT-scan could. While this may potentially benefit the patient, the use of an MRI may also be manipulated to generate profit for the hospital under the disguise of higher quality images. In cases such as these, it is important to consider the overall benefit of the patient rather than concern oneself with how much can be made from a proce71
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dure. Presenting the options to an autonomous patient in an objective manner is one way physicians may promote ethical conduct and prevent biased decision-making. Not only is there is an implicit feeling of shame when a provider misuses the trust given by the patient to seek personal profit, their reputation is also damaged if the patient realizes what is happening. The patient can choose to find a new provider, or worse, the patient may consider the treatments suggested by the provider unnecessary; they may stop taking their medicine. If there was any truth to the treatment offered by the physician, the patient may be harmed for not adhering to the physician's advice because they found out the physician lied to them. In addition, the news of any healthcare provider exposed to seeking profit at the cost of the patient inevitably harms the credibility and benevolent nature of genuine medical practice. Not only does that physician lose the respect of the patient, their conduct may be demeaning for the entire profession. There is an overwhelming feeling of smallness when it comes to large-scale issues such as these. Individuals often claim that they are "just one person" and their actions are not significant in the grand scheme of medicine. The truth is, a little goes a long way in the healthcare community. Every interaction with a patient reflects exponentially on the entire practice. Most people do not go to see a healthcare provider every day. Taking that to heart, through the individual decisions made by each healthcare provider throughout America, the integrity of medicine can be made stronger. Even though private interest is a cornerstone of professionalism, it is only one aspect. It should not play a role in the attitude between the healthcare provider and patient. Indeed, there are very few certainties regarding ethics and healthcare. Practitioners should aim to serve the needs of the patient above all else. That being said, one thing that I am certain about is that I need to find a new optometrist.
REFERENCES [1] Gray, BH. The Profit Motive and Patient Care: the Changing Accountability of Doctors and Hospitals. Cambridge, Mass. [u.a.: Harvard Univ. Press, 1991. Print. [2] Mahar, M. Money Driven Medicine: The Real Reason Health Care Costs So Much. New York: Collins, 2006. Print. [3] Asplin, Brent , Rhodes K, Levy H, Lurie N, Crain L, Carlin B, Kellermann A. "Insurance Status and Access to Urgent Ambulatory Care Follow-up Appointments." The Journal of the American Medical Association 294.10 (2005): 1248-1254. Print. [4] Greider, K. 2003. The Big Fix: How the Pharmaceutical Industry Rips Off American Consumers. New York: Public Affairs. [5] Tu J, Pashos C, Naylor D, Chen E, Normand S, Newhouse J, et al. 1997. Use of Cardiac Procedures and Outcomes in Elderly Patients with Myocardial Infarction in the United States and Canada. The New England Journal of Medicine, 336, 1500-1505. [6] Himmelstein DU, Thorne D, Warren E, Woolhandler S. 2007. Medical Bankruptcy in the United States, 2007: Results of a National Survey. The American Journal of Medicine, 122 (8): 741-746.
Scope of the Scope Benjamin Cox
The stethoscope is an important medical instrument, but it is also a symbol that holds a variety of meanings for different groups of people. The patient sees the stethoscope around an individual's neck and instantly recognizes that individual as a healthcare provider. The doctor visualizes the stethoscope as an important piece of diagnostic equipment. The young medical student visualizes the stethoscope as a symbol of pride and acceptance into the healthcare community. An experience on Bellevue's inpatient pediatric floor taught me that while my stethoscope certainly functions as an identifier and a tool, it can also be used as a powering teaching instrument. One of my patients on the pediatrics floor was an energetic, adorable little kid who had been admitted to the hospital after a severe asthma attack landed him in the ER. While talking to his parents, I learned that he had previously been taking an asthma controller medication every day, but when the prescription ran out, his parents did not get a refill because "he seemed perfectly healthy." I know that asthma is a chronic inflammatory process that is occurring inside the little guy's body even if he looks fine on the outside, but the parents clearly did not. Once I was able to get the youngster to stop running around the room long enough to perform a physical exam, my suspicions were confirmed. I put my stethoscope against the patient's back and heard the wheezes in his lungs with textbook clarity. The smiling kid playfully broke away and ran back over to his mom; as she hugged him, she gave me a look that said "See doc!?! I told you he's a happy, healthy kid!" In a flash of inspiration, I asked the mom if she wanted to have a listen to her son's lungs. She looked at me dubiously, but then proceeded to take my stethoscope from my outstretched hand. As I put the diaphragm of the stethoscope against her son's back in just the right spot, I vocalized the highpitched whistling sound that she should listen for in a way that made the little patient giggle. Curiously, the mother put the eartips in her ears and as she listened, I saw a light bulb turn on in her head that was so bright that I'm sure that it could have been seen from Brooklyn. The mother finally understood that there was something really serious happening within her son's lungs even though he outwardly appeared healthy. No doubt, some previous doctor had heard the same wheezes that I did and had come to the same diagnosis and treatment plan that I had. However, it seems that he or she had failed to explain to the parents what was going on inside their son's body, why their treatment plan was important, and how the medicines worked to keep their son healthy. Without this information, the parents were unable to truly become empowered and to take ownership of their son's healthcare. The word "doctor" originates from the latin word doctoris which means "teacher." I think that a flaw of the fast-paced nature of clinical medicine is that it can cause students and doctors alike to lose sight of the true meaning of this title. At times, we operate solely as a care-giving machines that generate diagnoses and come up with treatment plans. We use our shiny stethoscopes and deft maneuvers to get access to information that is hidden within the patient – information that only we know how to obtain and interpret. This particular experience taught me that as a healthcare provider, it is in my best interest to get down off my high-horse and really take the time to share some of this information with my patients. The information I derive from my interview and physical exam allows me to get a deeper understanding of the disease process and guides my development of a diagnosis and treatment plan; though I have 73
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found that it is just as important to share this information it with its owner and allow the patient to get a deeper understanding of their own body and empower them to take control and manage their diagnosis and treatment plan. When I first got my stethoscope, I saw it as a symbol that I was a bona fide member of the healthcare community. I draped it around my neck and it made me feel like a doctor. Now I have a better idea about what that really means. When patients see my 'scope around my neck and call me "doctor,� I quickly correct them and tell them that I'm only a student doctor, but silently I smile to myself and bask in the glory of that title. I do like to think of myself as a doctor – that is to say, a healthcare provider and a teacher.
David Maerz Opportunity
Complications of PPROM: Preterm, Premature Reality of Medicine Diana Kirschner
I moved closer to my mother as we lay together in triage bed four. It was a wonder how we both fit on that bed at all. I had insisted on being as close to her as possible even if it meant having my back up against the cold guard rail and the side of my body stretched out in itchy hospital sheets while tangled up in IV lines and EKG leads. Two weeks earlier, mom had undergone an elective foot surgery to fuse her fifth tarsal-metatarsal bones in hopes that it would relieve her osteoarthritis. The surgery was "unremarkable" as health professionals would say, which to others translates to "nothing to worry about." Indeed, nothing worrisome did occur until two weeks later, when my mom was at the tail end of her two-week bed rest. My dad had been waiting on her hand and foot, no pun intended, as she recovered at home. One day my dad, a lawyer, came in to the bedroom with the Lovenox injection that he gave her daily, jokingly announcing, "Nurse Ratchett is here!" My mom laughed, a warm, hearty laugh that was followed by a bout of coughing and shortness of breath. It was the first "remarkable" thing that happened since the operation. Nurse Ratchett was worried that she was getting pneumonia, so he insisted they go to the Emergency Room. This was when I got a phone call, as I was living far away at the time. Mom was admitted to the hospital that night after a chest X-ray showed not a pneumonia, but a mediastinal monster. By the time I arrived, fresh off the red-eye from the West coast, she had already gotten a biopsy of the mass. We waited four hours in triage bed four, among the unfamiliar smells and sounds of the Emergency Room, for the results that would change our lives forever. It was Cancer. I moved back home to be with my parents and to take care of my mom as she battled through the first few months of aggressive chemotherapy. Of all the things I had done as a premed student, being in the hospital with my mom turned out to be the best preparation for medical school, which began five months later. It wasn't your average First-year student schedule. I attended class in the morning and then spent the afternoon and evening in the hospital with my mom. At times it felt like a curse, an emotional roller coaster that went upside down. Nevertheless, I'm thankful because the whole experience helped me define my personal and professional goals with respect to the doctor-patient encounter. I was blessed that my mother received some good old fashioned TLC, on top of the new medications like 5FU, 6MP, and MTX. Her physicians served as great role models to me, and they helped me define the type of doctor-patient interaction that I strive to emulate. Now that I am a third-year student, I have the ability to interact with patients one-on-one, discussing the intimate details of their health and diseases. It is frustrating that although you must memorize treatments, doses, and side effects, you cannot technically write prescriptions for patients. However, I found a way. When my mother was sick and times got really tough, I sought the company of my friends. The most comforting thing anyone ever said to me was "Wow - That sounds really tough," to which I responded immediately with, "Yeah, it does!" That simple gesture my friend extended to me normalized and legitimized what I was feeling, which made me feel instantaneously better. So, when a patient tells me their chief complaint, now, before I gather anymore information, I look him straight in the eyes and say, "That sounds really tough." In that moment, I dispense empathy, and I am able to prescribe. I am writing for "Legitimab" and "Zelnormalize," and it is immediately effective, both for the patients and for me as a doctor-in-training. No matter where I go or what I do, these "drugs" will always be on my personal formulary, at no cost, and with unlimited refills. 75
The Modern Bloodletters Charles Volk
Bloodletting was once considered as much a profession as an art. If one came down with any number of diseases up until the mid-19th century, you would often find yourself on the business end of a gleaming blade. All along, the physician wielding it assured you that this was for your own good. In the very limited treatments of the time, bloodletting was often called upon to relieve suffering and possibly to cure the imbalanced humors that were believed to be the source of disease. Funny how in the current era hospital patients often feel they are being subjected to the same treatment. Instead of brass springloaded scarificators or ornate knives, we now have gleaming surgical steel hypodermic needles and colorful plastic tubes. The patients are constantly assured the blood they give will be used for diagnosis, but the connection between the bloodletting of antiquity and the modern age is inescapable. The people who find their niche in the world as these "modern bloodletters" are called phlebotomists. A phlebotomist is a technician who specializes in drawing blood samples. The majority of states in the US have no law requiring phlebotomists to be certified, although many hospitals give special consideration to those who are. However, more consideration is given to people who have previous phlebotomy or laboratory experience. I was a recently unemployed college student looking for a new job, and I wanted to work in the medical field, so this looked like an attractive entry-level position. I had no certification, and I didn't have the time to duck out of my already significant school workload to take a 4-6 week course on drawing blood. Nevertheless, I did have a pretty significant laboratory background, and I stressed that as much as I could. I submitted my application and waited to hear back. As luck would have it, I got the position and soon started my new job as a phlebotomist. My starting wage was about $13/hour. I found out later that this was about the national minimum, but it was more than I had ever been paid before and I was just happy to have my foot in the door. I had no misperceptions that this relatively high wage was because of the inherent danger of the job. When one works with blood and needles all day, a mistake could mean contracting a serious disease or harming a patient with a poorly executed blood draw. I found I had a knack for venepuncture and completed my monitored training quickly. This took about a week. My hospital really just wanted to teach me the basics and assumed I'd pick up the rest on the job. If I had gone through the certification course, they would have taught me about regulatory agencies, venepuncture equipment, legal issues, and the cells and fluid in blood. Surprisingly, what the blood tests actually look for or the medical indications for said tests are not in the curriculum, as this is not considered important. All these things I learned in the coming weeks of my job and I am of the opinion that certification probably wasn't a very time-efficient method of preparation. However, if I had been certified, I probably wouldn't have been quite so nervous the first time I stuck a needle in a patient. My hand was shaking so vigorously I was afraid I would miss the vein. My first patient was actually someone about my age; early twenties. She had veins big enough to hit blindfolded, but this was the first day I was actually on the floors of the hospital instead of just doing administrative paperwork. Bumbling and putting in the needle upside down, I still wound up drawing the blood correctly, all while the patient just smiled at me and said I was doing a good job. I have a sneaking suspicion she just thought I was cute. My coworkers were a diverse group, but could be lumped into three major categories: Students: Like myself, there were a number of people who were either premed or were at some point in their nursing career. There were also a few people who were trying to go to a radiology technician 76
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school or other medical technician training. We all found phlebotomy to be an excellent entry-level medical job to get experience. Foreign-Born: These people had advanced medical degrees in other countries, but for one reason or another their qualifications just didn't come to the U.S. with them. Of these people, the person that most exemplified this category was a physician from Ethiopia. While working on getting his MD certifications reinstated here in the states, he needed a job with minimal qualifications even though he was vastly overqualified. 'Lifers': Some people inadvertently fall into jobs that they simply do well. While the first two categories of people work at most a few years, 'lifers' have a considerably longer lifespan. They have found something they do well and that pays well. They don't have any particular love of medicine as a profession, but they're happy right where they are. The level of knowledge required to do this job is very minimal. The powers that be just want you to be able to stick a needle in a vein and hit it almost every time. After a couple of months, pretty much everyone is proficient enough to hit 90% of their blood draws. This may seem low to many people, but don't forget that this is a hospital, and some of these patients have already had blood drawn twenty times in the past week. This means that many of the sites used for blood draws are no longer available, and very sick patients have a tendency to have fewer sites and worse veins. Chronic illness takes its toll. Within a year, most people hit their peak and get anywhere from 95-99% of their assigned blood draws. There is a certain amount of luck in every venepuncture and skill simply allows the portion ascribed to luck to account for less and less, but one can never get to 100%. This really is true for every medical procedure, however. This is simply the skill portion of the job, though, and most people stop right there. Medical knowledge and insight are not technically required, but it is disheartening to always tell a patient who asks you which tests are being run, "I don't know." That being said, simply knowing a little about medicine goes a long way. For example, I had an order to draw an A1C level (shows long term glucose control by looking at markers on hemoglobin in red blood cells) on a patient, but looking over their previous labs I noticed that we had run a considerable amount of blood typing for transfusion. I figured that this test might produce an erroneous value because of all the donor blood the patient had in their veins. Instead of getting the patient's A1C, the ordering physician would get some summation of all the different donors' A1C values, confounding the result. After asking a number of nearby lab personnel if this line of reasoning was correct and receiving blank stares in the process, I ventured on into the forbidding land of the pathologists. I'd like to take a brief foray here into the unspoken separation between physicians and lower employees. There is a feeling that doctors are too busy to answer your menial question or to be bothered by a mere phlebotomist. Whether cultivated by society or to some extent by physicians themselves, this created a gulf between those who take care of patients, and those who dictate that care. That is, if you can ever even get a hold of a doctor. As luck would have it, the pathologist who specialized in blood disorders happened to be in his office. If it was after business hours, I don't really know what I would have done; probably shut my mouth and presumed the patient's doctor knew what they were doing. I brought my question to him and to my relief, he agreed. He calculated that at least 25% of the patient's blood was from a donor, and that this test would probably come back erroneous. He thanked me and called the physician to notify them the test could not be run. It is things like this that make knowing a little about how a human body works helpful in allowing a 77
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hospital employee to stop a problem before incorrect results are posted. If I hadn't noticed it, it would have gone through the system without a peep. Every phlebotomist has a story like this, and this shows that some knowledge about medicine is useful and shouldn't be stifled just because of the fear of legal reprisal. Knowledge can help head off problems before they begin and prevent the kind of errors that end up in lengthy court battles. There are many different kinds of patients. I'm not talking about patients with specific complaints. I'm talking about abrasive patients, interrogating patients, apathetic patients, comatose patients, etc. It isn't long after dealing with them that you have a bag of tricks to deal with most every type of personality you encounter. That being said, the majority of patient types want to know what you are doing when you walk into the room with a cart full of needles. When I started, since I got little to no training on what these tests actually mean, I had no other option than to reply, "I don't know. Please ask your doctor or nurse to explain it." I knew that this was passing the buck and that it was doubtful the nurse (who was the likely one to be asked) even knew what exactly had been ordered. This wasn't out of ignorance, but because they didn't have the time to memorize their patient's lab tests. The next time the ordering physician came in, I doubt they'd take the time to explain every test in detail. That is, if the patient even remembered to ask. I felt like I was really in the ideal position to explain what I was doing and maybe even provide some rationale as to why the doctor ordered it. For routine labs, the reason they were ordered was usually too general to be able to determine. For example, the physician may have ordered a complete blood count (CBC). The reasons for wanting this test are so numerous I could never say exactly why it was ordered. However, even with those general tests, simply explaining what a CBC looks for (a test that looks at all the cells in your blood) is usually sufficient. It actually takes a few trial runs to learn how to explain a test to a member of the general public. You never really know where the person you are talking to is coming from and you don't want to shoot over their heads or talk to them like they are children. I often found myself erring on the side of vague. For example, the subtleties of iron metabolism are not common knowledge and the numerous tests that look at iron regulatory proteins in the body can really be summed up with, "These tests will look at how your body is handling iron." Usually people were satisfied with this level of explanation. On the other hand, when a physician orders a serum drug level, it is abundantly clear what they are looking for. Perhaps this was taking my job too far and overstepping my "place" in the hospital hierarchy, but I don't want to be part of a system that treats people in the same way as a mechanic would fix a car. I would like to have patients be a willing partner in their medical care, not just a passive recipient. I had to draw a blood level of an antibiotic on a patient one evening. I stepped in to the room, made my introductions and then said, "I need to draw some blood to get a level of the antibiotic you are taking. We want to be sure that you aren't getting too little that it won't be effective, and not too much that it will start to cause undue side effects." The patient responded, "I sit here all day and have random people jab needles into me for who knows what reason. I feel like it is worthwhile if I at least know why. Thanks." Similarly, I had a patient who was getting calcium levels checked every few hours. A bit annoyed at the frequent disturbances, she asked me why this was happening so often. I saw gauze taped to the front of her neck. I knew that the parathyroid glands had something to do with calcium control, that they reside in the neck, and that surgery was usually curative. So, I asked if she came to the hospital for a parathyroid surgery. She answered "yes" and I said that since parathyroid disease causes blood calcium level abnormalities, we were checking her calcium levels to make sure her treatment was successful and that we didn't need to do anything further. After that explanation, she was more than happy to get the testing done. 78
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In another scenario, there is a newborn screening program where a phlebotomist collects blood from babies once they pass 24 hours of age. It involves using a lancet on the baby's heel and blotting the blood on filter paper. The phlebotomist usually also has to apply a gentle massage of the foot to keep the blood flowing. About half of babies cry and the other half don't. The majority of those who cry are actually doing so because you are holding their foot. Other than the slight pinch of the lancet, the procedure is painless. However, from the parent's point of view, it appears like we are stabbing and crushing their baby's foot. It looks kind of barbaric. This was one of the most universally despised blood draws amongst my colleagues. When I was being trained, my colleagues would only describe the test to the parents in the most basic of terms and hand them a pamphlet, referring them to an absent nurse or doctor for more information. This did nothing to assuage their immediate anxiety of mortal danger to their newborn child. They would then leave the nonplussed parents to make the baby undergo what appeared to be a horrifying procedure. The phlebotomist knew they were actually causing no harm and would get frustrated when parents got upset. The whole situation made us look like monsters. After a mother broke down in tears while I was collecting a specimen, I decided I needed to change something. I did my research on what exactly the test looked for and why it was done. I sat down and read through the pamphlet we would hand out as well as looked the testing up on the internet. From that point on, as soon as I entered a room to do one of these tests I would start a lengthy spiel about how the test can prevent serious disease and how it really isn't painful. I would even go as far as demonstrating the massage on a parent's hand to show I wasn't going to crush their child's delicate foot. After that, collecting these tests was a breeze. The couple of minutes it took me to explain everything in detail resulted in less frustration, saved time, and made for a better birth experience for the parents. It was a uniquely satisfying experience from that point on. Much to the delight of my coworkers, I gladly snatched up these orders. I've walked in on plenty of physicians talking to their patients about their treatment plan, and the most common thing physicians say about blood draws is, "Someone will come up here in a little bit and draw blood for some tests." I can't really blame them for being so vague. It's likely the doctor is not yet totally sure what they're going to order. However, it's very doubtful that after the orders are put in the doctor comes back and explains in great detail exactly what they ordered and why. Presumably the doctor doesn't want to overload the patient with the minutiae of their care. The doctor moves on to another patient and the phlebotomist is left holding their orders in one hand and a bunch of patient questions in the other. It was standard practice that if there was a question about a blood draw, we would ask the nurse. One, because they were always there and relatively easy to get a hold of. Two, it was presumed that the doctor had explained something about the tests they ordered. At the very least, they knew the patient so they could perhaps extrapolate why. In most cases, the nurse could figure out the problem. Largely, they were scheduling or duplicate order errors, but there were occasional problems where an order didn't make medical sense. They would then be stuck in an uncomfortable position between us and the doctor. For example, there was a patient admitted the afternoon of Christmas Eve. The doctor ordered some routine labs but put them in the computer incorrectly. They were ordered to be drawn immediately instead of the next morning when normal "routine" labs were drawn. I had no reason to doubt the orders, so I went and collected the tests. By the time I got back to the lab, the orders had been cancelled and retimed for the next day. It essentially meant the blood in my hand was useless. I called the nurse to explain what had happened and that we should just use the blood 79
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I collected and not get more tomorrow, since they're just routine admission labs anyway. We don't have any previous lab values to compare these to, so it didn't matter if we collected them now or tomorrow. She came back at me with the old catchphrase, "Well, if the doctor ordered it…" It occurred to me that since it was a holiday, the floors were mostly staffed with their most inexperienced staff (read: those who didn't have the leverage to get the day off) and this nurse sounded fresh out of college. She didn't want to possibly ruffle any feathers, and I can't really blame her either. It's tough out there for a new nurse. In this case, despite my continued protestations, she wouldn't relent on her position and I gave up. I threw the blood I had just collected away and the patient was drawn the following morning for the same tests. As relatively benign as this case was, it highlights a more pressing concern. The common sense of the hospital staff is purposefully confined since the legal ramifications of allowing them to think for themselves are just too damning. It seems like a stretch to claim that a phlebotomist saying routine admission labs are as good now as they will be tomorrow morning is tantamount to practicing medicine without a license, but I'm sure the hospital legal department would come to a different conclusion. However, I am of the opinion that one doesn't necessarily need a medical license to point out a glaring fault in logic. The examples I gave were not me trying to hand out my own brand of medical advice. In fact, a lot of the things I said to patients were just explanations of what tests were being run and what they look for, with me not even trying to guess what the doctor wanted to see. I didn't have that information and in most cases the patients didn't want to know that much. They just wanted to know what was happening to them and to have some semblance of control after they've been stripped of their clothes, possessions, and made to live in a small room while strangers come and stab them with needles. Training phlebotomists to give small explanations of their orders makes the patient feel like they are a part of their own care. We don't need to train phlebotomists to make life-or-death medical decisions, but merely to know what the tests look for. Just knowing which color tube to put the blood in is the minimum requirement. Perhaps we really need to push for more. Time after time, I was put into impossible situations. I would go up to the floor and the patient would ask me detailed questions about their labs that I could not possibly answer. I had never met the patient before and I didn't know their diagnosis. I wasn't even allowed to look at their chart. When I would try to find answers for them, I found a nurse who had no idea what the doctor was thinking and a doctor that was nowhere to be found. The answer to this dilemma, of course, is "Keep your head down and do what you are told." This is probably why 'lifer' phlebotomists stay on for so long. They don't want to know what a blood test is because then they will have to explain it to a patient once they ask. A woman who had been working there over ten years and had probably drawn several thousand CBCs did not know what the test looked for – just that the test required a purple top tube. This is likely why people like me stay only a couple of years at most. It's a great way to get your foot in the door, but there is just no growth. This is true of many of the medical technician jobs. It seems like the only person allowed to use their head is the doctor, and this is the antithesis to the multidisciplinary approach. We are all a team in the hospital, and I honestly wanted to help the patients I drew blood from. The phlebotomist is in a unique position where a good amount of time is spent talking to the patient during the procedure. Lab personnel are also less intimidating than the overworked doctors and nurses. People would open up to us and they felt like it was okay to complain, but I was powerless to make any change for the better. Confining phlebotomists to doing a robot job may be efficient, but once the process breaks, the individual pieces are helpless to respond. 80
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As luck would have it, a few years after starting the phlebotomy job was my first day of medical school; training to be the person writing the lab orders instead of collecting them. Once my day comes to explain to patients all the tests I want to run, I have no doubt that I will likely say, "I'm going to order some blood tests," and leave it at that because I have 20 more patients to see. However, I will do my best to try to come by the same patient's room a little later and ask if they had any particular questions about the labs that were drawn, all the while wishing I could empower the "modern bloodletter" who drew the blood to give the patient the detailed explanation they deserve.
Luke Selby Glacier National Park, Montana
Broken System Holly Foote
I had heard of the sentiment of a heart falling into the stomach, of the giving way of what held them distinct from each other. I had heard of this before. But I wondered when it happened to me why no one had elaborated on the phenomenon. Why no one ever mentioned that it wasn't a sinking feeling, akin to losing your stomach on a roller coaster, but that it was a hot iron mallet pounding your heart, decimating it until it melted into the lower recesses of your abdomen. And on the roller coaster, when you start to head back up on the track and find your stomach suddenly in your throat – it wasn't like that either. My heart stayed on the floor. My first year of medical school was the hardest year of my life for more reasons than simply that it was my first year of medical school. A good portion of my pain during that year came from watching my very best friend in the world, Amy, become more and more ill. Worse, I watched her become less and less her. We were nine when she was diagnosed with Type I diabetes mellitus, and after the ravaging effects took over her body, the sickness began to creep into her soul. Her kidneys were the first to begin to fail, but more organs began throwing in the white towel as her body and spirit became exhausted. I remember the last meal I had when the world was still normal and not broken. After finishing our last final on the last day of our first year, my friends and I went to eat cheese and drink wine to celebrate. We left there full of the richness of the meal and of the communion with friends who had survived so much together. As I walked down the street, I listened to the voice mails that had accumulated during the meal. My best friend had gone to the hospital again. Nothing new; she was probably vomiting again, and only the hospital had drugs strong enough to calm her stomach and soothe the pain. She had to be resuscitated. This was different. But, I had sat beside her during dialysis a few times and watched her erratic blood pressure and respiratory rate. Once, as the number continued to fall as I stared at it, I looked at her alarmingly and called out, "Amy! Are you breathing?" She suddenly sat up and said she was trying. She was in a coma. And everything stood still. It was as if the wind quit ripping around the buildings of Manhattan. My friend's voices became blurry murmuring in the background. And my heart fell into my stomach. I boarded a plane. I laid my head in my own lap during the long flight home and seeped soft and continual tears into my pillow. I knew I was going home to say goodbye, and it wasn't the way it was supposed to be. I needed answers to what had suddenly happened to my friend, why she had lost this fight, why no one seemed to have been able to help her win this battle. The truth rolled out, just as the CT scan printout did so I could read the words that said my friend might be lying in that bed and her heart might be beating and her lungs might be expanding, but she wasn't really there anymore. Amy was alone at the emergency room, and although she was a "repeat offender," and her ejection fraction was recently as low as 6%, she was not hooked up to any kind of monitoring system. They couldn't say why her heart had failed, or how long it had been since it had done so by the time they looked in and noticed she was unresponsive. They just knew that she had not taken a breath on her own since, and this was over. 82
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My heart still pummelled, numbness gave way to a staggering rage coming all the way up from my toes and threatening to explode out my ears. My questions went unanswered, partly because there was no record of the actual event that ended her consciousness and partly because only a devoted nurse was there to offer support. I never saw a doctor, neither while Amy was on life-support nor after her heart slowly stopped beating again and she slipped away. I don't know if her blood sugar was checked initially; I don't know her potassium level; I don't know if she was scared, if she sat up suddenly, trying to catch her breath or if she simply nodded off to sleep on the pain medicine. And sadly, no one else does either. My friend died alone. No one was sitting beside her in the emergency room watching her numbers because no numbers were being monitored. Amy's heart was only this sick because when she told her family doctor that she was having problems breathing when supine, her doctor told her it was just panic attacks, ignoring the obvious sign of congestive heart failure. This proceeded for months before a routine heart test for being on the kidney transplant list found the severely depressed heart function. Although she had more doctors than most people have keys on a keychain, there was not cohesiveness to her care, and her health suffered. Just as she slipped away with the ED unaware, Amy slipped through the cracks of medical care in the grander scheme. My broken friend was treated by a broken system, where communication is not key and patients as individuals aren't paramount. A heart stopped, and hearts broke. Amy's was a complicated case, and this warranted more time and care from her specialists and them communicating with each other. Complacency was evident in both her established medical relationships and in the emergency room. The holes must be tended and the cracks mended. We must repair this system and find a way to grasp tighter to our patients and hang on for dear life.
At a Loss for Words: Language Choice in the Doctor's Office Evan Schloss
As we push on further into the 21st century, rising rates of immigration combined with increasing globalization have diminished the need for ethnic communities to assimilate into American culture. It is well established that there are significant disparities in health-care existing along ethnic and racial boundaries. Cultural and political pressures push communities to pick and choose which aspects of the native cultures to preserve in their new environment. Thus the differing cultures clash and the most apparent of these clashes is language. To function in society, individuals must communicate with others using language, creating a dynamic interplay between different languages. In this kind of situation, it is unclear when, where, and how each language takes precedence. The doctor-patient relationship is one of the closest interactions that exist, where the patient reveals his or her lifestyle, emotions, and personal views to the doctor, and the doctor reciprocates by using that information to comfort and heal. Of course, this is the epitome of the ideal doctor-patient relationship, and things are not so simple in practice. It is the words doctors and patients use to interact that are essential to the outcome. So the question is: how do we choose what words we say to others? And furthermore, how do those choices affect the other person's attitude toward the relationship? Let us put aside the doctor-patient relationship for now, and examine language choice from a linguistic point of view. There can be many reasons why a person chooses to speak a certain way to another person. For example, a child may address an adult in a formal way to express the power disparity between them. Similarly, that child may speak more frankly using slang to one of his or her friends. Linguist Joan Rubin extensively mapped out the boundary between two endemic languages in a bilingual society when she investigated the use of Spanish and Guarani (a native language) in Paraguay.1 Rubin aimed to expand upon earlier studies with a comprehensive look at all the factors that influenced language choice, including location, first language acquisition, and predicted language proficiency. The location of bilinguals (either rural village or urban city) greatly influenced their language choice of either Guarani or Spanish, as a result of assumptions and internal assertions about the likelihood of whether those they encounter would speak either language. This is in addition to how they judge the specific individuals they wish to speak with, and their backgrounds in each language (degree of bilingual-ness). In general, formal situations like talking to a teacher, a well-dressed stranger, or any stranger in a city would warrant a bilingual person to speak Spanish (as the language of the establishment), while any other situation with even a hint of informality would warrant a bilingual speaker to speak Guarani, the "common" language. Indeed, this criterion is supported by others investigating this subject. Linguist Peter Farb writes of the Guarani speaker "quickly feeling his inferiority…coming to market in the city" and generalizes that "probably all bilingual situations equally stigmatize those who use low-prestige languages."2 Thus the overarching influence that molds the "norms" determining language choice appears to be what opinions one has about either language, and how that choice will make him or her appear to others. Of course, this opinion depends on where and to whom the speaker is speaking, among other criteria. How can such linguistic interactions shed insight on the doctor-patient relationship? It is exactly these covert calculations that determine the course of a medical interview. The doctor-patient relationship is primed to behave like interactions in a bilingual society because it is a power relationship. The doctor speaks two dialects, the vernacular and medical jargon, in either English, another language, or multiple languages, and the patient may speak multiple languages at varying proficiency with his or her own level of understanding of medicine, traditional or non-traditional. The moment a patient steps through the door, a negotiation of these cultural norms begins. What race is the patient? How is the patient dressed? Does the patient speak with an accent? Content with his or her 84
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impression of the patient, the doctor begins to speak to the patient. After several exchanges, the doctor may receive new signals and switch to a different speaking tone or level of vocabulary. Linguistically, this is called "code switching." Meanwhile, the patient may be completely different from doctor's assessment and speak very formally, holding back information because he or she is intimidated by the doctor. The patient may even be offended by the doctor's code switching mid-interview, based on the doctor's own cultural assumptions. By the end of the interview, the level of information obtained by the doctor and the patient's satisfaction can widely differ depending on the cultural negotiations during the clinical encounter.3 Language choice and cultural assumptions between doctor and patient have genuine effects. A study reported that residents viewed African Americans as less likely to abstain from substance abuse, less educated, less intelligent, and less likely to pursue a healthy lifestyle. This could translate into residents not considering African Americans as worth the effort to treat to the same standard as other groups. Another study found that Hispanic men received less analgesia compared to Caucasian men for the same amount of pain. Most striking, especially considering today's emphasis on empathy in medical education, is a study that reported Hispanic patients feeling less empathy and rapport building even when interviewed in English. Clearly there is some incongruity between what the patient conveys as his or her concerns and how the doctor interprets those concerns, resulting in unsatisfactory care and an unproductive doctorpatient relationship. 4 This means that no matter how good an interviewer's interpersonal skills, no matter how they tried to convey empathy or cultural understanding, there was a fundamental disconnect between interviewer and patient. I don't think this was an active bias. Medical professionals do not choose where they grew up or what their cultural background is, and it can be difficult to relate to patients who speak differently and have a different background. Doctors and patients cannot just hand each other a written summary of their backgrounds and cultural views. Instead, they must gather this information during a brief clinical encounter, judge it against their own cultural assumptions, and decide to speak a certain way, all without flinching from their duties as doctor and patient. It is no surprise that there are so many health-care disparities today. If there is always some cultural bias in doctor-patient interactions, then the only viable solution would seem to be matching patients and doctors based on ethnicity. Indeed, it has been shown that minority patients have expressed greater satisfaction and greater utilization of health-care services when their providers are of their own race.5 However, it is impossible for every patient to have a doctor of a race of his or her choosing. Perhaps health-care professionals could research as much as they can about cultural aspects of their patient's lives to lessen the burden of cultural negotiation during an interview. Professional interpreters should be used as much as possible to salvage patient information vulnerable to cultural misunderstandings. There can never be a perfect system where the doctor comes precisely from a patient's culture and speaks the same "language." Still, we can look to linguistics for a model of the dynamics of the doctor-patient cultural negotiation juggling act. REFERENCES [1]
Rubin, Joan. "Bilingual Use in Paraguay." Readings in Sociology of Language (1968): 513-529.
Farb, Peter F. "Linguistic Chauvinism." Word Play: What happens when people talk. Ed. John J.Gumperz. 4th ed. New York: Bantam Books, 1976. 170-174.
Fisher S, Groce SB. Doctor-patient negotiation of cultural assumptions. Sociol Health Illn. 1985;7(3):342-374.
Ferguson WJ CL. Culture, language, and the doctor-patient relationship. Fam Med. 2002;34(5):353-361.
Laveist TA NA. Is doctor-patient race concordance associated with greater satisfaction with care? J Health Soc Behav. 2002;43(3):296306.
Informed Consent: A Cultural Dilemma Emily Junck
In America, we take it for granted that we make our own healthcare decisions. We expect our doctors to present the facts about important treatments and procedures, and to let us make choices about whether or not we want to receive them. We see this as a right and to treat without consent is a set-up for a lawsuit. However, in some countries, it is customary for particular decisions to be made by the patient's doctor or family, and the patient may even become offended if asked to make a choice. I learned about such beliefs when an elderly Korean woman, whom we will call Mrs. Lee, was admitted to the hospital last year. She had become severely anemic from a gastrointestinal bleed and needed a blood transfusion. The resident grabbed the consent form and walked down to her room to explain the treatment. Mrs. Lee was sitting in her hospital bed with her daughter nearby. The resident offered to call for a Korean interpreter, but the patient asked her daughter to translate instead. The resident began explaining her medical diagnosis, why she needed a transfusion, the pros and cons of such a treatment, and the risks of refusing a transfusion. He went over the small risk of contracting HIV, Hepatitis, and TRALI, the very rare but serious condition of 'transfusion-related acute lung injury.' Both the patient and her daughter became more agitated and wide-eyed during this discussion, and the Korean explanations were becoming lengthier. At last, the resident leaned forward to offer Mrs. Lee the consent form and a pen, and asked her if she would receive the treatment. Mrs. Lee sat still and did not reach out to take the form. She slowly shook her head, and said something to her daughter in Korean. The daughter hesitated, then explained that her mother did not want to sign the form. Over the next day, the reasons behind her refusal were revealed. In Korean culture, it is traditionally considered bad luck for a patient to know about a serious diagnosis or a poor prognosis. Decisions are typically determined for the patient by the doctor or the family, which is considered to be in the patient's best interest. Being ill, the patient is in no state to have to think through such decisions and their consequences. But more importantly, without knowing about his or her condition, the patient is able to maintain hope. Traditionally, Koreans believe the doctor is the expert and will make the best decision for his or her patient.1-3 While Western medical decision-making styles are becoming more widespread, it is not uncommon for doctors to make major decisions for their patients without their input. Mrs. Lee interpreted the young doctor's detailed explanation of her diagnosis and treatment plan as a reflection of his incompetency and unprofessionalism. She believed it would have been more respectful to have first presented the situation to her family and to have allowed them to help decide how to explain it to her. There were many cultural barriers that affected this interaction. Medical discussions can often be very technical and the interpretation may not have been accurate. A professional translator would likely have led to a more clear and culturally-appropriate understanding. Also, the patient was likely wary about signing an official document. It is not as common to ask for a signature in some countries and people may be more cautious about signing a document for fear that doing so may bring legal or financial consequences. Another factor that may have led to patient dissatisfaction is that the resident provoked anxiety by describing the details of Mrs. Lee's medical care. In many countries, including Korea, death and disease are taboo topics and medical information, including statistics about risk, are not as commonly discussed. Patients may also not want to intervene with aggressive treatments because of religious or cultural beliefs. They may believe that their disease is a consequence of actions they made during their life and that taking a passive role is a type of repentance. A patient's religion may teach that it is up to a higher power to decide when their life will end or how it will proceed. 1-3 Potential cultural differences such as these must be kept in mind when healthcare providers approach the process of informed consent. 86
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Western practices of full disclosure are becoming more common in Korea. However, this change seems to be inspired more by a desire for legal protection by healthcare practitioners than by a change in patient attitudes. Lee et al published a study in 2008 in which a selection of forty-eight Korean physicians, nurses, and patients and their family members who had recently undergone a major medical decision were interviewed about their beliefs and experiences with informed consent. Patients, their families, and nurses viewed informed consent as a "coercive process" that negatively impacts the patient and is performed as a formality to protect physicians against legal consequences. However, the majority of patients and their family members wanted better communication with their doctor and felt the doctor's attitude was authoritarian and discouraged questioning. Younger patients complained that they would prefer to make their own decisions, but that explanations were more often provided first to their family members and that their physicians seemed to place a greater value on the wishes of the patient's family members than on their own. Physicians felt that the process of informed consent builds trust and creates a better relationship with the patient and their family, though they acknowledged that it has a legal purpose as well.4 These results illustrate the differences between physicians and patients in their views of informed consent. Patient preferences are changing with younger generations, but old practices in Korea remain ingrained in the medical system. Patients are beginning to desire more information and more power in their own medical decision-making, but family-centric values still dominate in the approach to this process. Though a patient may wish for the doctor to make decisions for them, or may wish to receive a treatment without having to sign a document, we still must observe Western practices in the American system. However, confusion and discord can be avoided by using a few techniques when approaching this topic. Explaining the process of informed consent is important to educate patients about their role in their own healthcare. One such approach would be to explain that each person has different values that affect the quality and quantity of his or her life. By making a decision, the doctor is not abandoning the patient or refusing to advise him or her, but simply allowing the patient to be involved in deciding what is important in his or her life. The doctor should include in his or her explanation that the patient can involve family and friends in their decisions, although he or she will be the one to designate his or her final choices. The purpose of the signature should be explained and the patient should be ensured that the document only releases the doctor to do the specified treatment, but that they will have to ask the patient in order to perform any further interventions. It should be guaranteed that if the patient changes his or her mind, the procedure or treatment can be stopped at any time. The resident in our story thought that using Mrs. Lee's daughter to translate would make her more comfortable and would allow the team to receive consent and begin treatment more immediately. However, he did not attain the intended results and would have likely been more successful with the use of a professional translator. The process of informed consent requires thorough explanation, attending physician involvement, and skilled translation. Many residency programs are now conducting courses about proper methods to obtain informed consent, but some residents feel that time constraints restrict them from strictly following the recommended procedures. However, taking the time to assure that the patient understands their diagnosis and treatment options will produce greater patient satisfaction and more efficient treatment long-term. Using a multicultural approach to informed consent can help decrease miscommunication and conflict. Healthcare providers cannot assume that a patient will hold certain beliefs simply because they are foreign. Likewise, they cannot assume that a patient will understand or accept the conditions surrounding a treatment because they look "American" or speak without an accent. Mrs. Lee eventually received her blood transfusion, but not until the attending physician discussed the issue with her entire family. A hospital translator helped with the challenging explanation of the possible complication of TRALI and calmed her fears about contracting HIV. Her case teaches us lessons about tactful approaches to explaining complicated medical topics. The process of informed consent is important to 87
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allow patients an active role in their healthcare and should be performed thoroughly and sensitively with all patients.
REFERENCES [1] Sohn, Linda (2006). "Older Korean Americans." Doorway Thoughts: Cross-Cultural Health Care for Older Adults. Volume 2. Ed. Reva Adler. Sudbury, MA: Jones and Bartlett Publishers. 96-111. [2] Kim-Rupnow, Weal Soon (2001). "An Introduction to Korean Culture for Rehabilitation Service Providers." Center for International Rehabilitation Research Information & Exchange Monograph Series. Ed. John Stone. Retrieved from <http://cirrie.buffalo.edu/culture/monographs/korea.pdf>. [3] Crow, K, Matheson, L, and Steed, A (2000). Informed Consent and Truth-Telling: Cultural Directions for Healthcare Providers. Journal of Nursing Administration. 30(3): 148-152. [4] Lee, W, Kim, I, Kong, B, Kim, S, and Lee, S (2008). Probing the issue of informed consent in health care in Korea—concept analysis and guideline development. Asian Nursing Research. 2(2): 102112.
A Polish Grandmother Andrei Kreutzberg
It was easy to understand why my grandmother was such a unique woman. Her father was reported to be a practitioner of the occult practices, painting an enormous eagle on their garage, meant to ward off evil spirits. His spell books were purported to have a page with an attached piece of mysterious skin. Her mother held séances to communicate with the dead and enjoyed chasing her young grandchildren with a vacuum cleaner. My grandmother met my grandfather at age 16, and he was the first and only man she ever kissed. On one of their early dates she held her arms out and proclaimed, "Kiss me like they do in the movies." These were the days when a kiss meant a lot, more than just "I kissed a girl and I liked it." This was a kiss that sealed the deal; babies, grandbabies, the whole ball of wax-that kiss took her on a journey from New Jersey to Jamaica, to California, and finally to Washington State. This woman was entirely irrepressible, her strength was legendary. While her husband was out saving the world with the cause du jour, she was working to support her family and raising her two daughters. Animals and children loved her; she was like Mother Theresa with a Jersey accent. I recall how effectively she handled my grandfather's occasional fits of rage. During the peak of yelling, he would begin an exorcism process, making the sign of the cross and compelling the spirit of my great grandmother, Helen, to go back to the grave. "Christ commands you, Helen, leave the body of my wife." Her retort was typically a raspberry and a bird. Argument over. And yet despite the work, the children, the arguments with grandpa, she always left time for her life's passion, her art. My grandmother was always an artist, she loved to draw, paint, weave, but it wasn't until my grandfather built her a studio that her ability to produce art really took off. Interestingly this was about the time she began to show signs of the horrible disease that would take her life: Alzheimer's. It was almost if somehow she knew this was her last opportunity to give birth to the art that was inside her. Her tapestries are breathtaking. Her piece de resistance is a 30 by 15 foot tapestry of various colors and figures which still hangs in my grandfather's home. Of course their home is a converted barn, only such a large room could house such a large piece of art. Over time her comments became more and more bizarre. Upon leaving the dinner table, she commented that my cousin "not get any fatter." She noted that my brother had a "nice round face." After my grandfather commented on my good looks (he's very near-sighted), she made sure to add "and hes got a big nose too." After a visit I put all my bed sheets in the hamper to aid the cleaning process. She took my mother aside in private to tell her that I had wet the bed and stuffed all the sheets in the hamper. I'm pretty sure I didn't wet the bed. Pretty sure. Little by little she disappeared into the nebulous fog that characterizes Alzheimer's disease. The horrible, soul killing disease that rips loved ones away piece by piece, leaving behind a shell that only serves to mock the greatness of the former being. But I'll remember my grandmother not the way she was when she was sick, but the way she was when she was enjoying life with her family. I'll remember sitting on her lap as a small child while she showed me a book about exotic animals, and I'll remember her in the kitchen cooking up one of her extraordinary creations. But most of all I'll remember her keeping my grandfather in check.
Sabrina Perrino Pole Pole (Slowly, slowly) - A State of Mind Zanzibar circa 2007
Thoughts in a Disaster Sean Kivlehan
"What is your deployment status?" It was the second week of my third year Psychiatry clerkship when my phone rang and I heard the excited and nervous voice of my old ambulance partner. Instinctively I answered "available," and 72 hours later I was on a plane to Haiti. Immediately on arrival, the fragility of the human mind was recognized. Tempting as it is to draw lines between the providers and admitted inpatients, the reality is that their separation is merely by a thin line of circumstance. This is not always readily apparent, but after a few conversations most patients can be related to the provider. Many have had difficult lives, others succumbed to intangible psychoses or anxieties, and even more have both. In American inpatient units, patients are well defined and manageable. Spending time with each during the day and exploring their history is beneficial to both the interviewer and interviewee. By hearing about the patient's situation, their opinions, and events leading up to the admission, both people gain an insight and understanding that neither could have achieved alone. When in a crisis, putting the situation into words requires reflection and organization . This type of emotion and thought management is helpful not just in resolving the current crisis, but also in preventing future ones. While medication therapy is important and proven, as are modalities such as electroconvulsive therapy (ECT), psychiatric care providers must remember that they are adjunct to the simpler treatment of conversation. These observations were made during the first few days of my Psychiatry clerkship, before the Haitian Earthquake occurred on January 12th ,2010. During this time I discovered that the dialogue was the most enjoyable and satisfying part of psychiatric treatment. Medications, while often effective, did not provide the intimacy with a patient's psyche needed to truly appreciate his or her condition. By relating to each patient through detailed interviews, I was able to detect subtle changes in their condition and determine whether or not medications were working. Here in the United States, healthcare providers have that luxury, the ability to utilize different therapies in conjunction with each other. Here, we have the diagnostic tools, lab tests, imaging, medication trials, and most importantly, the luxuries of time and a controlled environment. In a disaster zone none of these exist: it is only the provider and the patients. Earthquakes are raging and indiscriminate events of power and destruction. Our self imposed societal boundaries and divisions are mocked by the shockwaves rippling through the land. Palaces and shanties fall together; ministers and criminals are injured and killed simultaneously. It is within this context of total devastation that all members of a population experience the same emotions: shock, fear, misery, and hope. Catastrophe is the great equalizer, but it also becomes the greatest unifier. The first unification is with the shock and fear. Many don't understand how such a horrible thing could occur. As the magnitude of the earthquake was revealed, in this case over 200,000 killed, one million orphaned, and up to three million homeless, the affected become unified in misery. It is at this point that the role of psychiatry becomes evident and the skill of exploring feelings and emotions becomes life-saving. I was guilty of underestimating psychiatry, even upon my arrival in Port-au-Prince. Preparations were for treatment of traumatic injuries: fracture reductions, wound debriding, amputations, and suturing, as well as for medical complaints such as respiratory and wound infections, fevers, and infectious diseases. On the evening of the first full day of wandering though internally displaced persons (IDP) camps and treating hundreds of victims, my reflections surprised me. Sitting against a crumbled stone wall watching a person I had just comforted dig his family out of the pile that was once his house, I realized that it was those discussions with the affected that helped more than any physical 91
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treatment administered. This man, who had escaped rubble yet was crushed on the inside, came to me with hopelessness. I listened to his story, sympathized with him, and steadied him while he took this load off of his back. Survivor's guilt had left him directionless; being told that it was not his fault was a sort of forgiveness that he needed to go on. Suddenly I realized that the most common injury in Haiti was emotional trauma, and the most important treatment that our team brought was our capacity for listening. The patients treated that first day had a wide variety of injuries and medical complaints. But all had the same need for support. It was very different from the inpatient ward only a four hour flight away in New York City, yet the interpersonal connections were the same. Those first few weeks of experience with the various patients had built a foundation of skill that I was unaware of until then. We didn't have the diversity of conditions like bipolar and schizophrenia, and there was no time to explore personality disorders. There were no psychotropic medications or advanced diagnostic techniques or readily available follow up. However, there was a raw emotion of pain and suffering with universally shared stressors: every single person I encountered had lost a family member, a friend, a home; all that was left was despair. In response, we performed psychiatry in its purest form. People were encouraged to express their emotions and explore their pain. Beneath the tears and heartache, together we were able to find the hope that everyone still had within them. Giving this back to the people, showing them what they did have left, and helping them move forward was more healing than any suture stitched. Victims of the earthquake became more than just patients over the first few days: they became part of our team. Volunteer translators from the destroyed neighborhoods were ubiquitous and worked relentlessly. Bridging the gap between our English and their Creole provided them with a purpose that helped heal their wounds. All of them were living outside without reliable access to food or water and had lives to rebuild. Yet, they spent their days helping us help others. One "terp" as the military referred to them, Francillon, thanked us for giving him a way to "help the living go on with their lives rather than dig through the dead that cannot be helped." Francillon was a smart 25-year-old who spoke near perfect English and picked up quickly on the various medical procedures he saw. On our last day he slipped a letter to our team that explained his plight: "Dear Brothers and Sisters I greet you in the precious name of our Savior and Lord Jesus Christ. It has been so long time ago, since I'm facing the road alone. My father is gone since I was a little boy and my mother can't work to give everything we should need, my mom had four children there's one of us who's not with us anymore, the older, she's gone too. Last Tuesday when the earthquake came, it ruined every thing I had before and now I sleep outside. I completely fear the night when it comes for I don't want to be sick like the others." This excerpt is representative of the emotions shared by all survivors of the earthquake. To many, the psychological impact was debilitating. It was this internal trauma that is far more difficult to treat than the external lacerations and avulsions. We would spend countless hours listening to everyone's stories and demonstrating that people did care. The trauma was still so raw and the thought process teetering off the fringe of stability that it would only take one aftershock to reverse all we had done. Analogous to the few unstable buildings still standing that collapsed with the new tremors were the frail minds that finally broke from the stress as the ground shook again. For a time it seemed that nowhere was safe: staying indoors risked death from secondary collapse, outdoors the risk was illness, infection, and violence. Helplessness, however, was relieved by collective support. At night hundreds of people would march past the tent hospitals and sing hymns of prayer for both the injured and ill as well as the providers working to treat them. Mothers who lost their children staffed what are now outdoor orphanages that grew in size every day. Helping others and rebuilding a society became self-medication for acute stress disorder. 92
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Modern Psychiatry struggles with the quantification of its many diagnoses. In attempting to unify the field with more of the definitive diagnostic methods of surgery or medicine it runs the risk of labeling people rather than helping them. Of course, such labels are important to maintain order within the field and useful in guiding treatments and research. However, I learned that sympathy and an ear can placate many. The resilience of people is unquantifiable, and the most important psychiatric tool of compassion is within us all.
Alina Djougarian, SUNY Stony Brook Floating Away
Writing in Afghanistan Ali-Reza Force
Nuristan, a remote region of Afghanistan hidden within the Hindu-Kush valley, was once a nonIslamic region known as "Kafiristan (K ferest n), land of the non-Islamic and thus 'heathen' (k fer), until its enforced Islamization in 1896 brought 'light' or 'enlightenment,' (nur), to the area."1 Coincidentally, Nuristan, now under the control of the Taliban, has become one of the most devoutly Islamic regions of Afghanistan and one of the poorest as well with little to no infrastructure. The region suffers dramatically from lack of accessible health care services, poor education, and due to its remote location and hostile environment, outside resources such as those delivered by Non-Governmental Organizations (NGOs) are unable to assist either. As a result, the people of Nuristan had little to no contact with the outside world, other than military personnel, until late July and early August of 2010 when Dr. Karen Woo and nine other members of a medical team organized an expedition to provide basic medical services including "the distribution of eyeglasses and toothbrushes, pain relief and prenatal care to remotes villages they reached on foot."2 Weeks later, nine of the ten members, including Dr. Woo, would be killed as they ventured home, shot outside their caravan as they stopped for lunch in the hills of a region once known as "the land of the unbelievers." A thirty-six year old surgeon from England at the time of her death, Dr. Woo spent close to two years in Afghanistan working as a doctor and as a member of the organization Bridge Afghanistan, a coalition of doctors, journalists, and writers who "help support those in greatest need by attracting aid from different parts of the world including within Afghanistan itself."3 During her time in Afghanistan, Dr. Woo also worked on producing a film which documented the lives of Afghan and non-Afghan women imprisoned in Kabul for various crimes without habeas corpus.4 While investigating her life further in periodicals and editorials, I also discovered that Dr. Woo documented her own life in Afghanistan via a blog account. Written from December of 2009 to July 2010, these blogs served as a guide back into her life as I searched for meaning beneath the remnants and wreckage of both a country and a war I had only read about in newspapers and witnessed in pictures of crumbling buildings and bloodied bodies online. Before reading her blogs, however, I made the assumption that for the most part, they would consist of medical related experiences with tidbits of observations about the war, the culture, and the soldiers stationed in Afghanistan. Yet as I made my way through her entries I found that this was not the case. Rather, these blogs rarely dealt with the specifics of her time working as a surgeon in Kabul, focusing on her personal thoughts and feelings which stemmed from observations of the people and places she encountered in the middle east and back home in Europe. Soon it began to appear that these blogs served as a medium for Dr. Woo to situate herself within the milieu of the new environment she found herself navigating both physically and mentally, alone as a foreigner and as a woman. The blog served as a bridge between two worlds, western and middle eastern, past and present, herself and the reader, linking the two yet simultaneously forging something new in the space between. Dr. Woo's writing served as a way for her to further explore herself, as well as the hidden meanings within the hotels, storefronts, apartments, and operating room tables in the new worlds she occupied. Yet as the blog exists in the realm of the public, these multiple worlds collide and engage in an active dialogue catalyzed not only by the author but by the readership, forcing Dr. Woo to push further, deeper, and clearer into her own identity and mission abroad. In Afghanistan, alongside the reader, writing served as a tool, like a surgeons scalpel, allowing her to literally see more of who she was, where she was, and perhaps, why. Dr. Karen Explores Healthcare In Afghanistan is the official title to Dr. Woo's blog account. Her log begins in Dubai with an entry simply called "London-Dubai-Kabul" dated Friday, December 11th, 2009. Within this entry we find Dr. Woo adrift in the city, her hotel, and a water-park as she awaits her departure to Afghanistan. One intriguing moment in particular begins as she awakens from a nightmare in her 94
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hotel, only to encounter the sights and sounds of a city much more foreign than a dream: I wandered about the hotel in a daze for a few hours before they found me somewhere to go, a pretty room but with no electricity; I couldn't switch down the aircon or dry my hair, but after a massive hot bath at least I was clean and could get into bed for a couple of hours. I fell into one of those deep and confusing dream states, I was having a nightmare, in this one an evil man was killing lots of people, torturing them, dragging them around the town. I was woken by Crispian ringing me, usually I am instantly alert but it took ages to pull myself from the syrup of my awful dream and I could barely speak. It's a strange thing that one can be surrounded by so called luxury - fine linen, soft pillows, a totally controlled environment and yet none of it feels real. There's no earth in dubai, no true oxygen, and the trees are not free, by the roadside I saw that they'd painted the brown trunks green in order that they match the colour of the hedges behind them, I felt sick. I drove around in a taxi, divorced from the concrete environment, knowing all the while that the taxi driver probably resented me as yet another white colonial face, money in my pocket and an attitude to match. Though I don't have an attitude and I am wracked with guilt as I go about my 'luxury' life there.5
The horror of the dream resonates and sustains an interpretation of the people and places Dr. Woo encounters riding in the taxi. The physical world, "divorced from the concrete environment," loses meaning and value as the trees themselves become painted and false. Reality itself becomes suspect. The familiar transforms into something fake, as seen even in the hotel where "fine pillows, soft linen" are rejected as inauthentic, just as the air and the ground and eventually, Dr. Woo's own image of herself as well. The world unravels and the image of herself begins to fragment within the kaleidoscopic middle eastern landscape of Dubai. And as her "white colonial face" appears in the rear view mirror of the taxi like a mirage, Dr. Woo confronts how quickly her identity has shifted simply by entering this new world. In the entry titled "Biting creature turns girl into boy..." dated shortly after on Sunday, December 20th, 2009, the reader finds Dr. Woo situating herself now in Afghanistan, adapting to both the clothes and the people there. Here, Dr. Woo crafts a more distinct dialogue between both herself and the reader, actively altering her relationship between the two. Specifically, as Dr. Woo begins to engage with the reader directly, she also begins to analyze herself more deeply. The blog then becomes shaped not only by what she has to say, but by the fact that she is conscious of there being someone, somewhere reading her words: I'm here in the office, I've lost track of what day it is and I'm waiting for my first patient to arrive. I'm pretty sure it is Monday. I'm now slowly morphing out of my London life, no sexy dresses and high heels here; I find myself blending in with the blokes. I've got my 5.11 tactical trousers on (they had to have them tailored for me, so I'm now wearing a pair of mens trousers but with short legs) lets just say they're a bit long in the crotch and therefore look a bit like clown pants - v glam. Anyway, it doesn't really matter here and pseudomilitary clothing is considered normal. So the butch side of me is getting way out of control :)
At the beginning of her entry, Dr. Woo contextualizes herself within a place and a (rather ambiguous) time, indirectly acknowledging the presence of a reader. Dr. Woo then addresses how her image has begun to "morph" by virtue of her new, more masculine attire, and how it brings out a different "side" of her. At the end of this paragraph, Dr. Woo again acknowledges the reader, however this time via the colon-parenthesis smile she inserts at the end of the sentence. Seemingly insignificant, this symbol serves as another reminder to both her and the reader that there is an exchange, or dialogue, if you will, taking place. Dr. Woo not only consults her own thoughts about her changing appearance, but her perception of the reader's interpretation of her becoming "butch" as well. This symbol thus serves as a tool for Dr. Woo to seemingly reach across time and space, actively bridge a gap between herself, her thoughts, and the imaginary reader that suddenly becomes real. 95
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The acknowledgement of the readers' "presence" directly alters Dr. Woo's focus a few sentences later as her discussion about clothing slips into a memory from the night before: As I lay in bed last night, the generator had stopped and the power was off - I'd just been wandering the house with my head torch on, and now I was wondering about fate and why it seems that one is made for particular things. Happiness or satisfaction in life seems partly to do with whether you can match what you were made for with where you end up. All the advice, well meaning or not, from family, friends, teachers and work colleagues doesn't make a bit of difference if they don't know you. They can tell you what they might want for you, what they project upon you, or what might be beneficial for them, but it takes a very wise person to see what it is that you need, to be able to say that what might really suit you may be quite different from what everyone else expects. Oh, and don't worry, I'm not about to come out of the closet, if that's what you're thinking ;)
Again, Dr. Woo contextualizes and allows for the reader to re-imagine the night she wandered around her house in the dark thinking about fate. Just as she confided in the reader earlier about her changing physical image, Dr. Woo confides in the reader that "it takes a very wise person to see what it is that you need." Similar to the passage written in Dubai, the same theme of perception recurs and directs Dr. Woo's discussion as she interprets the image of her herself and how others, characterized here as "family, friends, teachers and work colleagues," witness or interpret that image as well. The spectra created by all of these different perceptions, including that of the readers, drives a metamorphosis of thought and directs the course of her discussion from that of her changing physical appearance to a more philosophical evaluation on identity, on "seeing" yourself truthfully. The screen becomes her mirror, and the words her reflection seen by not only herself, but by those beyond the plasma, imagined yet real, like you and I, reading her world and evaluating the images and thoughts created. Toward the end of this same entry, one again experiences Dr. Woo bridging that gap between herself and another world when she states: "what might really suit you may be quite different from what everyone else expects. Oh, and don't worry, I'm not about to come out of the closet, if that's what you're thinking ;) ." In this passage Dr. Woo catches a different, unintended interpretation of what she has said, i.e. that she is homosexual, and playfully responds, punctuating again with a smile. Yet by using the personal pronoun "you're" Dr. Woo decides to directly speak to the reader as if they are there, in real time, communicating with her in silence as she writes. Within the format of the blog, not only does the presence of a reader influence Dr. Woo's own assessment of her writing, but acts as a catalyst for her to confront the images or reflections she sees of herself. For as the author recognizes the reader after the statement "what might really suit you may be quite different from what everyone else expects" one can argue that Dr. Woo communicates her conclusion on "fate" because she assumes someone is there listening, feeling, and engaging with more than just the words on the screen all along. Thus, in a very real way, the reader actively contributes to Dr. Woo's assessment and evaluation of her own identity. Just as a patient allows a doctor to "heal," the presence of a reader permits the writer to explore both herself and her actions and to bridge the two, leading to the affirmation made at the end of this same entry: At the Afghan Military Hospital I spotted one of the American's arriving in a burkha, all that was visible were her tan desert combat boots poking out of the bottom. I look forward to a time where Afghan fashion is truly resurgent, there are some amazing fabrics, beautiful designs but very rarely do we get to see them displayed and worn in all their glory. Pride and bearing are strong parts of being Afghan, it's one of the things that you notice about the men, they are masculine even when cycling a bike, a heavy blanket casually draped n a wrap around them. They do not wear track suits for leisure and they are not fat and lazy. The women too have presence but for many it's a confused presence; they are not themselves sure what their profile should be outside the home (or at least where I encounter them) and it hurts me that they are often so subservient and silent, as if they are safer if no one 96
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notices them [...] So for now, I'll continue to cause a stir by putting on my makeup in my combats whilst sitting at the ops room table; waterproof mascara is a must for any hostile environment.
In this final paragraph Dr. Woo, for a moment, comes to terms with herself. There is a movement away from a preoccupation with what people think as a call to action is made when she emphatically states "So for now, I'll continue to cause a stir by putting on my makeup in my combats whilst sitting at the ops room table." Through writing and working her way through her blog, Dr. Woo re-experiences and revisits what she has seen and what she has felt. The questions too return, as do the dreams and thoughts from nights before as Dr. Woo begins to put the pieces together of her own life while trying to assemble the lives of others from the operating room table to the women in the bazaars, hidden behind their own veils. In doing so, Dr. Woo morphs into something androgynous, with multiple roles and multiple eyes, pushing for new meaning and a new identity within the words, beyond this "hostile environment" yet necessarily a product of it, too. Perhaps, then, this is one of the many reasons Dr. Woo worked and lived and wrote in Afghanistan for it made her think and act different, engaging with herself and others in dangerous yet more meaningful and profound ways. In the final paragraph of an entry posted just a month prior to her death, dated July 11th, 2010, Dr. Woo captures this ideal again as she compares and contrasts English and Afghan cultures: This is a very different place from England though and family and the social hierarchy are strong. The upsides are the generosity, the subtleties like the terrible driving but the lack of road rage, the lack of food, space and money, but the offer to share nonetheless. The downsides are the rigidity of the system, the safety in conformity and therefore the lack of courage to break the mould by being an individual. It's difficult to explain but to step outside of normal behaviour here results in rapid condemnation either because people believe it is 'dangerous' or have to be seen to be saying that they believe it to be dangerous. Either way, the downside is that attitudes change very slowly.
As Dr. Woo attempts to consolidate the discrepancies which separate the two cultures, we see her pinpoint one aspect she finds especially damaging, "the lack of courage to break the mould by being an individual." Beliefs and customs and even ones identity are all things that Dr. Woo refused to accept as given. The danger which Dr. Woo outlines here is not dying, but staying silent, by finding "safety in conformity" and simply accepting the world and your life as it is. This passage then highlights the true mission in which Dr. Woo set out on and in many ways completed: to displace conformity in order to fully understand and appreciate both herself and those around her, creating change in the process. By writing in Afghanistan and publicly engaging in a dialogue about her experiences, her mission was able to fully evolve and reach those of a different place, of a different time, listening again now to the words left behind, and witnessing how one broke that mould and gave their life to do so.
REFERENCES [1] Klimburg, Max. "Nuristan." Encyclopædia Iranica. 20 July 2004. Web. 29 Dec. 2010. [2] Dewan, Shaila, and Rod Nordland. "Slain Aid Workers Were Bound by Their Sacrifice." The New York Times. 9 Aug. 2010. Web. 29 Dec. 2010. [3] Woo, Karen, and Firuz Rahimi. Bridge Afghanistan. Web. 27 Dec. 2010. <http:// bridgeafghanistan.blogspot.com/> [4] Rubin, Elizabeth. "Renaissance Woman." The New York Times Magazine. 21 Dec. 2010. Web. 27 Dec. 2010. [5] Woo, Karen. Web log post. Dr Karen Explores Healthcare in Afghanistan. 11 Dec. 2009. Web. 28 Dec. 2010. <http://explorerkitteninafghanistan.blogspot.com>.
Attitudes in Psychiatry in Bangalore, India Akshay Lohitsa
Gated from the bustling Bangalore streets, fresh information technology firms, and even fresher fruit vendors, the campus of the National Institute of Mental Health and Science is at once beautifully serene and unbelievably hectic. The clinical, research, administrative, and dormitory buildings are nestled amongst colorful flowers and foliage which grow wonderfully in the temperate southern India climate. Dress shirts are short-sleeved, and I dropped both my tie and starched white coat after the first day. White coats are worn in Neurology and Neurosurgery, the other two clinical departments that exist here, but this is out of utility as exam rooms carry only plastic chairs and a wooden table. I did see a tie on my way to morning didactics, but, given its bearer's bag of samples and general aloofness to the growing throngs of patients, I suspect that he was a pharmaceutical representative. There are twenty-six residents per year in Psychiatry here (the best in the country I am told), and the inpatient unit boasts around 500 beds. The outpatient numbers are no less staggering, and, as the staff attending repeatedly chimes, we have to "see patients fast". A week on general adult psychiatry is structured thusly: Monday is senior resident rounds, Tuesday is outpatient specialty clinic, Wednesday is attending rounds, Thursday is electro-convulsive therapy, Friday is general outpatient for new patients, and Saturday is general outpatient for follow -up patients. Days start around 9:00 AM, coffee is around 11:30AM, afternoon lectures are around 4:00PM, and residents may be admitting emergency patients and completing clinical duties until 9:00PM.
…my first impressions had me feeling that … psychiatry at the National Institute of Mental Health and Science was more evidence-based, methodical, and systematic than my experiences in the United States."
The lectures were all excellent and show the current of research and scientific rigor underlying the great clinical work of this institution. Some of my favorite topics include informed consent ethics in psychiatric populations and mental health issues surrounding assisted reproductive technologies. Equally impressive to the didactics is the interdisciplinary approach; our team of MDs is often accompanied by School of Social Work and M.Phil students who are training to be therapists. To ensure a dequate training, the Psychiatry residents will rotate for the next three years through general adult, child, addiction, and family psychiatry, a fascinating therapeutic model where the entire family is admitted and treated as a whole. I came to India to see how the modern psychiatry establishment here interacts with integrative, complementary, alternative, or as they sometimes say out here in the East, traditional medicine. Both sides of my family hail from Bangalore, and I credit my philosophical mother's side with my ample exposure to meditation and yoga in my youth. More than the specifics of the ancient traditions and wisdoms, I sought to comprehend the way the patients and physicians use, misuse, reject, and embrace these teachings. With the increasing interest in America towards herbalism, Ayuerveda, and homeopathic medicine, I wanted to be prepared to infuse the best and most scientific of these practices while effectively educating against potentially dangerous misconceptions. I quickly realized that my conception of the practice of psychiatry in India was quite limited. 98
Akshay Lohitsa: Attitudes in Psychiatry in India
Let me start by emphasizing how pharmacologically minded the practice of psychiatry is here in Bangalore. Residents are frequently asked the level of evidence for the first three pharmacological options for mental illnesses. I overheard several mechanisms of action questions, and it was assumed that incoming residents had a strong handle of side effect profiles and optimal dosing for each disease. The doctors here were being trained to be very comfortable with tricyclic antidepressants and first and second generation antipsychotics. Doctor's were sensitive to pricing and wary of pharmaceutical industry influences. They were appropriately aggressive with medication, treating side effects as they arose but pushing doses to the upper ends of therapeutic ranges. The patients seemed to be less averse to medication than Americans; the stigma of mental illness was not usually further compounded by having to take medications. The overarching attitude of the patient was this: the doctor has prescribed a medication that he or she believes is most appropriate for my illness, so I will take it. What, then, was the attitude towards therapy? The Cognitive-Behavior Therapy heavily utilized for anxiety disorders, namely in Obsessive Compulsive Disorder clinic, seemed to be very structured and rigorous. Patients moved to Bangalore for 3-6 months just to get the therapy, often taking their families with them. Therapy was not oversold, but the efficacy statistics for psychotherapy, pharmacological, and combined approaches were frankly discussed with the families. Many patients had already sought meditation or some sort of mindful awareness therapy from spiritual sources. It was insisted that this therapy was completely distinct from Cognitive-Behavior Therapy and, while not detrimental to their well-being, would be unrelated to the skills and approach they would be utilizing from here on out. Thus, like the pharmacology, the psychotherapy here at the National Institute seemed very scientific and informed by western medicine. It should be noted again that individuals came from all over the country seeking this care and that advanced psychotherapists are nearly impossible to come by in India, being fewer in number than psychiatrists themselves. As for psychoanalysis, there was no mention of formal psychoanalytical therapy sessions. Furthermore, the terminology of psychodynamics, such as repression and projection, rarely made their way into patient discussions. It seems as if Freud and Jung were historical figures studied by literature and arts students rather than by therapists or psychiatrists. If anything, my first impressions had me feeling that on the spectrum of art to science, psychiatry at the National Institute of Mental Health and Science was more evidence-based, methodical, and systematic than my experiences in the United States. There seemed to be more room for personal cultural preferences, acupuncture and complementary therapies, and for questioning the hospital-based modern psychiatric methodology in America. Granted I was working at a very modern and scientific academic center in a major Indian city, but this was still a stark surprise. Whatever makes the delivery of mental health care here unique, it is not "traditional" medicine. I will leave you with one crucial difference. A difference which explains why psychiatric practice and the mentally ill patient in India are completely divergent from the practice and the patient in America: India lacks resources financially, structurally, and in terms of sheer number of mental health providers. It is still wrestling with charlatans, and alternative medicine is a hodgepodge of natural cures and pseudoscience. India's trump card, however, and this was my ultimate epiphany, is that it has the amazing resource of family. During intake interviews for inpatient care, a routine question is to ask which family member will be staying with the patient. At every single outpatient visit I attended, the patient was accompanied by a family member. Family members were expected to provide lifelong care to afflicted spouses, children, or parents; it was assumed that a family member would administer medications daily and watch closely for signs of relapse or disease progression. At first, the emphasis on family seemed excessive to my unaccustomed American mindset. Interviews would often directly and almost entirely be conducted with family members of the patients. I wondered what would happen if family members were contributing to a patient's mental illness, but I quickly realized that by and large family did much more good than harm. Family-centered therapy was 99
Akshay Lohitsa: Attitudes in Psychiatry in India
embraced given limited public resources to look after the mentally ill and given the existing value of family in society. And even though family "was all they gotâ€?, it should not be minimized; a quick Pubmed search reveals that India boasts at least equivalent cure rates for mental illness at a lower cost and with less hospital-based care. I will not speculate on the various other contributing factors, but I believe the family fabric definitely contributes to the success of mental health efforts in this and other developing countries. This seems to hold true even when the power of family is systemized and tailored to a hospital setting such as the family psychiatry unit. Watching an entire family receive intense inpatient psychotherapy was a truly unique experience. Reflecting back on inpatient psychiatry in the United States, I can hardly imagine parents and siblings taking leave of work and school to gather around one of their mentally ill members. So often it seems that many of those inpatients are estranged from their families or a strong loving network of any kind. Even in an individualistic and autonomous society like America, I am not convinced that this needs to be the case. I have always felt that these patients do no need to be fighting alone. As I pack my bags and eat my last supper with my uncle, an industrious and selfless endocrinologist who has made ten house calls after his clinic work before finally breaking for dinner, I am suddenly aware that this thing called family is everything here and often is not limited by blood. Yes, my uncle has been the family doctor for years. He has also through charity and his own earnings, a small sum by any American standards, put several of his Type 1 diabetic patients through nursing, pharmacy, and graduate school. He has employed several of them and has helped others get married. He tells me how they have been there when my grandmother got sick and how they acted as an extra set of eyes and hands in the busy ICU to insure she got appropriate clinical attention. He challenges me to find more trustworthy and devoted humans. Our driver eats with us, refusing every item and then being forced to try each dish by my uncle. My uncle calls them all, his driver, his teaching staff, his secretary, his clinic nurses he calls them all exactly what they are: family.
Alina Djougarian, SUNY Stony Brook Discovery
Olfactory cleft inflammation present in seasonal allergic rhinitis & intranasal steroids Anita Sivam
PURPOSE: Allergic rhinitis (AR) is commonly associated with olfactory loss, although the mechanism is not well studied. This study was designed to determine the effect of mometasone furoate (MF) on olfactory loss in seasonal AR (SAR) and to study its effect on inflammation in the olfactory region. METHODS: We performed a randomized, double-blind, placebo-controlled, parallel clinical trial in 17 patients with SAR who had symptoms of impaired olfaction (Table 1). Subjects received MF or placebo for 2 weeks during their allergy season. Before and after treatment, we measured nasal peak inspiratory flow (NPIF), chemosensory quality of life, and objective olfactory function (the University of Pennsylvania Smell Identification Test) (Figure 1). Additionally, nasal cytology samples were obtained from each visit, and a unilateral endoscopic biopsy specimen of the olfactory epithelium was obtained at the end of the study and scored for inflammation. RESULTS: Treatment with MF was associated with improved nasal symptoms (p < 0.015) (Figure 2a), NPIF (p < 0.04) (Figure 2b), reduced nasal inflammation (p < 0.05) (Figure 2c), and chemosensoryspecific quality of life (p < 0.03) (Figure 3). Histological analysis of the olfactory region reveals fewer eosinophils in the MF group when compared with placebo (p < 0.012). We found no improvement in objective olfactory function (p > 0.05). CONCLUSION: The use of MF in SAR is associated with reduced eosinophilic inflammation in the olfactory region and improved symptoms of AR. The presence of eosinophils in the olfactory area in SAR may indicate a direct, deleterious effect of inflammation on olfactory epithelium in this disease. In this study, we show that inflammation in SAR can affect the olfactory cleft, implicating a direct role for allergic inflammation in smell loss. Treatment with intranasal steroids is associated with decreased inflammation in the olfactory region in humans. Table 1. Characteristics of the Study Population. Mometasone Furoate (n=8)
40 (24-49)
(n=9) 38 (23-52)
Male n/%
2 (25)
5 (56)
Ragweed n/%
5 (63)
6 (66)
Grass n/%
3 (37)
3 (33)
Chemosensory QOL (mean±SEM)
24.3 ± 0.808
28.7 ± 1.92
UPSIT Raw Score (median, range)
32 (27-37)
31 (17-37)
NPIF (median, range)
103 (90-147)
118 (67-191)
TNSS (median, range)
16.5 (13-26)
12 (6-26)
Eosinophils (median, range)
1.55 (0.5-4)
0.5 (0-1.5)
Age (mean, range), y Allergen Sensitivity
Baseline Values
Anita Sivam: Olfactory Cleft Inflammation & Intranasal Steroids
Figure 1. Study Design. Both treatments were daily nasal sprays given in the morning. NPIF indicates nasal peak inspiratory flow, QOL, quality of life, UPSIT, University of Pennsylvania Smell Identification Test.
Change in Nasal Symptoms 15
S y m p to m S c o re
Figure 2a. Change in total nasal symptom score from initial visit to two-week treatment with mometasone or placebo. Individual data points are depicted with the horizontal bars representing medians. Mometasone led to greatreduction of symptoms than placebo.
Anita Sivam: Olfactory Cleft Inflammation & Intranasal Steroids
Change in NPIF 60
Figure 2b. Nasal peak inspiratory flow (NPIF). Regarding changes from initial visit for all measurements of NPIF, a negative number represents worsening, and a positive number represents improvement. Horizontal bars depict medians.
Olfactory Cleft Inflammation MF
Figure 2c. Biopsy specimens were scored for inflammation by counting the number of eosinophils in three high power fields, with the average reported. Subjects receiving MF showed significantly reduced numbers of eosinophils in the olfactory region compared to placebo.
Mean Eosinophils/HPF
8 6
2 0
Placebo 105
Anita Sivam: Olfactory Cleft Inflammation & Intranasal Steroids
Quality of Life Score
35 33 31
29 27 Placebo
Figure 3. Change in chemosensory quality of life (QOL). The overall quality-of-life score calculated from the Coping Style Questionnaire (CSQ) is shown. Mean Âą SEM for the 2 groups at enrollment (V1) and after 2 weeks of treatment (V2). Increases on the y-axis indicate better quality of life.
Jeremy Shugar, Touro College Bottoms Up
ORAL PRESENTATION WINNERS CLINICAL SCIENCE RESEARCH 1st Place - Nicole Scripsema Nicole Scripsema, MS II; Syril Dorairaj, MD; Ruojin Ren MD; Sung Chul Park, MD; Gennady Landa, MD; Katy Tai; Paul A Sidoti, M.D; Richard B Rosen, MD; Robert Ritch, MD: Effect of b-Zone Parapapillary Atrophy (bPPA) on Retinal Blood Flow Velocity in Primary Open-Angle Glaucoma (POAG) and Exfoliative Glaucoma (XFG).
2nd Place - Humera Ahmed Humera Ahmed, MSII; Petr Neuzil, MD; Jan Skoda, MD; Jan Petru MD; Lucie Sediva, MD; Stepan Kralovec; and Vivek Y. Reddy, MD: Renal Sympathetic Denervation Using an Irrigated Radiofrequency Ablation Catheter for the Management of Drug-Resistant Hypertension.
3rd Place - Aaron Trimble Aaron B. Trimble, MSII; Mehul M. Patel, DO; Isaac Galandauer, MD; Sheiner, Patricia, MD; Shireen A. Pais, MD; Edward Lebovics, MD: The Incidence and Endoscopic Management of Recurrent PostOrthotopic Liver Transplantation (OLT) Biliary Strictures After Initial Successful Endoscopic Management.
BASIC SCIENCE RESEARCH 1st Place - Helmi Thinzar Lwin Thinzar Lwin, MSI; Jing Yang, PhD; Mark Eckhart; Etienne Denis, PhD: The Role of Proteases in Twist Induced Tumor Invasion.
2nd Place - Stephanie McCarty S. McCarty, MSII; O. Girard, PhD; R. Ramirez, BS; E. Savariar, PhD; and R. Mattrey, MD: Quantification of Iron Oxide Nanoparticles in Cellular MRI.
3rd Place - Basel Touban Basel M. Touban, MSII; John J. Arcaroli, PhD; Aik Choon Tan, PhD; Marileila Varella-Garcia, PhD; Rebecca W. Powell, BS; S. Gail Eckhardt, MD; Paul Elvin, PhD; Dexiang Gao, PhD; and Wells A. Messersmith, MD: Gene Array and Fluorescence In situ Hybridization Biomarkers of Activity of Saracatinib (AZD0530), a Src Inhibitor, in a Preclinical Model of Colorectal Cancer. 108
1st Place - Edward Hurley "Exploring The Role Of The Rs4880 Polymorphism In Manganese Superoxide Dismutase In The Development And Severity Of Bronchopulmonary Dysplasia" 2nd Place - Navid Shams "Emergence of Babesiosis in the Counties North of New York City within the Lower Hudson Valley Region of New York State"
BASIC SCIENCE RESEARCH 1st Place - Zenas Chang "A Study of Unusual Metabolic Variants of Aeromonas caviae and Aeromonas hydrophila Using a Polyphasic Taxonomic Approach" 2nd Place - Matthew Duda "Development of Novel Compounds for the Treatment of Alzheimer's Disease: Synthesis of 2-(pyridin3-yl)-1H-benzo[d]imidazole Analogues of GTS-21, a Potent and Selective 7 Nicotinic Acetylcholine Receptor Ligand: a Potent and Selective 7 Nicotinic Acetylcholine Receptor Ligand" For full abstracts please visit: http://www.nymc.edu/Clubs/quill_and_scope/index.htm
Paul Janoian Tarrytown Lake
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Yaakov Liss (email@example.com), New York Medical College, Class of 2011, is a 3rd generation Bronx native who lives in Riverdale with his wife and daughter. Yaakov will begin his residency in Internal Medicine at Mount Sinai Medical Center in Manhattan this July. Akshay Lohitsa (email@example.com), University of Michigan Medical School, Class of 2011, is planning to start a residency in Psychiatry in 2011. He is interested in global perspectives, psychodynamic psychiatry, and medical education. He attended Harvard College and is from West Bloomfield, MI. Anchit Mehrotra (email@example.com), New York Medical College, is currently completing his Masters in Basic Medical Sciences. He completed his undergraduate degree at Washington University in St. Louis, graduating with a Bachelor of Science in Business Administration, while double majoring in Finance and Health Care Management. He is currently applying to medical school and hopes to be a member of NYMC's class of 2015. Breige O'Donnell (firstname.lastname@example.com), New York Medical College, Class of 2014, received a B.S. in Biology with a focus in Genetics from Stony Brook University. Upon graduating from college, she spent two years working in Emergency Medicine at North Shore University Hospital in Manhasset, New York where she conducted clinical research, mentored high school and undergraduate volunteers and developed and implemented an assessment protocol for patient flow. Breige was recently selected as the new Administrative Director for La Casita de la Salud for the upcoming academic year. She has an avid love of dance and enjoys running. She continues to take classes in both dance and yoga in her free time. Varunkumar Pandey (email@example.com), New York Medical College, is a PhD student in the Department of Experimental Pathology. His research is in the field of molecular genetics of hypertension. His future Interests include Fundamental and Applied research in Biomedical Sciences. Jin Packard (email@example.com), New York Medical College, Class of 2014, was born and raised in Kyoto, Japan. He graduated from Johns Hopkins in 2004 and served in Peace Corps Guyana for 2½ years. He has a 2010 MS/MPH from Tufts University School of Medicine. He currently lives in Grasslands building 12 with an Irish-Italian roommate who also served in the Peace Corps, who is famous for sculpting cute little shapes on his bountiful chest hair for special occasions. To clarify, Jin is not the one with the chest hair. Vivek Rajasekhar (firstname.lastname@example.com), New York Medical College, is a graduate student. Yousuf Sayeed (email@example.com), New York Medical College, is a Master of Science student. Yousuf graduated from Loyola University in Chicago with a BA in Philosophy and a BS in Molecular Biology, along with a minor in Bioethics. He was born in Karachi, Pakistan, and grew up partly in Justice and Naperville, Illinois. Even Schloss (firstname.lastname@example.com), New York Medical College, Class of 2013, is a native of Westchester, he studied biochemistry and math at Union College in Schenectady, New York. During downtime he enjoys cooking and staring up at the night sky. He is keeping all his options open for the future.
Anita Sivam (email@example.com), Touro College of Osteopathic Medicine, is a native of the Chicagoarea. She graduated with a degree in Chemistry, and minors in Spanish and Medical Humanities, from Indiana University Purdue University Indianapolis. After graduating, she spent time performing research at the University of Chicago, Department of Surgery, Section of Otolaryngology-Head and Neck Surgery. Research topics included allergic rhinitis, the inflammatory response in sinus disease and recurrent tonsillitis, and more. Personal interests include traveling, trying ethnic foods, and reading. Christine Shaver (firstname.lastname@example.com), New York Medical College, Class of 2013, is a 2009 graduate of M.I.T. where she received a bachelor's degree in biology. She is currently co-president of the American Medical Association and also enjoys giving tours to NYMC interviewees. As a Boston native, she likes to stir up ruckus in New York by rooting for the New England Patriots and Boston Red Sox in her free time. Jim Shen (firstname.lastname@example.com), New York Medical College, Class of 2012. Daniel Sonshine (firstname.lastname@example.com), Weill Cornell Medical College, Class 2012, graduated from Brown University in 2007. He spent a year before medical school working as an EMT on the ski patrol in Vermont and training to be a Divemaster in Honduras. He has a particular interest in international surgery and has worked in the orthopaedic surgery department at an academic medical center in Tanzania after his first year of medical school. Jordan Teitelbaum (email@example.com), Touro College of Osteopathic Medicine, Class of 2014, graduated with a BA in English from the University of Michigan, and he misses the humanities. Jordan thanks the Quill & Scope for allowing him to submit his pieces and for encouraging medical students to keep up with their passions. Charles Volk (email@example.com), New York Medical College, Class of 2013, intends to eventually pursue an internal medicine residency. He is originally from Bismarck, North Dakota and received his B.A. in physiology from the University of Minnesota - Twin Cities. He is the class of 2013 scribe president and is an active member of the NYMC community garden and music performance club. He is currently an officer under the Navy HPSP scholarship and when not studying enjoys cooking and spending time with his wife, Katrina. We extend our sincere appreciation to the following individuals for their artistic contribution: Katrina Bernardo Alina Djougarian Anna Djougarian Paul Janoian Julie Grimes Calley Levine David Maerz Sabrina Perrino Luke Selby Jeremy Shugar Ernest Yushvayev
QUILL & SCOPE STAFF Humera Ahmed (email@example.com), New York Medical College, Class of 2012, received her B.A. in English from Boston College in 2007. In the intervening two years before medical school, she spent time researching the safety and efficacy of novel, catheter-based approaches to the treatment of cardiac arrhythmias. Following in the footsteps of her idols: Paul Farmer, MD and Sanjay Gupta, MD, Humera hopes to touch the world by avidly pursuing her passions for medicine, literature, social justice, and travel. Roopa Chari (firstname.lastname@example.com), New York Medical College, Class of 2014. Joshua Davis (email@example.com), New York Medical College, Class of 2014. Linda DeMello (email@example.com), New York Medical College, Class of 2013, is the CoPresident of the American Medical Women's Association and Co-Editor-in-Chief of Quill & Scope. She graduated magna cum laude from the University of Massachusetts Dartmouth in 2007 with a BS in Biology and a minor in Biochemistry. She worked in clinical laboratories for six years in several hospitals across southern New England before her acceptance into NYMC. When she doesn't have her head in the textbooks, she writes fiction and she spends as much time as possible with her husband. She loves to run, drinks coffee by the gallon, and she still doesn't know what kind of doctor she wants to be when she grows up. Anna Djougarian (firstname.lastname@example.com), New York Medical College, Class of 2013, received her B.A. in Psychology from Macaulay Honors College at CUNY Hunter. She loves art! Aside from Quill and Scope, she also contributes to the NYMC Art Exhibition. Though not as much on the sporty side, she also enjoys playing tennis, joined intramural softball, and even attempted surfing. Jonathan Drake (firstname.lastname@example.com), New York Medical College, Class of 2013, received his B.S. in Zoology from the University of Massachusetts Amherst in 1993. Following graduation, Jon worked for nine years in ophthalmology research, including seven years at the University of California San Francisco, and two years at Miyata Eye Hospital in Japan. He then shifted to neuroscience research while receiving master's degrees at Boston University School of Medicine and at the University of Massachusetts Boston, and while working in neuropsychology and neuropathology at the Framingham Heart Study. Jon plans to pursue neurology as a specialty, and enjoys rock climbing, windsurfing, cooking, and traveling in his spare time. Matthew Duda (email@example.com), New York Medical College, Class of 2014, graduated with a bachelor's degree in Chemistry and Biochemistry from Eastern Washington University in 2008. He presented his undergraduate research in synthetic medicinal chemistry, regarding Alzheimer's disease, at a regional meeting of the American Chemical Society. In his two years prior to medical school, he administered medication and cared for assisted living center residents afflicted with dementia aside from visiting Poland and Italy. He is an executive board member of New York Medical College's student run clinic, La Casita de la Salud, and tutors high school students as part of the S.T.E.P. program. He enjoys snowboarding, salsa dance, his beloved Siberian husky, and a good coffee. Justen Elbayar (firstname.lastname@example.com), New York Medical College, Class of 2014. Amin Esfahani (email@example.com), New York Medical College, Class of 2014, was born in Tehran, Iran and moved to Toronto, Canada at the age of thirteen. He obtained both his Bachelorette and Master of Science degrees from the University of Toronto, Canada. He is the co-Managing Editor of the Quill & Scope. His research interest is in the field of Nutritional Sciences with emphasis on dietary approaches to prevention and management of diabetes and heart disease. He has contributed to over
published works in books and peer reviewed journals. He has also participated or contributed to more than thirty presentations at scientific conferences across the world Ali-Reza Force (email@example.com), New York Medical College, Class of 2014, is a graduate of New York University where he studied English and American Literature. Loren Francis (firstname.lastname@example.com), New York Medical College, Class of 2013, received her B.S. in Applied Mathematics and Biology from Brown University in 2009. She is a member of the Pediatrics Interest Group and the soon-to-be famous flag football team Valhallabackers. When not studying, she enjoys reading, spending time outdoors, and baking anything chocolate. Marissa Friedman (email@example.com), New York Medical College, Class of 2013, received a bachelor's degree in psychology from New York University, with a minor in creative writing. Before attending medical school, she received a Master's of Health Administration with Distinction from Hofstra University, and taught MCAT and SAT review classes for Kaplan. While at New York Medical College, she has served as a literary editor for Quill and Scope for two years. She is also the President of NYMC's Chapter of the American Medical Association. She is very involved with the Medical Society of the State of New York, and has recently been elected Secretary of the Medical Student Section. In addition, she has been involved in several things around campus including; organizing Biochemistry and Physiology review sessions for first year students, planning the NYMC Community Health Fair, and conducting research with the Neurosurgery department. Padraic Gerety (firstname.lastname@example.com), New York Medical College, Class of 2014, received his B.A. in Political Science and Religion from Amherst College in 2007. Following graduation, he served with the Peace Corps in Namibia as a Community Health and HIV/AIDS Prevention Volunteer. During his service, he led various disease prevention trainings, gave self defense classes, and co-authored two abstracts exploring the epidemiology of HIV. In addition to Quill and Scope, he is an active member of AMSA, the Emergency Medicine Club, and the International Medicine Club. Maximilian Klein (firstname.lastname@example.com), New York Medical College, Class of 2014, is pursuing an MD/MPH dual degree program with an MPH focus in Health Promotion and Behavioral Sciences. He attended the University of Georgia for undergraduate where he received a BS in Biochemistry & Molecular Biology. Throughout his career he hopes to be a leader in the fight against diabetes and obesity. Though he would be too modest to admit it, Maximilian is a wine connoisseur and a member of NYMC`s Wine Club. He is also one of the elected first-year class Senators. Yiyi Liu (email@example.com), New York Medical College, Class of 2014, graduated from the University of Pittsburgh with a B.S. in Neuroscience and a B.A. in English Literature. She hails from the exotic land of Connecticut and adores the New England area. During her undergraduate career, she was involved in research into protein markers in the development of cervical cancer as well as quantification of a responses on social cognition tests. During her free time, she rock climbs, runs and enjoys all kinds of music. W.G. Stuart Mackenzie (email@example.com), New York Medical College, Class of 2013, was born and raised in Canada. He is a graduate of both the University of Toronto and Boston University. Having spent time working in International Development and Infectious Disease, he is excited to read other NYMC students' perspectives on International Medicine.
Danielle Masor (firstname.lastname@example.com), New York Medical College, Class of 2013, graduated from Swarthmore College in 2003 with majors in French Literature and Economics. While slowly finding her way to the medical field, she has worked in the insurance and non-profit sectors, among others. She lives in Manhattan and loves exploring its many neighborhoods. David Maerz (firstname.lastname@example.com), New York Medical College, Class of 2013. Janet Nguyen (email@example.com), New York Medical College, Class of 2013, graduated from University of San Francisco with a B.S. in Biology. Following graduation, she worked at Genentech Inc. in Quality Control Stability. After dabbling in the industry, Janet joined the Research Institute of California Pacific Medical Center where she performed research on a novel gene therapy technique to treat monogenic diseases, such as Sickle Cell Disease. During her spare time, she enjoys cooking, watching TV and spending time with her family and friends. Chris Ours (firstname.lastname@example.com), New York Medical College, Class of 2013, is just a city boy, born and raised in south detroit. He took the midnight train goin' to New York, class of 2013. He graduated from The College of William and Mary with a B.S. in Biology and Philosophy. In Williamsburg, Virginia, he did research on germline stem cells of Drosophila melanogaster and worked as an Emergency Room scribe for over two years. At NYMC, he serves on the 1st and 2nd year curriculum committee and has helped out on the SPAD fundraising committee. When not neck deep in notes, he enjoys cooking, mysteries, and terrible television medical drama. Sarah Pozniak (firstname.lastname@example.com), New York Medical College, Class of 2013, graduated from Boston University in 2006 with a B.A. in American Studies. After graduation she worked for three years as a medical assistant to a primary care physician in Cambridge, Mass. She likes pilates, running and reading The New Yorker. Sarah is interested in primary care. Mike Rahimi (firstname.lastname@example.com), New York Medical College, Class of 2014, graduated magna cum laude from The George Washington University in 2009 with a BS in Biological Sciences and minors in Psychology and Art History, and was a DJ and talk show host for his campus radio station for four years. Mike is the co-Managing Editor of Quill and Scope. Prior to coming to NYMC, he worked as a clinical research coordinator of Neuroradiology at the Hospital of the University of Pennsylvania, and played electric guitar for several bands in New York, Washington, and Philadelphia. Vivek Rajasekhar (firstname.lastname@example.com), New York Medical College, is a graduate student. Amy Reed (firstname.lastname@example.com), New York Medical College, Class of 2013, graduated from University of Illinois at Chicago (2008) with a BA in Psychology and BS in Biology with a minor in Asian Studies. After graduation, she worked for one year as a Production Coordinator at CSL Behring Pharmaceuticals in Kankakee, IL supervising the development of plasma derived medical supplies for those suffering with Alpha-1 Trypsinase Deficiency. She is attending medical college on a full scholarship from the US Navy, and plans to pursue a PC residency program in the USN. Meaghan Roche (firstname.lastname@example.com), New York Medical College, Class of 2014, received a B.A. in criminal justice and a B.S. in psychology from the University of Maryland in 2004, and in 2010, she received an M.A. in Medical Sciences from Boston University. From 2004 to 2008, Meaghan worked in forensics as a serologist and DNA technician in both the public and private sectors, all the while dabbling in creative writing and plotting her return to academia. Though she has often contemplated pursuing an M.F.A. in creative writing, she is pleased to announce that an M.D. will be her last degree! For now, Meaghan is just excited to finally be in medical school and has no idea which spe-
cialty she'll choose, because they all sound fun. Ramsey Saba (email@example.com), New York Medical College, Class of 2014, received his B.S. in Biology and a minor in Computer Science from Purdue University in 2009. Upon graduation, Ramsey joined the Weaver Group chemistry lab where he worked on modules for researching small molecule antiviral drug development and for research in the plasma enzyme system and its effect on dairy foods. He enjoys art, technology, and traveling. Navid Shams (email@example.com), New York Medical College, Class of 2013, is interested in Pediatrics and the Infectious Disease specialty. He has an undergraduate degree in Creative Writing and Biology from Carnegie Mellon University. Prior to medical school, he attended Boston University for a Masters in Public Health, with concentrations in International Health and Epidemiology. Gavin Stern (email@example.com), New York Medical College, began his journey as a student in the MD/MPH program. Time has revealed a new path. Gavin is currently completing his Masters in Public Health and will begin study in the Doctor of Public Health program this fall. Gavin Stern graduated from the University of Michigan in 2008 where he studied English, biopsychology, and biology. He enjoys performing stand-up comedy almost as much as he loves Michigan Football. Yin Tong (firstname.lastname@example.com), New York Medical College, Class of 2013, graduated with a BS in Human Development from Cornell University in 2008. She grew up in Beijing and Alaska as a misguided snowbird (summers in Beijing, winters in Alaska) and served as the executive editor of Cornell's Ivy Journal of Ethics. At NYMC, she is a first year coordinator for Big Sib Lil Sib, helps out on the SPAD PR committee and is a tour guide. She enjoys skiing, reading, sleeping and cultivating an irrational fear of birds, clowns and occasionally, the dark. Audrey Uong (email@example.com), New York Medical College, Class of 2014. Jordan Whatley (email@example.com), New York Medical College, Class of 2014, graduated from The Ohio State University in 2009 with a B.S. in Biology and a minor in psychology. Following graduation, he taught MCAT Organic Chemistry and Verbal Reasoning for the Princeton Review. Jordan enjoys filming and editing movie parodies based on medical disorders, and performing songs with Samuel Kim. He is considering specializing in pediatric neurology.
Published on Mar 21, 2011
Student Journal of New York Medical College