After a few snow storms delays, BUSM's second year medical students finally...
Boston University School of Medicine has developed an affiliation with Northern California Kaiser Permanente to offer two new clinical clerkship sites for our third-year medical students.
Beginning in May 2015, 12 third-year students will begin their clerkships at Kaiser Permanente Medical Centers in San Jose and Santa Clara. After an orientation with their classmates in Boston, six will stay for a full year, while six will stay for six months. Students will rotate in family medicine, OB/GYN, internal medicine, psychiatry and neurology at the San Jose site and in pediatrics, surgery, radiology and psychiatry at the Santa Clara site. Although this program is new for BU, Kaiser has a strong and well-established medical education framework that includes students from Stanford, UC-San Francisco, UC-Davis and Drexel.
In addition to an excellent clinical experience, the Kaiser Campus Third-Year Curriculum Program will expose students to Kaiser’s healthcare technology, preventive medicine and progressive healthcare delivery model. Students will participate in quality improvement training programs, master their electronic health system, and develop their own quality improvement projects.
Kaiser has revolutionized health care and health-care technology, providing more immediate and responsive patient care. A leader in patient safety and quality improvement, the Kaiser system has been the model for the future of medicine. Their focus on preventive care and an outpatient-centered care model reduces hospital admissions and testing.
“We are delighted to offer our students the opportunity to work in another innovative and evidenced-based system that is committed to high-value, high-quality medical care,” said Karen Antman, MD, BUSM dean and provost of the BU Medical Campus.
Despite the distance from Boston campus, students will receive uniform didactic instruction. Program Manager Monica Parker-James is coordinating the online educational experiences. Recorded lectures can be reviewed at the student’s convenience. The students also will be able to participate in live small-group discussions and case vignettes with Microsoft Lync access.
Microsoft Lync is a platform for unified communications including online meetings, instant messaging, audio and video calls, availability info and sharing capabilities.
Dr. Harley Goldberg, who has a long history of service in the Kaiser system and is involved in quality evaluations at San Jose, will coordinate the training and supervision of our students in California. He will work with students via video conferencing prior to June and will orient and mentor the students during their time in the Kaiser facilities. He has worked closely with the BUSM Kaiser Committee and clerkship directors to provide a seamless transition for the students.
Assistant Dean Paige Curran in the Office of Student Affairs will monitor student mental and physical health and support academic and career development through online communication and quarterly visits to California.
The BUSM students will have faculty support while in California and many will also be close to family and friends. In addition, we are planning a California BUSM alumni network for additional student support, mentoring and career development. Several alumni have already expressed interest, including Veronica Santini, BUSM class of 2000, an assistant professor of neurology at Stanford.
“We are impressed by how vested our counterparts in California are in making this a successful partnership,” said Anna Hohler, MD, assistant dean of academic affairs at BUSM. “This collaboration is a win-win. Kaiser will work with students who are smart, dedicated and professional. Our students will train in a leading health care system that shares our commitment to high-quality medical education, devotion to diverse patient populations and a vision for excellence in health care. We are thrilled to be able to offer this opportunity to our students.”
Robert Stern, PhD, neurology, neurosurgery, CTE Center; Julie Stamm, PhD candidate
As the 100 million viewers tuning in to this Sunday’s Super Bowl can attest, Americans adore football. And for many, the love affair begins in childhood: Pop Warner Tiny-Mites start as young as age five, and many adults retain warm memories and friendships from their youth football days.
But a new study from BU School of Medicine researchers points to a possible increased risk of cognitive impairment from playing youth football.
“This is one study, with limitations,” adds study senior author Robert Stern, a MED professor of neurology, neurosurgery, and anatomy and neurobiology and director of the Alzheimer’s Disease Center’s Clinical Core. “But the findings support the idea that it may not make sense to allow children—at a time when their brain is rapidly developing—to be exposed to repetitive hits to the head. If larger studies confirm this one, we may need to consider safety changes in youth sports.”
“Sports are important, and we want kids to participate in football,” says Stamm. “But no eight-year-old should play a sport with his friends and end up with long-term problems. We just want kids to play sports more safely.”
Read the full article.
In two lines they marched, the 164th entering class of BUSM, greeted by the smiles and clicking cameras of family and friends. With a white coat draped over their arm, they entered the tent raised for the White Coat Ceremony held Monday, August 6. The white coats signify the students’ entry into the profession of medicine.
“The White Coat ceremony marks a major life transition, the beginning of your formal medical education,” said Dean Karen Antman. “When you put on your white coat for the first time today, the message is not that you are expected to become a professional, but that, as of today, you are now already a part of the profession. When you see your first patients in the coming weeks, you represent the profession.”
The 181 members of the entering Class of 2012 were chosen from a pool of 11,780 candidates. They represent 80 undergraduate institutions. Forty-four percent are women. Thirty-five percent hold a graduate degree at the Master’s level or above, and some have more than one advanced degree.
“All of you have met academic and personal challenges; all of you have had successes and failures; all of you have sacrificed much and accomplished a great deal to reach this moment,” noted Robert Witzburg, MD ’77, associate dean for admissions, as he presented the class for matriculation. “As you move into the next phase of your journey, your entry into the sacred trust that is the profession of medicine, each of you will struggle. What will sustain you in these difficult moments will be your own skill and talent, your own resilience and strength of character, the support of your classmates, the love of your family and friends, and the commitment of your teachers and mentors.”
For the first time at a BUSM White Coat Ceremony, the class was grouped by their Academy of Advisors. BUSM medical students are assigned an academy to which they will belong throughout their medical education. Each of the six academies provide students mentoring and career development and offer ongoing guidance and support from experienced faculty members, educators, and role models of professionalism to the students.
Douglas Hughes, MD, associate dean for academic affairs, called the students to podium, while faculty and deans helped each one don their white coat to begin their journey where upon the newest members of the BUSM community recited the Hippocratic Oath led by Samantha Kaplan, MD, assistant dean for diversity and multicultural affairs.
As the guest speaker, Kenneth Grundfast, MD, assist dean for student affairs and chair of the Department of Otolaryngology-Head & Neck Surgery, addressed the dramatic change about to take place in their lives as they transition from student to physician. “By the time you finish medical school, you will be ready to accept the weighty responsibility that comes when people look to you to help alleviate their suffering, to cure them of cancer, to help restore their mental health, to help them give birth to their children and to be the doctor for their children. It is a sacred privilege to be given the opportunity to take care of patients. I loved it as a medical student and just as much today.”
View pictures from the ceremony on facebook.
Darrell Kirch, MD, president and CEO of the Association of American Medical Colleges (AAMC), visited the Boston University Medical Campus on June 13, during which he presented “The Role of Boston University School of Medicine in Transforming Health Care” before a full Keefer Auditorium crowd.
Dr. Kirch focused on the evolution of health care research, education and delivery in the US. He explained that he is looking for institutions to serve as the catalysts to initiate change. According to Dr. Kirch, BUSM is well positioned to be part of the solution that transforms the unsustainable healthcare system currently in place.
Key points from Dr. Kirch’s lecture include
- Academic medical centers, like BUSM, have an excellent opportunity to transform health care delivery in the US.
- The AAMC is making changes to the Medical College Admissions Test (MCAT) that will include a broader list of criteria that place value on candidates with the skills necessary to “practice medicine.” This is a departure from the current focus of recruiting candidates with the scientific aptitude to successfully complete the first two years of medical school.
- There is a need to connect the broader medical education community including undergraduate premedical studies, formal medical education, residencies, fellowships and practicing physicians. This would enable a true continuum of medical education.
- Transforming academic medicine will require a new view of excellence. Success will be measured by aligning to institutional mission; serving the community; recruiting students with attributes in addition to scientific aptitude; valuing educational quality; improving research outcomes; and focusing on wellness and prevention.
- BUSM’s mission is clearly demonstrated in the work being done on the Medical Campus, in the community and abroad.
Slides from Dr. Kirch’s lecture are available for viewing 6-13-12 BU FINAL
Boston University School of Medicine (BUSM) student Alexander Lankowski, class of 2013, was awarded a $2,499 grant from the American Medical Association (AMA) Foundation’s Seed Grant Research Program. Established in 2000, the program provides small grants to medical students, physician residents and fellows to conduct basic science or clinical research projects.
Lankowski is one of 43 individuals nationwide who received a seed grant this year. He is currently finishing a yearlong fellowship through the Doris Duke Charitable Foundation and Harvard Medical School. Lankowski will be applying for residency programs in internal medicine or pediatrics, hoping to pursue a career in academic medicine, infectious diseases, and global health. He will use the funds to study HIV/AIDS treatment outcomes in Uganda.
Patients in sub-Saharan Africa frequently cite difficulty obtaining transportation from home to clinic as a significant barrier to receiving HIV care. His research project aims to evaluate transportation barriers to HIV care in rural Uganda. It will more precisely characterize the association between transportation barriers and treatment outcomes in hopes of better informing programmatic decisions regarding decentralization of HIV care and expansion of rural clinics.
The Seed Grant Research Program was created to encourage more physicians to consider research as a career option. The program not only supports the scientific discoveries of researchers, but also gives young investigators a positive grant experience early in their careers.
Join David Satcher, MD, PhD, 16th U.S. Surgeon General and director of the Satcher Health Leadership Institute as he presents on “The Role of Health Reform in Addressing Mental Health Disparities” at the Psychiatry Grand Rounds on Thursday, March 29, 2-3 p.m., in Keefer Auditorium.
Dr. Satcher’s has deep experience in improving public health policy and is committed to eliminating health disparities for under-served groups, such as minorities and the poor and shedding light on neglected issues, such as mental and sexual health.
In 1998, Dr. Satcher was sworn in as the 16th Surgeon General of the United States and served as Assistant Secretary for Health in the Department of Health and Human Services from February 1998 to January 2001, making him only the second person in history to have held both positions simultaneously. He also served as Director of the Centers for Disease Control and Prevention (CDC) and Administrator of the Toxic Substances and Disease Registry from 1993 to 1998.
This program qualifies for continuing education credits for physicians, psychologists and social workers. For more information, please contact firstname.lastname@example.org.
Psychiatry Grand Rounds
- The Role of Health Reform in Addressing Mental Health Disparities
- Presented by: David Satcher, MD, PhD, 16th U.S. Surgeon General and director of the Satcher Health Leadership Institute, Morehouse School of Medicine
- Date: March 29
- Time: 2-3 p.m.
- Location: Keefer Auditorium, BUSM
Boston University Researchers Report NHL Player Derek Boogaard Had Evidence of Early Chronic Encephalopathy
Researchers at the Boston University Center for the Study of Traumatic Encephalopathy (BU CSTE), a collaboration with the Sports Legacy Institute (SLI) and the Bedford (MA) Veterans Administration (VA) Medical Center, announced today that National Hockey League (NHL) player Derek Boogaard had evidence of early stages of Chronic Traumatic Encephalopathy (CTE), a neurodegenerative disease linked to repeated brain trauma, when he died May 13, 2011, at the age of 28.
Boogaard played left wing for the Minnesota Wild from 2005-2010 before playing for the New York Rangers during the 2010-2011 season. He was considered by many to be the toughest fighter in the NHL. In 277 NHL games, Boogaard scored three goals, had 589 penalty minutes and reportedly participated in 61 regular season fights. He also reportedly participated in 174 career fights in professional hockey.
Boogaard had not played since Dec. 9, 2010, due to injuries sustained in a fight, including a reported concussion. His family reported he had “seen stars” in a game two weeks prior to his final game. Boogaard had been diagnosed with post-concussion syndrome twice, and his family believes he spoke of having his “bell rung” (a term athletes use for a mild concussion) at least 20 times, although he reported few of them to his team or medical staff. Boogaard dealt with drug addiction and exhibited abnormal behaviors, including emotional instability and problems with impulse control, along with short-term memory problems and disorientation, for two years prior to his death.
Boogaard was diagnosed with mild CTE by neuropathologist and CSTE co-director Ann McKee, MD, professor of neurology and pathology at BUSM and the director of the CTE brain bank located at the Bedford VA Medical Center. CTE can only be diagnosed by examining brain tissue post-mortem. Boogaard had evidence of early CTE in his cerebral cortex, although the severity of his brain changes was more advanced than most other athletes of similar age with CTE examined by Dr. McKee.
The association between Boogaard’s brain pathology and his clinical symptoms, specifically the behavioral changes and memory problems he experienced in his last two years, is unclear. For example, his clinical symptoms occurred during the same time period he was exhibiting narcotic abuse. CTE has been found in other deceased athletes who have died from overdoses or who had problems with substance abuse. It is unknown if the substance abuse is caused by the impulse control problems associated with CTE or if they are unrelated.
Dr. McKee found mild stages of CTE in former NHL players Rick Martin and Bob Probert. It is unclear if the degree of their pathology contributed to any clinical symptoms. More severe CTE was found in Reggie Fleming. Fleming, who died in 2009 at the age of 73 with dementia, displayed 30 years of worsening behavioral and cognitive difficulties and had advanced CTE.
“It is important not to over-interpret the finding of early CTE in Derek Boogaard,” said BU CSTE Co-Director and SLI Co-Founder Robert Cantu, MD. “However, based on the small sample of enforcers we have studied, it is possible that frequently engaging in fistfights as a hockey player may put one at increased risk for this degenerative brain disease.”
Added BU CSTE Co-Director and professor of neurology and neurosurgery at BUSM, Dr. Robert Stern, “Boogaard’s clinical history was complex, so it is unclear as to if or how much CTE contributed to his behavior, addiction or death. However, CTE appears to be a progressive disease in some individuals, so even if it was not directly affecting Boogaard’s quality of life and overall functioning before he died, it is possible it could have in the future.”
“Unfortunately this finding does not contribute to our knowledge of the risks of normal hockey play for most participants, as very few hockey players engage in as many fights as Boogaard,” said BU CSTE Co-Director and SLI Co-Founder Chris Nowinski. “Athletes and parents should know that anyone who experiences repetitive brain trauma may be at risk to develop CTE, but we are hopeful that risk is small in hockey.” Nowinski added that two other young non-NHL professional hockey players studied did not show signs of CTE at postmortem examination.
The VA CSTE Brain Bank contains more brains diagnosed with CTE than have ever been reported in the world combined. There are 99 specimens. McKee has completed the analysis of the brains of over 70 former athletes, and more than 50 have shown evidence of CTE, including 14 of 15 former NFL players, as well as college and high school football players, other hockey players, professional wrestlers and boxers. Early evidence of CTE has been found in individuals as young as 17. More than 500 living athletes have committed to donate their brain to the BU CSTE after death, including over a dozen former hockey players.
The Boogaard family requested that the diagnosis be made public at this time. A full report of Boogaard’s brain tissue analysis is embargoed pending publication in an academic medical journal.
The CSTE (www.bu.edu/cste/) was founded in 2008 and is the leading center in the world studying the long-term effects of repetitive brain trauma in sports and the military. The CSTE was created as a collaboration between Boston University (BU), Sports Legacy Institute (SLI) and the Department of Veterans Affairs (VA). Co-directors of the BU CSTE include Robert Cantu, MD, clinical professor of neurosurgery at BUSM; Ann McKee, MD, professor of neurology and pathology at BUSM and director of the VA CSTE Brain Bank; Chris Nowinski; and Robert Stern, PhD, professor of neurology and neurosurgery at BUSM. The mission of the CSTE is to conduct state-of-the-art research of CTE, including its neuropathology and pathogenesis, clinical presentation, biomarkers, methods of diagnosing it during life, the genetics and other risk factors for CTE, and ways of preventing and treating this cause of dementia. The BU CSTE has received grants from the National Institutes of Health and the National Operating Committee on Standards in Athletic Equipment (NOCSAE), and has received an unrestricted gift from the NFL.
Sports Legacy Institute is a 501(c)(3) nonprofit corporation founded in 2007 to advance the study, treatment and prevention of the effects of brain trauma in athletes and other at-risk groups. SLI partnered with Boston University School of Medicine to form the Center for the Study of Traumatic Encephalopathy in 2008. (www.sportslegacy.org)
CSTE co-directors Cantu, McKee, Stern and Nowinski serve on the NFL Players Association Mackey/White Traumatic Brain Injury Committee. In addition, Cantu serves as a senior advisor to the NFL Head, Neck and Spine Committee.
Fight data from www.hockeyfights.com
BU medical students learn about global health by running health education camps for children, working in clinics and hospitals, and living with host families in Ecuador, see the the video. (View closed captions on YouTube.)
Thumbs were not supposed to look that way. That was Owen Kendall’s first thought when he spotted the green wrapping around the thumb of an elementary school student in Obraje. The first-year BU School of Medicine student led the boy from the dim cinderblock classroom into the Andean sunlight of rural Ecuador.
Kendall (MED’14) squatted down and peeled a leaf from the boy’s thumb, revealing a swollen, mud-encrusted gash. He grabbed some wet towels and dabbed at the wound, asking the impassive boy in halting Spanish how and when he got hurt.
Seconds later, Kendall was on his cell phone calling for assistance. Within half an hour, a driver arrived from the Cacha Medical Spanish Institute (Cachamsi), a nonprofit international medicine program less than 10 miles away in Riobamba, through which Kendall and five other BU first year medical students were volunteering last summer. The driver questioned the boy in Quichua, the local language, then whisked him away to the nearest clinic.
For two days, as part of their monthlong health education camps for kids in the indigenous Cacha region, Kendall’s group had been talking to children about the best way to care for nasty cuts. Apparently that lesson hadn’t sunk in. The Quichua remedy, cover with mud or cow liver and wrap with a leaf, clearly trumped the Americans’ advice.
“I just hope that some of the stuff that we teach sticks,” Kendall said. “I think we’re doing a good job, but we just need to keep trying.”
The students in the Cachamsi group worked primarily as camp counselors, but they also took medical Spanish classes, shadowed doctors at hospitals and clinics, and lived with families. For some, the trip was an adventurous way to learn Spanish (a useful skill at Boston Medical Center http://www.bmc.org/ , where it is the first language of many patients). For others, it was a trial run at a career in global health.
They were the third wave of BU medical students to conduct health camps through Cachamsi, a program that Suzanne Sarfaty—MED assistant dean for academic affairs and director of international health programs—discovered and hopes will continue.
Sarfaty knows the value of an experience like Cachamsi, which teaches a few things that aren’t ordinarily learned from textbooks or rotations at BMC. And most of it is about the limitations of health care in remote parts of the world. Talking to kids about hand-washing falls a bit short when even the schools lack running water. Encouraging people to brush their teeth is tricky when local water is laden with parasites. And preaching about protecting the skin from the high-altitude sun is useless when most families have no access to (and can’t afford) sunscreen.
Few people beyond hikers and backpackers drive the four hours south of Quito, Ecuador’s capital, to Riobamba, a bustling city of 150,000 encircled by volcanoes with Quichua names like Chimborazo, Carihuairazo, and Tungurahua. Even fewer people travel to the mountains of Cacha, an autonomous union of 23 Quichua communities.
But at 7:30 each weekday morning, that’s where the BU medical students went, hopping from one Cacha community to another to talk about hygiene and health.
Just minutes outside Riobamba, their two pickup trucks, carrying boxes of long-sleeved T-shirts, markers, and notebooks as well as the students, turned onto a newly paved switchback path and started the climb. The trucks passed ruddy-cheeked Quichua men and women walking to Riobamba to buy supplies and to sell their hand-woven goods. They wore fedoras, scarlet red ponchos, and fuchsia shawls, adding splashes of color to a backdrop of zinc and cinderblock homes sprinkled among cornfields.
In recent years, 70 percent of the Quichua from Cacha have moved to Riobamba or to bigger cities like Cuenca and Guayaquil, seeking jobs and better education. Those who remain are the elderly, women, and children. They grow most of their own food and sell some of their produce in the Riobamba markets. That includes quinoa, a grain rich in protein that brings a high price on the market. They use the profit to buy cheaper, less nutritious foods like pasta, an economic trade-off that ends up boosting rates of malnutrition, just one of many common health problems.
Many Cacha adults suffer from rheumatoid arthritis (made worse by the cold mountain climate), high blood pressure, tuberculosis, and lung disease from cooking over wood fires. It’s not uncommon to find a seizure-inducing disease called neurocysticercosis, caused by tapeworm cysts from undercooked pork. (Whole, roasted hogs are sold at roadside barbecue stands all along the Pan-American Highway from Quito to Riobamba.) Cacha water is also problematic. Unfiltered and unchlorinated, it infects many people—especially children—with intestinal parasites.
In Shilpala, 10 minutes along the main road, Kendall and fellow students Caroline Mullin (MED’14) and Adriane Levin (MED’14) spilled out the back of a pickup and carried the boxes to an elementary school classroom, observed by several raven-haired children in the school’s cement courtyard. Respectfully shy and apple-cheeked, they were dressed in ponchos, wrap skirts, and vibrantly hued shawls, miniature versions of their parents.
Mullin, wearing an easy smile and a llama-print jacket, led the lesson on bones and muscles, while Kendall and Levin wrote notes on the whiteboard. Wooden desks and benches crowded the middle of the classroom. A dust-covered computer sat on a shelf, useless without electricity. In nearby fields, sheep bleated their presence.
The BU group originally planned to meet with 120 students at 8 sites; they ended up with 320, an increase attributed to the drawing power of Americans and to the fact that it was summer vacation. And while all of the medical students took daily immersion classes in Spanish, they often struggled to understand the children.
“We’ve had to learn to improvise,” Mullin said. “Half of the puzzle is really having the dialogue with the kids.”
Midway through the lesson, Mullin ushered the younger children into another classroom and shooed away a stray dog. She handed each child a long-sleeved white shirt and had them draw arm bones with markers.
“The area where these children live is very high up in altitude, very close to the sun,” she explained. “Even though the long-sleeved shirts might have cost us a little bit more, we thought that might be an appropriate decision to make for the kids.”
After class, students lined up for a snack of cheese sandwiches and bananas (another possible reason for large class sizes). Because there was no running water, Levin and Mullin washed the children’s hands with antibacterial lotion before they ate.
Health care is free in Ecuador, yet few Cacha residents take advantage of it, preferring to visit a doctor only when traditional medicine has failed. It’s the job of local doctors like Patricia Reátegui to earn their confidence and change their habits. Reátegui, who works in a four-room clinic in Machangara, Cacha’s central province, was one of the local doctors shadowed by BU students. When a mother explained that her young son and daughter had pain in their ears, Kendall listened carefully.
“Saca la lengua. Diga, ‘Ah,’” he said. The boy stuck out his tongue and breathed a long sigh. His mother and younger sister encouraged him by doing the same. Eventually, Reátegui sent the children home with medication for their earaches and for intestinal parasites. Because Cacha’s water is infamously dirty, the doctor says, she often deworms younger patients as a precautionary measure.
At the monthlong program’s end, the students agreed that their journey took them to another world, one in which hospitals and clinics have few anesthetics, antibiotics, and painkillers, let alone staff. Levin witnessed skin grafts. Mullin took medical histories for a pediatrician. And Stephanie Feldman (MED’14) assisted on a laparoscopic surgery to remove a gall bladder.
Some of the things they learned were heartening, and some were not. On one home visit, Peters Otlans (MED’14) saw a Quichua woman who had spread liver on a weeks-old gash and was in severe pain from the infected wound. After cleaning the wound, the doctor Otlans was shadowing told the woman to go to Riobamba for treatment.
“It’s eye-opening to see the way people are out here,” Otlans said. “Until you actually see it, it doesn’t have the same impact. The woman still refused to go.”
Who wants to be a doctor?
The BU School of Medicine Class of 2015 is being groomed for a respected profession now in financial upheaval and plagued by what many believe is a worrying trend away from the traditional, often nearly lifelong doctor-patient relationships nurtured by primary care. But despite concerns about health care access and future loan debt, interviews with incoming MED students reveal optimism about a career that will enable them to serve not just their patients, but their communities.
Plucked from 11,400 applicants, the 173 members of the new class hail from 32 states and 19 nations. On August 8, at the storied White Coat welcoming ceremony, they recited the Hippocratic Oath, and then, lest the proceedings get too solemn, were reminded by Kitt Shaffer, a MED professor of radiology, that “being a doctor is the best job on the planet,” and that “if you’re not having fun, you don’t have the right attitude.”
And then the grind began. Already confounded by the demands of gross anatomy, many first-year medical students are eyeing specialty medicine right off the bat—it’s not uncommon for even premed students to be planning careers not just in, say, orthopedic surgery, but in hand surgery.
“I always worry about people having a fixed idea so early, making decisions based on a very incomplete understanding of themselves,” says Robert Witzburg (MED’77), a MED professor of medicine and associate dean for admissions. But in recent years, says Witzburg, MED and other medical schools that had routinely selected applicants most adept in the sciences are now choosing students based on a more holistic review.
“That changes everything about the admissions process,” Witzburg says. “It creates a structure in which every element of the application is considered in the context of every other element. The academic record is no longer looked at as a stand-alone item, but rather in the context of the applicant’s life experience, the adversities he or she has faced, the advantages he or she may have had.”
He says adopting the holistic approach is part of an effort to “educate more students interested in community health and primary care specialties.” But, he says, “in essence we just don’t know yet.”
While he acknowledges the need for specialists, Witzburg echoes a growing sentiment in his profession that primary care is slighted by the payment system, and accumulating medical school debt is pushing young doctors toward the more lucrative specialties. Because doctors are compensated more for procedures like diagnostic scopes, scans, and biopsies than for services such as counseling or dispensing prescriptions, core primary care services are difficult to quantify and reimburse. The income gap between primary care doctors and those in subspecialties has grown steadily in the last decade, with a difference in median income of as high as $250,000 between primary care physicians and those practicing diagnostic radiology and orthopedic surgery, according to a report by the Robert Graham Center , which surveyed doctors’ incomes between 1979 and 2004. The disparity is seen as the main cause for a drop, by nearly one half, in the odds medical students will choose primary care. And the report estimated a drop of 30 percent in the odds a student will end up working in a rural health center.
The dramatic decline in primary care is compounded by an aging U.S. population and the expansion of health care access under the 2010 Patient Protection and Affordable Care Act, often referred to as Obamacare. A report by the American Academy of Family Physicians predicts a shortfall of almost 40,000 primary care providers by 2020. At the same time, the American Association of Medical Colleges estimates that among 2010 medical school graduates, average debt was almost $160,000, almost double the $87,000 in debt for graduates in 2002.
“There’s no doubt that students and residents tend to gravitate toward highly lucrative careers that are respected by their colleagues,” says Witzburg, an internist who as a young man turned down a prestigious cardiology fellowship. “And it’s common for people to turn their noses up at primary care after looking at primary care doctors struggling with paperwork and being paid poorly, and seeing other people doing high-class procedures, making disease go away in 60 minutes and being very well compensated for it. It’s not lost on medical students that these specialists are sought after by hospitals, have big fancy offices and big fancy cars, and live a different life than primary care doctors.”
But it’s not just concerns about income that is causing the shift in the medical landscape, he says. There are lifestyle issues—dermatology and ophthalmology, for example, have virtually no emergencies. Writing in the New York Times, surgeon Karen S. Silbert recently made waves by suggesting that women who want to work part-time—there’s an increasing trend for doctors to split jobs—should choose a profession other than medicine.
Heather Dehaan (MED’15), a University of Miami graduate from Nashua, N.H., thinks the attraction to lucrative specialized medicine has started to wane. “Today, doctors are seen as not being so selfish,” she says. “Doctors are seen as being more humanitarian and more involved with public health.” Dehaan hopes to be a pediatrician and is attending medical school on a U.S. Navy scholarship. Her lifelong resolve to be a doctor was strengthened as a college freshman, when her much younger sister became ill with cancer. “Caring for my sister reconfirmed what I already wanted to do,” she says. A biology major, she’s always wanted to work with children and believes that a career in pediatrics will afford her “the most influence and the most input” toward bettering kids’ lives. Under the terms of her scholarship, she’ll serve one year as a doctor in the Navy, beginning as a lieutenant, for each year of medical school. “I’m not going into this with the expectation of making a lot of money,” she says. The income question hasn’t come up in discussions with residents and fellow students, she says. Dehaan is engaged and would like to have children some day, but that will have to be put on hold until some point in the future. “And I’m okay with that,” she says.
Matthew McAdams (CAS’10, GRS’11, MED’15), of Vero Beach, Fla., believes that BU “actively selected our class for more humanism.” He and Luke Stevens (GRS’11, MED’15), of Winchester, Mass., completed BU’s master’s program in medical sciences, which they believe improved their medical school applications. They were thrilled to be accepted (it was McAdams’ second try), and they are allowing themselves to dream a bit, while coping with the much-dreaded anatomy lab. McAdams is interested in neurology; Stevens hopes to specialize in emergency medicine. Both expect to be well-compensated for their work, but as McAdams puts it, “if we wanted money, we’d go into business.” As for the prestige of being a doctor, “it’s not a bad thing,” says Stevens.
McAdams was drawn to medicine by his late grandfather, a general practitioner in rural Arkansas. He did house calls and sometimes took his grandson along. “I saw the magic in what he did,” says McAdams, who hopes to practice academic medicine, enabling him to have clinical hours, teach, and do research. He believes he probably “doesn’t have the wherewithal to perform surgery for 10 hours” and wants to work with people suffering from conditions like multiple sclerosis, neuropathy, and dementia—all of which have affected friends or family members.
“I’m committed to doing emergency medicine,” says Stevens, who completed EMT training as an undergraduate. “I have a short attention span.” And with an ER doctor acquaintance estimating he’d see 40,000 patients by the end of his four-year residency, Stevens decided the specialty would be a good fit for him. “They see about three patients an hour; they see everything,” he says, and they usher patients through initial diagnosis and treatment. With median salaries of nearly $247,000, ER doctors have an added lifestyle benefit. “It’s shift work,” he says. “You’re not committed to be on call for 100 hours a week or anything crazy like that. You work as hard as you can for the hours you work, and then you go home.” Most important to him is the notion that “in the ER you have a really big chance to make an impact on each and every patient—it’s an intersection between public health and medicine.”
Javier Rios (MED’15) and Deirdre Rodericks (MED’15) have their eyes on orthopedic surgery, which, along with radiology and invasive cardiology, is among the top-earning medical specialties, followed closely by cardiology. For Rios, from El Paso, Tex., and Rodericks, who grew up in Coles Neck, N.J., the specialty’s pull is less about income and more about results: both see orthopedists as doctors with great physical competence and as clinicians who fix people. Rodericks, the daughter of a Mexican-American mother and Egyptian-Indian father, was recently in India shadowing orthopedic surgeons. “I wanted to be a mechanic when I was really little, and it’s like being the mechanic of physicians—you use drills and saws, and can see an immediate effect,” she says. She wants a family and hopes that while she’ll restore flexibility in her patients, her profession will afford her some, too. “I’ll have to plan really meticulously,” says Rodericks. “Upperclassmen have been a really big help. Though the surgeons I spoke with are all men, BU’s residency program is now about half and half.”
A weight lifter and soccer and basketball player, Rios is drawn to orthopedics, specifically sports medicine. “It’s really fascinating to me,” he says. Rios envisions working with professional athletes, maybe being a team physician. But he also expects, as he puts it, to “have a life.” Marriage and family were not among the most urgent concerns of the male students interviewed, but they were discussed often by female medical students. “We have been talking a lot about what we’re going to do about having a husband and kids,” says Rodericks. “It’s a really big concern. We’ve joked about hiring surrogates. With so many women doing surgical residencies, you’re talking about nine more years of your life.”
Committed to doing medicine
When their conversation alights on issues beyond their new regimens and surroundings, the students share many concerns, and one that’s foremost in their minds is the lack of access to health care. “Access is a big deal for me,” says McAdams. “I have a brother who doesn’t have health insurance, and when he has an issue, he comes to his younger brother, who’s not a doctor yet, for advice. Access is the biggest problem we’ll always face.” Dehaan, too, worries about access, especially for children. “I didn’t have health insurance for a while when I was growing up,” she says. “My mom doesn’t have health insurance.”
Just moments after explaining their plans to enter specific fields, all the students interviewed conceded that everything could change. “I’m told every day that in four years I might be doing primary care,” says Rodericks. McAdams often hears that he “might come out on the other side wanting to do something completely different.”
But as Stevens puts it, what’s important is that “we’re all committed to doing medicine in some way.”
This BU Today story was written by Susan Seligson. She can be reached at email@example.com.
Nearly a third of women are sexually assaulted at some point in their lives, but less than half will seek medical care for their injuries. For those who do, emergency care often fails to conform to established protocol.
For the past 15 years, Judith Linden has worked to improve and streamline evaluation and treatment of adult sexual assault victims seeking care at hospital emergency rooms. The School of Medicine associate professor of emergency medicine has written an overview, published in the September 1 issue of the New England Journal of Medicine, of the evolving state of that care, which increasingly involves the use of sexual assault nurse examiners (SANEs). SANEs are quick-responding, specially trained, certified professionals who perform forensic medical-legal exams. When cases go to trial, the SANEs are available to testify. The program was pioneered at Boston Medical Center and there are now 650 nationally, according to Linden. Some—for example in San Diego—are at freestanding sites.
Linden’s review study points out that especially in the absence of physical injury (about half of all cases), victims “are often frightened, emotionally traumatized, and embarrassed. They often fear that they will not be believed, and they may also fear for their safety if they know the assailant or if the assailant has access to their personal information.” And she also reports that many rape victims doubt that their cases will be prosecuted successfully, a justified fear in light of the fact that in the United States fewer than half of rape cases end in convictions. Medical providers should understand, Linden stresses, that “it is not their responsibility to determine whether a sexual assault has occurred, since such a determination can rarely be made on the basis of examination alone.”
The U.S. Department of Justice , the World Health Organization, and the American College of Emergency Physicians have issued guidelines for the treatment of patients after sexual assault. Linden underlines the importance of following consistent procedures, from evaluation of traumatic physical injuries to emotional support to evidence collection. Although every sexual assault case is different, maintaining protocol is crucial, she says, noting that cases where SANE-trained nurses gather forensic evidence end in a 92 to 95 percent prosecution rate.
BU Today spoke recently with Linden about the demands of caring for sexual assault victims, how emergency medical staff is rising to that challenge, and what improvements can be made.
BU Today: Is the medical response to adult sexual assault close to being standardized or does it vary widely?
Linden: I don’t think it’s standardized at all. The beauty of having a SANE program or response team is that it establishes protocols. There are still a lot of community hospitals that don’t follow the same protocols.
What are some of the problems hospitals face in establishing sexual assault protocols?
I think staffing is a difficult issue. These cases can take a long time; it can take up to six hours for an exam, longer to make sure victims have proper treatment and the counseling they need. The ER is very unpredictable—traumas come in, and you have to prioritize patients. Sexual assault patients’ injuries may not be life-threatening. Each hospital, unless it’s SANE-certified, comes up with its own protocol. We’ve gotten to the point where EMS will often triage to SANE sites.
Are there common mistakes ER staff make in handling sexual assault cases?
The first common mistake is that some of the staff can be very judgmental. Often they may question the history given by the patient, who may be intoxicated. Some of the patients may be sex workers. As far as mistakes in treatment, people are often confused about the amount of time that can elapse before evidence degrades. In Massachusetts it’s 120 hours, a limit of five days for the vaginal exam; after that it’s less likely there will be evidence, and we don’t recommend doing a rape kit after that. For oral or anal assault it’s 20 hours.
Boston Medical Center has SANE examiners. What impact has the SANE program had?
That’s the million-dollar question if you want continued funding. Our SANE program funding is cut every year; last year it almost became unworkable, but it was restored in a supplemental budget. We’re hoping lawmakers will approve another supplemental budget. You want to show that these programs improve patient care and treatment, but you also want to prove that they’re cost-effective. Are they getting criminals out of the system, or are we saving the state money? Are they (the culprits) pleading out? Not that many studies have looked at this. There was one done in Massachusetts and several other states showing an increased prosecution rate. Anecdotally, in our SANE program there’s a 97 percent success rate when SANE is involved. Different districts don’t share information.
You write that it’s not the medical team’s responsibility to determine whether a sexual assault has occurred. Does that mean that every person arriving at an ER saying she or he is a sexual assault victim, regardless of degree of physical injury, gets the same response?
The response is the same for every woman or man who presents complaining of sexual assault. When practitioners perform a sexual assault exam they probably won’t be able to tell if there’s been an assault just from the exam. A practitioner isn’t asked to decide whether it did or did not happen. He or she is collecting evidence, and the whole thing gets passed on to the justice system. Sometimes people come in and say, “Can you tell me if I was assaulted? I passed out; I woke up with my clothes off.” My point is, it really doesn’t matter. When someone comes in with chest pain, it’s not alleged chest pain. You treat these people as sexual assault victims. It’s very rare that someone will go through this whole embarrassing, invasive questioning if nothing happened. One reason these cases are so scary to clinicians is they’re not familiar with them, and they’re scared of the justice system. They worry that they’ll have to testify. I try to bring it back to the care. We have to offer good medical care based on the latest protocol.
What happens first when a sexual assault victim comes to the ER? Is he or she afforded privacy? Do victims sometimes have to wait a long time for attention?
At least in our emergency department, they’re given top priority triage and get a room immediately. You don’t know if the attacker has followed them to the ED. Does this always happen? Maybe not. Best practice is they should not wait out in the waiting room. The other problem we have is, we take them back, close the door, and the practitioner will just leave them there. I don’t want that to happen either. What we can’t see, for example, is strangulation injuries. The victim may have bruising or difficulty breathing. I don’t want that person to sit in the waiting room.
After sexual assault victims are released, what kind of follow-up is there currently and what role does the hospital play in ensuring a victim’s safety once he or she leaves?
That’s where we ask for social worker colleagues. Safety planning is very complex. What we try to do, if the victim has identified the person (and most of the time they can’t identify the person), is we try to get creative, have them stay with friends or family. One of the more complex situations is if they live in a dorm—that’s where lawyers and crisis counselors are involved. Authorities can have a suspected attacker moved out of the dorm. Safety planning is not a cookie-cutter solution.
Which of your concluding recommendations is the most urgent?
First and foremost, to make sure that patients are believed, understood, and get the care they need and asked for. It’s important to treat them for STDs and possible pregnancy. In Massachusetts, it’s the law: we must offer all rape victims emergency contraception. And it’s important for them to know where to access services in the future.
How has your role evolved as clinician advocate for sexual assault victims?
I came to Boston Medical Center after my residency and never left. When I joined BMC 15 years ago it was right when the SANE program was being formed, and I loved the program because it was very nurse-driven. To me, it is incredibly important that we continue training our young doctors to offer accurate and compassionate treatment. I felt if I didn’t get myself trained as a SANE, my residents would be missing out. It’s important to train our future doctors, who may not have done a SANE exam by the time they graduate. It’s important that they go off to community hospitals with this knowledge. I keep up-to-date on all the latest protocols and treatments; I serve as a 24-hour resource to them and make sure that the medical community stays involved.
More information about support for sexual assault victims and reporting sexual assault can be found here.
This BU Today story was written by Susan Seligson.