Quill & Scope Fall 2014

Q SQuill & Scope

STUDENT JOURNAL OF NEW YORK MEDICAL COLLEGE

FALL 2014 | VOLUME VII

About the cover: !e Neurological ExamFrom the very start of medical school, we begin to accumulate various medical instruments—from stethoscopes to tuning forks. Pho-tographer, Andrew Staron (Class of 2015), thought it would be whimsical to share his medical school experience with friends and family through a series of snapshots of his medical tools.

Q SQuill & ScopeFALL 2014 VOLUME VII

STAFF EDITORSAnthony Casabianca

Elliot ChanNatalie Frassica

Meghan KileyEllen Liu

Sangeeta Ramani

David ShottlandParvati Singh

Jane Song

EDITORS IN CHIEFJulia CoopermanBailey Fitzgerald

Joanne LiuEric Routen

MANAGING EDITORSSherry Liou

Margaret Nguyen

EXECUTIVE FACULTY ADVISORGladys Ayala MD, MPH

FACULTY EDITORIAL BOARDFrancis Belloni, PhD

Julia C. de la Garza, MDMontgomery Douglas, MD

Jan Geliebter, PhDJennifer Koestler, MD

Ken Lerea, PhDStephen Moshman, MD

Stanley Passo, PhDElliott Perla, MD, FACP

Matthew Pravetz, OFM, PhDSusan Rachlin, MD, FACR

Pravin Sehgal, MD, PhDSansar Sharma, PhDGary Stallings, MD

Padmini Murthy, MD, MPH, MS, MPhil, CHES, FRSPH

ART EDITOROded Tal

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. !e articles selected for publication have been chosen for their literary or artistic merit. !ey 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.

GRADUATE SCHOOL LIAISONChandana Peddu

PUBLISHED ANNUALLY BY THE STUDENTS OF NEW YORK MEDICAL COLLEGE

iQuill & Scope 2014, Vol. 7

ii Quill & Scope 2014, Vol. 7

Dear Colleagues,

!is issue of Quill & Scope represents a variety of topics and ideas expressed in the written and spoken word. One of the ongoing debates in medical education concerns the persistent required prerequisite for admission to medical school of one year of college-level English coursework. With so many demands upon the time of under-graduates for learning biology, chemistry, mathematics, and physics, why are we persistent in insisting upon the study of Chaucer, Shakespeare, Twain, Eliot, and Fitzgerald?

!e answer, I think may be found in the pages of Quill & Scope. Physicians must be capable of communicating with each other, with patients, and with the family members of patients in clear written and spoken English. !e best way to hone this skill is by practice: by reading well-written prose, by writing high-quality prose, and by learning how to express and respond to a cogent oral argument. Physicians, therefore, have a longstanding a"nity to reading and writing poetry and #ction and non-#ction prose.

My congratulations to the authors and editors whose work appears in this volume of Quill & Scope.

Sincerely yours,

Edward C. Halperin, M.D., M.A.

�� #��#��

��!��#��

��

�� !�#��"��#�$�#�� #��

��

�� #��

�

��

��!��"�"��#��%�� '�#"��&�'#��)��&�%�#(&�'�#(��'�#%��#"&��%�'�#"��"��'��#!�&��%#!�'�� '�"�4%�� +�#5�'��'�!��"&�'#��"��#%�'�%#*��2�'�� &#�%��%&�'#�*��'�#"��&��&��"�'��!�%%#%2�� '�#"��"��!��&�("��%&'##��'#��#"&�&'�"'�*�'��'��#(��'�� 3&��"�'�#"��&�4�"��'�)��$%#��&&�#��+$ #%�'�#"��"��&�#)�%,35�'��'�4'(%"&��+$�%��"��"'#� ��%"�"�52�8>9��"�!�� (��'�#"�*��#�'�"�&$��#('�'�� 6 #"�� %"�"��$%#��&&2��%�� ',��&�'��'� ��6� #"�� %"�"��*� �"#'��+�&'�*�'�#('��"'%#&$��'�#"/�&� �6�)� (�'�#"/��"��+$�%��"'�� $'�)��%��&#"�"�2�"�'��&��#"'�+'��%�'�� %�� '�#"�'��&�#"��"��!��"�"��*��"��'��&��$$ ��'#�� "�� +$�%��"��&��"��%��%&�'#��$%#��&&�#��+$ #%�"��#"�3&�#*"�� &�&,&'�!&�*�� "� ,-�"��"��$(%$#&��( �*�,�'��&��+$�%��"��&��"�#%��%�'#�!��&�"&��#��'��!/�("��%&'�"��*�,�'��,�#��(%%��/��"��#"&��%��#*�'#��$$ ,�*��'��&� ��%"��'#��('(%��&�!� �%��+$�%��"��&2�8?9��#%�'�� '��%��$%#��&&�#"� /�%�� '�#"�$%#)��&��!��(!�'#��#!��"#* �� "��#!$�'�"'� ��%"�%&/��&�*� ��&��#!$�&&�#"�'��"��(!�"�&'��%��)�%&2��&��"�'(%"�*� ��!$%#)��$�'��"'��%�2�

��(� �:��#$�� '(��"'��#(%"� �$%#)��&��"��)�"(��#%�#(%�,#("��!�� $%#��&&�#"� &�'#�%�� '�($#"�'��%��+$�%��"��&��"�'�� &&%##!/�*�'��$�'��"'&/�*�'��!�"'#%&/��"��#'��%��)�"'&��"�'��%� �)�&2��,�&��%�"��'��&��%'�� &/�&�#%'�&'#%��&/�$#�!&/�$�#'#�%�$�,/��'�2�'��%��%��&�� &#��%#(��'��"'#�'��%�� '�)��!�"�6&�'2��

�&��%�� '�#"�'��#"'�"'&�#��'��&��#(%"� ��!� ��'�'#�#"��"��$$%��'��'��$%�)� ��'��&�'#��"�'��&�$%#��&&�#"��"��#*�� &&��!�'#�� &#�'#�*#%��*�'��'��&��)�%,�!( '�6'� �"'��&'(��"'&�#"�'��&��""(� �$%#��'2��!��*�&'%(��/��"&$�%��/��"��")��#%�'��,�'��%�$�&&�#"��"��'�#"�'��'�� &#��+'�"�&��,#"��'�� &&%##!2��,��!#"&'%�'��'��'�'��('(%��#��'��&�$%#��&&�#"��&�)�%,��%��'2�

�,��#"�%�'( �'�#"&��"��'��"�&�'#�� '�#&��'��'��#"'%��('��'#�'��!��"��#��'��&��'�#"/�� #"��*�'��&$�� %��#�"�'�#"�'#�'��'#%&6�"6��"��!�"��"��'#%&.��

��#$��,#(��"�#,�'��&��'�#"�#��'��#(%"� ��&�!(��&��)�.� �

��+��('�)��( ',��)�&#%�'#�'��(� �:��#$��

�8>92��#(��/��#��/�� %��8��&9�8>CB@9�� '�#"1��(%"�"��+$�%��"��"'#� ��%"�"�2� #"�#"/��#��"��8?92��-�%#*��2�#*��%�'�� %�� '�#"�'%��%&�'%�"&�#%!�'�)�� %"�"�2�"1��-�%#*��/��2��#&'�%�"��%�'�� '�#"��"��( '�##�1��(��'#��%�"&�#%!�'�)��"��!�"��$�'#%,� ��%"�"�2��"��%�"��&�#/��1��#&&�,6��&&0�>CC=1>7A�

�

iiiQuill & Scope 2014, Vol. 7

!e meaning of re$ection is to give serious thought or consideration and it comes from the Latin word “re-!exio”, which means to bend back or throw back. It also refers to what one sees in the mirror. Re$ection in academia is understood to be consistent with Boud et al.’s de#nition as “an active process of exploration and discovery” that “turns experience into learning”.† In medical education we o%en speak about the life-long learning process. !e reality is that life-long learning will not exist without introspection, self-evaluation, and experiential adaptive reasoning. In this context, critical re$ection takes on an added meaning when it is ap-plied to clinical experiences and refers to a process of exploring one’s own belief systems while analyzing these experiences in a purposeful way in order to make sense of them, to understand why they occurred, and to consider how to apply what is learned to future similar experiences.‡ For the healthcare professional, re$ection provides a medium to become knowledgeable and competent learners, as well as compassionate and humanis-tic caregivers. !is in turn will improve patient care.

!e Quill & Scope Medical Student Journal provides an avenue for our young medical professionals to re$ect upon their experiences in the classroom, with patients, with mentors, and on other events in their lives. By sharing these articles, short stories, poems, photography, etc. the reader is also brought into the re$ective mindset.

As I re$ect on the contents of this journal I am le% to once again appreciate the privilege it is to be in this profession and how blessed I am to work with these very multi-talented students on this annual project. I am awestruck, inspired, and invigorated by their passion and dedication that also extends beyond the classroom. !ey demonstrate that the future of this profession is very bright.

My congratulations and thanks to all those that contributed to the making of this edition, along with special recognition to the editors-in-chief and managing editors!

I hope you enjoy this volume of the journal as much as I have!

Gladys M. Ayala, M.D., M.P.H.

Executive Faculty Advisor to Quill & Scope

† Boud D, Keogh R, Walker D. Re!ection: Turning Experience into Learning. Abingdon, Oxon: Routledge; 1985.

‡ Mezirow J. How critical re$ection triggers transformative learning. In: Mezirow JA, Fostering Critical Re!ection in Adulthood: A Guide to Transformative and Emancipatory Learning. San Francisco, CA: Jossey-Bass; 1990.

�� #��#��

��!��#��

��

�� !�#��"��#�$�#�� #��

��

�� #��

�

��

��!��"�"��#��%�� '�#"��&�'#��)��&�%�#(&�'�#(��'�#%��#"&��%�'�#"��"��'��#!�&��%#!�'�� '�"�4%�� +�#5�'��'�!��"&�'#��"��#%�'�%#*��2�'�� &#�%��%&�'#�*��'�#"��&��&��"�'��!�%%#%2�� '�#"��"��!��&�("��%&'##��'#��#"&�&'�"'�*�'��'��#(��'�� 3&��"�'�#"��&�4�"��'�)��$%#��&&�#��+$ #%�'�#"��"��&�#)�%,35�'��'�4'(%"&��+$�%��"��"'#� ��%"�"�52�8>9��"�!�� (��'�#"�*��#�'�"�&$��#('�'�� 6 #"�� %"�"��$%#��&&2��%�� ',��&�'��'� ��6� #"�� %"�"��*� �"#'��+�&'�*�'�#('��"'%#&$��'�#"/�&� �6�)� (�'�#"/��"��+$�%��"'�� $'�)��%��&#"�"�2�"�'��&��#"'�+'��%�'�� %�� '�#"�'��&�#"��"��!��"�"��*��"��'��&��$$ ��'#�� "�� +$�%��"��&��"��%��%&�'#��$%#��&&�#��+$ #%�"��#"�3&�#*"�� &�&,&'�!&�*�� "� ,-�"��"��$(%$#&��( �*�,�'��&��+$�%��"��&��"�#%��%�'#�!��&�"&��#��'��!/�("��%&'�"��*�,�'��,�#��(%%��/��"��#"&��%��#*�'#��$$ ,�*��'��&� ��%"��'#��('(%��&�!� �%��+$�%��"��&2�8?9��#%�'�� '��%��$%#��&&�#"� /�%�� '�#"�$%#)��&��!��(!�'#��#!��"#* �� "��#!$�'�"'� ��%"�%&/��&�*� ��&��#!$�&&�#"�'��"��(!�"�&'��%��)�%&2��&��"�'(%"�*� ��!$%#)��$�'��"'��%�2�

��(� �:��#$�� '(��"'��#(%"� �$%#)��&��"��)�"(��#%�#(%�,#("��!�� $%#��&&�#"� &�'#�%�� '�($#"�'��%��+$�%��"��&��"�'�� &&%##!/�*�'��$�'��"'&/�*�'��!�"'#%&/��"��#'��%��)�"'&��"�'��%� �)�&2��,�&��%�"��'��&��%'�� &/�&�#%'�&'#%��&/�$#�!&/�$�#'#�%�$�,/��'�2�'��%��%��&�� &#��%#(��'��"'#�'��%�� '�)��!�"�6&�'2��

�&��%�� '�#"�'��#"'�"'&�#��'��&��#(%"� ��!� ��'�'#�#"��"��$$%��'��'��$%�)� ��'��&�'#��"�'��&�$%#��&&�#"��"��#*�� &&��!�'#�� &#�'#�*#%��*�'��'��&��)�%,�!( '�6'� �"'��&'(��"'&�#"�'��&��""(� �$%#��'2��!��*�&'%(��/��"&$�%��/��"��")��#%�'��,�'��%�$�&&�#"��"��'�#"�'��'�� &#��+'�"�&��,#"��'�� &&%##!2��,��!#"&'%�'��'��'�'��('(%��#��'��&�$%#��&&�#"��&�)�%,��%��'2�

�,��#"�%�'( �'�#"&��"��'��"�&�'#�� '�#&��'��'��#"'%��('��'#�'��!��"��#��'��&��'�#"/�� #"��*�'��&$�� %��#�"�'�#"�'#�'��'#%&6�"6��"��!�"��"��'#%&.��

��#$��,#(��"�#,�'��&��'�#"�#��'��#(%"� ��&�!(��&��)�.� �

��+��('�)��( ',��)�&#%�'#�'��(� �:��#$��

�8>92��#(��/��#��/�� %��8��&9�8>CB@9�� '�#"1��(%"�"��+$�%��"��"'#� ��%"�"�2� #"�#"/��#��"��8?92��-�%#*��2�#*��%�'�� %�� '�#"�'%��%&�'%�"&�#%!�'�)�� %"�"�2�"1��-�%#*��/��2��#&'�%�"��%�'�� '�#"��"��( '�##�1��(��'#��%�"&�#%!�'�)��"��!�"��$�'#%,� ��%"�"�2��"��%�"��&�#/��1��#&&�,6��&&0�>CC=1>7A�

�

iv Quill & Scope 2014, Vol. 7

A Letter from the Editors-in-Chief!e life of a medical student is a study in balance. In previous volumes, Quill & Scope has focused on the macro aspects of this balance, the constant tension between the human selves replete with ideals and interests that all students bring to NYMC, and the persona of the clinician-scientist that we are all working so hard to cultivate. Balance enters everywhere. We balance big and we balance small. We balance our goals, our aspirations, our families, and our friends. We balance di&erential diagnoses, weighing epidemiology against histories. We balance the exam #ndings we garner, picking evidence we can see, hear, and touch. As clinical and measured as we try to make this process, it is always a matter of harmonizing the perspectives we perceive. !e cover to Volume VII captures this concept with a student’s view of the instruments of the neurological exam, the tools used to formulate a more complete picture based on a patient’s perceptions. !e neurolog-ical exam is quite a #tting symbol for the act of balancing as it involves a literal balancing act on the part of both examiner and patient: one positioning vibrating instruments strategically on various parts of the body to elicit responses, the other performing feats of balance in an attempt to maintain upright positions without the use of all of one’s limbs.

Perfecting the art of balance requires crossing an intellectual chasm that we are slowly but surely learning to span, using not only instruments such as the ones depicted on the cover, but also the tools of artistry, human-ism, empathy, and curiosity so well embodied in the pieces within this year’s journal. We balance by leaning on our knowledge gained from valued professors and texts. We balance by leaning on the clinical instruments that we are learning to use. We balance by leaning on our colleagues, which is why we are so proud to present this collection of work produced both by and for this student body and the greater NYMC community. On a personal note, we lean on our managing editors, who have risen to the challenge of putting together this year’s journal despite balancing school and other commitments along the way. We are deeply grateful for all of their hard work. To Dean Ayala, our faculty advisor, the faculty editors, the student editors, and all who support the journal, we thank you. We could not do this without you.

We hope that this journal will inspire you—our readers—to take a break from your daily routine and re$ect on how you stay balanced. Quill & Scope Editors-in-Chief,Julia CoopermanBailey FitzgeraldJoanne LiuEric Routen

vQuill & Scope 2014, Vol. 7

A Note From the Managing EditorsWhen we inherited the journal from last year’s managing editors, we were apprehensive about the amount of latitude we were given in terms of the scope and design of this year’s journal. Starting the seventh volume of Quill & Scope was daunting, but over the course of a year, this volume has blos-somed from a to-do list scribbled on a piece of paper to a representation of New York Medical College and everything it has to o&er.

We were in awe of the submissions we received from our colleagues. As #rst year students, we did not know what to expect when we asked the community to submit articles to the journal. However, as the pieces came in, we started learning about the diverse abilities at NYMC. We received rigorously researched papers, evocatively striking artwork, and deeply insightful re$ections. We are honored to be among such accomplished and passionate individuals.

Although we did not have a speci#c theme for this volume of Quill & Scope, the pieces we have chosen to include in the journal provide a comprehensive review of the talents and perspectives of our col-leagues here at NYMC. We sincerely hope that by the time you reach the last page of this journal, you will have learned something about yourself, about the practice of medicine, or about each other.

We would like to show our deepest gratitude to our Editors-in-Chief for being a constant source of support over the past year. We would also like to thank Dean Ayala and the rest of our faculty editorial board for their guidance and hours spent reviewing pieces for publication.

It has been a pleasure to produce the seventh volume of Quill & Scope—we hope you enjoy the collec-tion of works within it.

Quill & Scope Managing Editors,Sherry LiouMargaret Nguyen

vi Quill & Scope 2014, Vol. 7

Interview with Dr. Matthew Pravetz 1Q&S Managing Editors

Lighthouse 5Henry Feng

Interview with Dr. Marietta Lee 6Q&S Managing Editors

Doctors Are Patients Too 10Daniel Mangels

A Boston Man: Sir Oliver Wendell Holmes 11Bailey Fitzgerald

EMR: !e Good and the Bad 14Sherry Liou

Inspiring Compassion for Rare Diseases 16Colton Margus

An Introduction to Moyamoya Disease 18Michael Shen

Ethics of Placebic Deception: Emerging Evidence in a Re-emerging Dilemma 20Tejas Pulisetty

Truce 23Michael Shen

Addressing the Health of Refugees: Vitamin D 24Laura B. Madsen

Path by Sunshine Cottage 34Michael Shen

Water 35Parvati Singh

Crossroads 36Parvati Singh

Our Tree of Enlightenment 38Nidhi Shah

Convocation of !anks Remarks 40Christopher MonsonVinod RavikumarIsrael Ackerman

Beyond My Window 43Anastasiya Holubyeva

Multipotent Adult Stem Cells (MASCs) for Tibial Exposure Regeneration 44Rachel Talley-Bruns

Functionalized Nanoparticles: Old Drugs, New Tricks 45J. Henry Feng

Increasing Volume of Non-Neoplastic Parenchyma in Partial Nephrectomy Specimens Is Associated with 46Chronic Kidney Disease Upstaging

Michael B. Rothberg

Table of Contents

viiQuill & Scope 2014, Vol. 7

TABLE OF CONTENTS

EGFR and PDGFRA expression heterogeneity and interaction in glioblastoma oncogenesis 47Diana V. Punko

Homeostatic Response to Hepatic Lipid Metabolism in the Absence of ApoB 48Christina Wang

Mechanism of Sinus Node Activation in Cardiac Tissue 49Vinod K. Ravikumar

Tension Band Plating for Anterior Tibial Stress Fractures in High-Performance Athletes 50Robert M. Zbeda

Subgroups of Bladder Cancer Patients Prior to Radical Cystectomy: A Cluster Analysis 51Michael Goltzman

Hydrogel delivery of co-embedded EPC-MSC for treatment of AKI and modulation of macrophage 52cytokine/chemokine release

Joseph A. ZulloAscultations 53

Andrew Staron

1Quill & Scope 2014, Vol. 7

CONVERSATIONSInterview with Dr. Matthew PravetzQ&S Managing Editors

We chose to interview Dr. Matthew Pravetz because we want-ed to peek into the mind of the individual who has played an integral role in the education of every medical student who has passed through the doors of NYMC since 1982. !e path he took to become a professor of future medical profession-als was non-traditional, and because of his training both as a scientist and as a friar, Dr. Pravetz teaches the science of both anatomy and human empathy. We were touched by the vignettes that Dr. Pravetz shared with us during his inter-view, and we are excited to share with you his words of wis-dom and his advice to the future generation of physicians. We hope that you will "nd a similar inspiration in his words.

Managing Editor (ME): Did you ever consider studying a sub-ject outside of anatomy or a career outside of science or aca-demia?

Dr. Pravetz (P): It’s very interesting. From the very begin-ning, in my senior year in high school, I wanted to teach gross anatomy in medical school. When I was in undergraduate school, I wanted to be an anatomist. It goes all the way back to undergraduate school, when I studied comparative anatomy.

ME: "at takes a lot of planning and foresight.

P: Yes, and my classmates thought that it was weird. !ey asked, “gross anato-my, what is that?” I #rst learned about it from a brochure that I got at a career day in high school. I looked at it and thought, “Wow, that is very interesting,” and I put it in the back of my head and went to college. !en in college, I decided that was what I wanted to do.

ME: Did you have a family member that was in the medical #eld?

P: No. I’m the #rst member of my family to go to college, and up to that point I was one of the few members of my family to graduate from high school. It was really uncharted territory.

I also had this other idea, in the meantime, to become a priest. In the middle of my studies, I entered the Franciscan Order. A%er I #nished my training with the Order, I went back to studying because I wanted to be in academics, and I have been in academics since the very beginning. I am a parish priest too, but I am primarily in academics. !is is my 50th year teaching.

ME: "at’s amazing. Congratulations!

P: When I used to hear people say that they have been teach-ing for 25 years, I thought to myself, “!ey’re so old!” And now all of the sudden, here I am. But, I thoroughly enjoy it.

ME: What made you interested in pursuing a career in academics?

P: I have always been drawn to academics—to teaching. I have always wanted to teach medical doctors, so the training program in the Anato-my Department here at NYMC seemed like the perfect mix, and it has been wonderful.

!e NYMC Graduate School no longer has the Clinical Anatomy program that I was enrolled in, but at the time, I took medical school courses. Subsequently, I did re-search and a dissertation. !e college provided a terri#c back-ground for my career in Clinical Gross Anatomy.

ME: Was there a speci#c reason for why you wanted to teach medical stu-dents?

P: I was interested in training people for a profession—a good and noble profession. For me, teaching gross

anatomy allows me to have an impact on more people, by way of my students, than I could have if I were a clinician.

ME: Besides being the anatomy course director, what other work are you involved in at NYMC, Westchester, or our other a$liate hospitals?

P: I participate in the programs of all three NYMC schools. I am on many, many committees in the University. !e admin-istrative aspect really takes up a lot of my time.

I work with medical and physical therapy students and resi-dents in programs with surgical subspecialties. I used to go to the hospitals to teach residents, but now with our expanded facilities, the residents come here on their didactic day. I also oversee some morbidity and mortality conferences.

ME: How do you prioritize di%erent goals and projects from these di%erent responsibilities?

P: It’s di"cult because so many things have the number one slot. I always say that my primary responsibility is to the stu-dents whom I am teaching, and the other responsibilities fall into place. If any of the committee work were to distract me from that, I would remove myself from that committee.

“I was interested in training people for a profession—a

good and noble profession.”

2 Quill & Scope 2014, Vol. 7

My primary responsibility is to shepherd medical students through the course that they are working on and to help them move to the next level.

ME: As the anatomy course director, you are intimately in-volved in the bequeathal program. Can you tell us a little bit more about this process?

P: It’s very interesting; we are probably the #rst medical school to have a Convocation of !anks program in the Unit-ed States. !is year we are in our 26th year, and we are involv-ing the family members more and more in the process. Because of the Convoca-tion of !anks, people learn about us. It’s all by word-of-mouth. In addition, the Convocation has received much space in the press.

People have asked me to come to address small groups in the tri-state area. I don’t solicit [their attention]; the program has just blossomed over the years.

ME: You have been able to speak to many of those who have decided to donate to the bequeathal program. What are some of their reasons for wanting to be a part of the program?

P: First of all they are very generous. !ey are people who think of more than just themselves. Many of the people whom I have spoken with come here to the school. We chat over a cup of co&ee because they want to see the medical students.

As soon as they see the medical students, they say, “!is is perfect.” Before coming here, they don’t know what kind of person a medical student is. When students walk by, they are so friendly to me and to everyone else. !ey say hello to the people who are visiting, and the visitors say, “!ese are going to be wonderful doctors. I want to help to teach them.” !at’s how it works. !ey do have a kernel of generosity to begin with and could do all sorts of other things but they really feel strongly about the bequeathal. At the beginning, it might be tough for family members when someone says, “I want to do-nate my body.” But when the family members come to the Convocation years later, they say that it is the best thing their loved one has ever done. It’s humbling.

ME: You are in charge of coordinating the Convocation of "anks every year. What do you #nd is most rewarding about this event? How do you help families cope?

P: For me, the most rewarding aspect of the Convocation of !anks is for me to be in the background and watch this group of medical students transform. !e group is di&erent from the initial one on the boat cruise. It’s not a surprise be-cause I know that it will happen, but it’s just so overwhelming to see the transformation that takes place.

!e convocation falls at the end of the student’s #rst year. By then, you can see how the students have become more ar-ticulate and assured. It’s interesting, when family members

are having a hard time at the ceremony, the students are the ones who talk to the family members. I don’t do anything. I encourage students to talk to those who seem to be struggling, and you can see the wagons get circled around. !e family members actually share with the students, and the students have a lot of experience, a%er having taken Behavioral Sci-ence, on how to support people who are mourning. It’s most-ly listening. You don’t have to say very much; you just have to ask the right question. It is the students who have taken charge of the whole process. It is the students’ convocation, not mine.

ME: You are the course director for one of the very #rst courses that medical stu-dents take at NYMC, can you tell us a little more about your experience with that? Is it a lot of pressure?

P: Students are nervous at the begin-ning, but they don’t know how ner-

vous I am! It’s such a huge responsibility. Maybe I’ve put it on myself, but it’s there. It’s nerve-wracking for anybody who is taking on a group of neophytes, who are enthusiastic and bright-eyed, but uninformed. However, as long as you get the #rst step right, everything will follow in its place.

I plan and plot my lessons. I look for the best analogy so that people will not have a rocky start, be disappointed, or be over-whelmed. Yet at the same time, I want them to be challenged. For me, that’s the part of education that I like. It’s scary and challenging, but these things keep my adrenaline going.

Some people ask me, “Do you get tired of doing the same-old, same-old, explaining the spleen or showing where the gall-bladder is?” !at has nothing to do with it; that is boring. !e learning process is what excites me. When people suddenly say, “Ah, I got it.” !at puts the “D” in my day.

ME: You are also involved in the Ethics in Medicine curricu-lum, how do you imagine this course evolving in the future?

P: !e ethics curriculum started out as a co&ee table session, once a week. It was pick-up, like pick-up basketball. !ere was no one in particular who was leading it. We would have little discussions literally in the cafeteria. !is was before there was any such thing as an ethics curriculum. It evolved to become more over the years. !e Liaison Committee on Medical Education (LCME), the licensing commission, sees that it is necessary for students to be aware of ethical thinking.

Medical education is becoming very challenging because there are so many things that are necessary for students, such as a humanities component. !ey are not just there to do physical things with people; there are other elements to becoming a healthcare professional.

ME: What do you hope students take away from the Ethics in Medicine course?

P: !e most important thing would be to understand that

“...the most rewarding aspect...is for me to be in

the background and to watch the group of medical students be transformed.”


CONVERSATIONSsome questions have no speci#c answer. !e student has to be able to #gure that out. Most people with a science background are looking for the answer, and when you are looking at eth-ics, there isn’t one. !ere are so many di&erent parameters involved. Most medical students are not comfortable with liv-ing in that gray zone.

ME: What would you say is your most memorable teaching experience?

P: Teachers have to deal with occasional surprises. My most memorable teaching experience came as a complete surprise. It was the day a%er the horrendous 9/11 tragedy. I had not been using PowerPoint presentations yet, so the lights were on and I looked directly into the faces of 196 deeply con-cerned people. “I’ll just carry on, business as usual,” I thought. As soon as I opened my mouth, I began instead with some of my thoughts on why, at times like these, society has high expectations of us, as professionals, to maintain focus and to continue under duress. !e surprise was that I have no idea where the words came from; it was certainly not in my “script” for that lesson. As I continued for perhaps ten more minutes, I started to realize that I have never, ever had such rapt attention; it was unsettling. What was so memorable was what came a%er I #nished—dead silence. Everyone was still holding me in their sight. I could hear sounds of sni'ing and choked tears. I’ll never forget that moment. It was a complete surprise.

ME: Do you remember your greatest teaching achievement or something that you have been very proud of in your teaching experience?

P: Of course pride is not a virtue, but I get annual twinges of it once a year on Match Day. I vicariously feel pride for being part of the learning process of these newly minted doctors. It doesn’t get better than that.

ME: If you could give one piece of advice to all of your students who are on the path to becoming a physician, what would it be?

P: !ere are three things. !e #rst is that it is really a privi-lege for all of you to be a medical student. Even on the worst day, it is a privilege. I think you have to remind yourself of the privileges you have. Many other people—and society in general—have pulled together to allow you the opportunity to practice this noble profession. Most of the time we are just thinking about end diastolic volume and all of that, but what a privilege to be able to do that! Most people in the world couldn’t even begin to do that.

!e second thing: recall how at the very beginning of medical school you packed away your ego in mothballs. You are even-tually going to pick up that ego again. !e thing is, I suspect that you are going to #nd that the ego is di&erent. Just keep an eye on yourself and remember who you are now.

!ird, when you actually get to practice med-icine, you have to remind yourself to take the time to look the patient deep in the eyes and look deep into their heart—every patient. Nev-er, ever have an experience where you don’t look that person in the eye. !at takes practice.

ME: O&en, in the midst of studying for basic science courses, we can lose sight of our #nal goal: being a patient advocate. Is there something you recommend medical students do in order to put our educational journey into perspective?

P: You are going to have so many mentors along the way. You don’t have to be a tail on their kite, but observe and learn from some of the things that they do—I think that would be the best thing. You have to be able to put the right lenses in your eyes to #nd people who are really virtuous, good, hero-ic, and empathic—the whole nine yards. You have seen them and you know who they are already. I don’t think that there is any single person, but look at the broad spectrum for dif-ferent styles.

ME: Has being in the Franciscan Order helped you become a better teacher? How have you felt that side of your life in!uence your teaching and academic career?

P: It has been helpful because as part of my training we were taught that you must, as Pope Francis says, “Smell like the

$ock.” You can’t be above everybody else. In my training we learned skills by practicing in the marketplace, so to speak, with people. We were taught to interact, to try to understand, and to get to know people wherever they are.

If nothing else, it taught me to be humble in the presence of students from the get-go, because we were trained never to feel superior to students. Never. Sometimes it is di"cult to swallow, but that is the challenge, to approach teaching with simplicity and humility.

ME: Going along with that, is there any one particular lesson that you learned from a student?

Years ago, I received some “sage advice” from a teaching mentor who told me not to smile until Christmas. “!at way you’ll get their respect,” he said. And so I was very serious, no nonsense in my approach. In the anatomy laboratory, you don’t have to eavesdrop to hear conversations at the neigh-boring table, and sometimes the conversation can be very hu-morous. Many years ago, while I was working at a particular table, I overheard a story by a student. I couldn’t help myself; I laughed so hard. In turn, that very student turned to me and said that he had never heard me laugh out loud. For me, that was a well-learned lesson from a student.

ME: In what other ways do you feel that your role in science is related to your role in religion?

P: !ey are very related. Of course, I look at creation through

“...at times like these, society has high expectations of us,

as professionals, to maintain focus and continue...”


the eyes of my faith. !ere are certain things for which there are no answers, and yet I believe, because of my faith. !ere are certain things that can be answered, the scienti#c. It has never been di"cult for me. People have o%en asked me, “Is there a con$ict?” !ere is not, because there are certain things that I just know can’t be answered . People ask me about evo-lution—that’s a big one. I’ve been an evolutionist from the very beginning. It doesn’t contradict any of the teachings.

ME: "ank you Dr. Pravetz for taking the time to speak with us and to share about your experiences at NYMC.


CONVERSATIONS

LighthouseHenry Feng


Dr. Marietta Lee is the winner of the 2013 Dean’s Research Award. We chose to interview her for this volume of Quill & Scope because she is a successful female scientist in a pro-fession that is largely male-dominated. Dr. Lee proves to be a force outside of the NYMC lecture halls as an important contributor to the research behind the structure of DNA polymerase delta. !rough the years, she has managed to be devoted to her family and to the graduate and medical stu-dents that she has mentored. What follows is an account of the events and turning points that have allowed Dr. Lee to become the prominent researcher she is today.

Managing Editors (ME): Congratulations on receiving the Dean’s Research Award this year. Could you please tell us a little about your work?

Dr. Lee (L): My laboratory studies the protein machinery required for DNA synthesis. In particular, we are studying DNA polymerase delta, a key enzyme that has to replicate DNA with the utmost #delity to avoid mutations. My group is focused on the study of human proteins—ours is one of the few laboratories in the world that studies polymerases that replicate the human genome. Our goal is to understand their role in maintaining the integrity of the genome through the avoidance and repair of mutations. We use a wide range of biochemical, molecular, and cell biology approaches.

ME: You began your career as a researcher studying poly-merase delta. Do you expect to continue in the same direction, or has the direction of your research changed?

L: My early research was focused on the biochemistry of DNA polymerase delta. When I was a postdoctoral fellow at the University of Miami, I puri#ed DNA polymerase delta to homogeneity from calf thymuses and identi#ed the two-sub-unit core. I also demonstrated that DNA polymerase delta has an intrinsic proofreading 3’ to 5’ exonuclease activity and is a di&erent enzyme from DNA polymerase alpha. When I moved to New York Medical College, I found the two addi-tional DNA polymerase subunits and reconstituted the poly-merase delta holoenzyme in baculovirus-infected insect cells. Over the years, my research has continued to focus on poly-merase delta, but has evolved to include studies of the role of polymerase delta in DNA repair, its regulation in response to DNA damage, and its regulation during the cell cycle. Right now, I am collaborating with Dr. Zhongtao Zhang (NYMC Department of Biochemistry and Molecular Biology) to solve the structures of the polymerase delta proteins.

ME: Who has played an indispensable role in shaping who you are today?

L: !e #rst person is Dr. Erminio Costa. A%er I graduated from college in Kentucky, I was of-fered a scholarship with a professor in parasitol-ogy at St. John’s Univer-sity in New York, but I was not interested in parasitology. Soon a%er, Columbia University o&ered me an interview for a research position, and I ended up inter-viewing because I was curious to see the work of other scientists. Dr. Costa, who was then starting a labora-tory as an Associate Professor of Pharmacology at Columbia, o&ered me a position as a laboratory technician. I went back and declined the position at St. John’s University and joined him. Once I started working with him, he told me that I had the potential to be a good scientist.

Eventually, he decided to move back to Washington, DC and arranged for me to go to Georgetown University for my Ph.D. and be an investigator in his group. He was so charismatic—I was always enthralled during his talks. I really liked him, and he helped me gain a lot of con#dence.

!e second person who has played an indispensable role in shaping my career is my husband. I don’t think that I would do him justice if I did not mention him here. He is 10 years ahead of me, not in age, but in terms of academics, and he is very, very supportive. His input is always invaluable.

Finally, I would say that my high school teachers also had a very in$uential role in shaping me as a person. I went to an all-girls high school, and the teachers really instilled in us that if we fall down, we should get back up. I remember a skit I had to do in my senior year: they had us say over and over to the younger students, “If at #rst you do not succeed, try, try, try again.” !at stayed with me.

ME: How did you #rst come to teach at NYMC?

L: We came because they had two o&ers for both my husband and me. Before I received NYMC’s o&er, I was headed for the Paci#c Northwest Laboratories in Richland, Washington. It was more of an administrative position, which would have made it di"cult to interact with students. I had even bought a condo on the top $oor of a building that I was going to reno-vate, and I was going to $y back to Miami every month. In the end, I got cold feet. My husband and I came to the decision

Interview with Dr. Marietta LeeQ&S Managing Editors


CONVERSATIONSthat we should not live separately and that commuting from the East coast to the Paci#c Northwest would be too di"cult.

When I #rst came to NYMC, I was so intimidated. I o%en sat in the back of the lecture halls trying to learn from the profes-sors who students said were good teachers. I was attending a lecture by Dr. Susan Olson, and she asked me, “You know this material already; why are you here?” I told her that I want-ed to learn how to improve my lectures. One of the students that I sat next to in a few of the lectures, told me that he was quite impressed that I was making an e&ort. When Dr. David Frick le%, I volunteered to teach his lectures because I had the background for it. I had already been teaching the masters students and so the transition from teaching the masters stu-dents to the medical students was simple. !at is how I came to teach medical students about DNA replication and repair.

ME: At what point did you decide to priori-tize both research and teaching? Many people choose either or. Why are both important en-deavors to you?

L: I started teaching around 1996, one year a%er I was admitted to the graduate faculty at the University of Miami. Prior to this, I worked with only postdocs and un-dergraduate honors students. I was sent to the main campus to teach the undergraduates, which was a new and exciting experience for me.

At NYMC, research and teaching became my career goals. I really think teaching was my next calling. In teaching, you have to explain known material as clearly as possible. In re-search, you discover new material. It opened my eyes to how ful#lling it could be to teach as well as to conduct research.

Research is ful#lling when you get a grant or when your pa-pers are accepted, but when you receive critiques from stu-dents saying they really liked your lectures, or when students become managers in the industry, postdocs at Harvard or Cornell, professors, and doctors—it is rewarding on a di&er-ent scale. As an educator, you are building the next genera-tion of scientists and doctors.

ME: "at leads us into our next question. Do you think you are where you envisioned yourself to be when you started out in the #eld?

L: My career could have been better, but it could have been worse. I am pretty happy with where I am, but of course, be-ing an ambitious soul, I could have been better.

I was lucky that I never had to look for a position a%er my Ph.D. I always had di&erent options available to me, and I am glad I made the choice to balance work and family.

ME: What is the most rewarding aspect of your job? What are the most challenging ones?

L: It is very rewarding when students tell you that they appre-ciate your e&orts. One of my critiques said that my lectures

were “crystal-clear”. I don’t know how many times I re-read that critique. It is also reward-ing when the students keep in touch with me. I love hearing about what they are doing now and seeing the pictures they send.

In my work as a researcher, it is very, very gratifying when a paper is accepted or when a grant application is approved. Our laboratory tries to explore new technologies as they be-come available, and it’s rewarding to see students master these technologies. When they ask intelligent questions, take on challenges, and attempt to explore new directions, they are maturing as scientists and I know they are ready to go. I feel proud when they are accepted to good postdoctoral positions and later succeed in their professions.

It’s challenging when papers get rejected. But sometimes, rejection can be good. We submitted a paper on p12 degradation in response to DNA damage, and the review-er said that there was no evidence that it was targeted for proteasomal degradation

by ubiquitination. We went back and developed an assay to prove that it was. !is work in turn led to the identi#cation of the E3 ligases that are involved.

Another challenge is when grant applications are denied, es-pecially when I know that a grant has been improperly re-viewed. For instance, one of the reviewers mentioned 12 times that I was working with polymerase gamma, a mitochondrial enzyme. It’s the wrong enzyme—I work with polymerase del-ta, a nuclear enzyme.

ME: As an educator of medical students, what is one piece of advice you would give to medical students?

L: If you don’t know something, ask. Do not pretend, espe-cially when you are a resident.

Additionally, know your oath, you really must adhere to it and try your best to save lives. Whether your patients are poor or wealthy, insured or uninsured, treat everyone regardless of their status.

ME: And for Ph.D. students, what advice do you have for them?

L: Graduate students are undergoing a very hard time be-cause of funding issues. !e pot of money is just too small. Ph.D. students really must be the best in order to succeed.

In a paper from the April 2014 Proceedings of the National Academy of Sciences, “Rescuing US biomedical research from its systematic $aws”, Dr. Bruce Alberts et al. discuss how the growth of the #eld is reaching its limits:

"ere is now a severe imbalance between the dollars available for research and the still-growing scienti#c com-munity in the United States. "is imbalance has created a hyper-competitive atmosphere in which scienti#c produc-tivity is reduced and promising careers are threatened.

“In order to do research, you need drive and passion.”


"e US research community cannot continue to ignore the warning signs of a system under great stress and at risk for incipient decline.

In this funding climate, it is important for institutions and the government to help young scientists, both men and wom-en, for the good of the next generation of science. When I began my career in science, it was easier for young scientists to get started with an R01 research grant and make it. Now there is more competition and this rarely occurs. But don’t be discouraged because most of the time you can turn negative things around. Persevere, #nd mentors, and network.

ME: Are you involved in other activities at NYMC, and how are you able to balance those responsibilities with teaching and re-search?

L: I am on the Advisory Committee for new Ph.D. students and the Graduate school Curriculum Committee to help evaluate new courses to see if they are appropriate for stu-dents. I am also on the Graduate Faculty Council, the In-tramural Research Grants Committee and Radiation Safety Committee. Previously, I was on the Research Support Ser-vices Committee.

I balance my research, teaching, and committees by delegat-ing. I learned how to delegate from a very successful scientist at the University of Miami, Dr. Mary Ann Fletcher. She once asked me, “Are you still spending all of your time splitting hy-bridomas? Do you want to get tenure?” She explained, “Look, you have to have time to read and think. !e best way to do that is to delegate and have people help. You’re the one who is supposed to look at the big picture. If you’re splitting cells, you cannot think globally.” Don’t be afraid to admit that you can’t handle it all and to let someone else take a bigger portion of the pie.

ME: Do you think that attitudes toward women have changed since you started in the #eld, and if so, how have they changed?

L: When I started, there were far fewer women in science. But I was lucky, I never felt that I was in the minority as far as those who were working in the area of DNA replication were concerned. In actuality, several of the well-established scien-tists that studied DNA polymerases were women.

I had some lucky breaks in my career. One of them was meet-ing Dr. Bruce Alberts, who came to the University of Miami to be an external examiner. He was a reviewer for a paper I submitted—a paper that was initially rejected. When I met him, I discussed my work with him and made sure all of his questions were answered. A%erward, Dr. Alberts talked to Dr. Antero So, the principal investigator of my lab at the time, and told him that he had the right person working on poly-merase delta. Before he le%, he told me, “Marietta, you’re go-ing to purify polymerase delta to homogeneity. I know it.”

When the time came for me to apply for an Established In-vestigatorship Award from the American Heart Association, I needed someone whose name carried weight in the scienti#c community to write me a letter. Dr. So suggested that I ask Dr. Alberts, and he agreed to help. He was and is an outstand-ing, honest, and well-respected scientist, so his letter meant a lot to the reviewing committee.

!e award helped me gain a tenure track position, and the chairman in the Department of Medicine at the University of Miami, Dr. John McKenzie, switched me from Research Assistant Professor to the tenure-earning track. !is was very

unusual in a clinical department. Dr. Fletcher, the scientist who taught me to delegate, spoke to the chairman and helped get me that position.

However, when it was time for the committee to decide on my tenure, I had a hard time. !e tenure com-

mittee was critical of my maternity leave. !ey did not think that I was a serious researcher because I took time o&. Fortu-nately, Dr. McKenzie spoke up for me. Our o"ces were on the same $oor, and he saw me working during evenings and on weekends. I think it also had to do with a seminar I gave that he happened to like, so he vouched for me.

Dr. Bernie Fogel, the Dean of the School of Medicine at Mi-ami, was also very supportive. He realized that I needed to teach graduate students and initiated my switch to the De-partment of Biochemistry and Molecular Biology. When I became a full professor and joined the Department of Bio-chemistry, I was one of only two women in a department of over 20 faculty members.

ME: What do you think still needs to be improved for women in science?

L: !ings have changed greatly since I #rst started, but there is still room for improvement. Women faculty are still under-represented. I was surprised to read in a Nature paper from 2013 that “in the United States and Europe, around half of those who gain doctoral degrees in science and engineering are female—but barely one-#%h of full professors are wom-en.” Furthermore, there are still disparities in salaries for women in science. !e Nature article cited that on average, women earn just 82% of what male scientists make in the United States.

At NYMC, our department is unusual in that we are almost balanced in the number of female versus male faculty mem-bers. !e general increase in the number of women faculty is an improvement from what it was when I started out.

ME: How do you think women scientists can better support other women in science?

L: !ere are societies with workshops for women in science.

“...know your oath. Whether your patients are poor or wealthy, insured

or uninsured, treat every-one regardless of status.”


CONVERSATIONSActually, I was on the committee for Equal Opportunity for Women in the American Society of Biological Chemists. I was also a panelist in the discussion of Women in Science in a program for young women scientists at the 16th Interna-tional Congress of Biochemistry and Molecular Biology in New Delhi, India, in 1994. !is past May, I attended the 2014 Women in Science meeting in San Diego. I was pleased to see more women scientists networking and helping each other. Female scientists should mentor younger female scientists.

!ese meetings can be helpful because everyone talks about the problems they experience and how to handle situations. I remember that there were discussions about maternity leave. I think we should be more accepting of women taking mater-nity leave. If she is a good scientist, she will be able to catch up.

ME: If you could give one piece of advice to your students who are interested in pursuing research, what would it be?

L: In order to do research, you need drive and passion. You need to have a desire to succeed. !e rest will come. Try your best and be persistent. If you don’t love your work, it shows.

In the present climate, it might be more di"-cult, but if you have the drive to reach your full potential, it might unlock doors.

Set high standards.

Always think positively. “Pessimism never won any battles.”

Don’t hesitate. Start, and the tools you might need to over-come obstacles will be found along the way.

Try to collaborate. !e world of research has expanded so much that you cannot sit in a corner and conduct research alone. Before, I was struggling on my own, but now I feel very happy that I am collaborating with Dr. Zhang. We are go-ing to solve the structure of polymerase delta—it’s something that I couldn’t even dream of before.

!roughout my career, I followed my instincts for what I thought was right, and I’m very happy with where I have end-ed up.

ME: "ank you Dr. Lee for sharing your journey on becoming the accomplished academic you are today.


As soon as the door shut, everything became quiet. !e si-lence of the room quickly sharpened my awareness to the fact that it was now time for me to interview my patient. Before entering, I was instructed by my resident to obtain a focused history. As a newly minted third year medical student, I was eager to put my long hours of practice history-taking to good use.

I introduced myself to my patient and proceeded to take her history. As I began asking her questions, I could see that she felt uncomfortable. !en again, why wouldn’t she be? I was a medical student and was far from the physician she had in-tended to meet that day. I might as well have been a complete stranger. Furthermore, my questions probably seemed for-matted and dry because, well, that was what they were. In fact, much of my history taking up until that point had consisted of regurgitations of written scripts I had been taught to ask during medical school. How could this patient ever open up and share her story with a stranger reciting rehearsed lines? Something had to change.

As we continued our conversation, I relaxed from my stan-dard history taking format and simply asked her about her-self. I wanted to get a glimpse into her life so that she could see that I was not only interested in extracting medically-relevant information from her. When I asked about her hobbies, I was delighted to hear that she was an avid moviegoer. We chatted about the current movies playing in the box o"ce, then talk-ed about the weather, my journey as a medical student, and #nally back to what brought her to the hospital in the #rst place. By the time I returned to the focus of her visit, she felt more open about sharing her story.

As it turned out, she had initially complained of right arm and bilateral breast pain. When I later asked her about her home life, it became clear that her pain was likely the result of domestic violence, which she later con#rmed. Looking back, I realized that her discomfort at the beginning of our con-versation likely stemmed from her feeling vulnerable about such a sensitive and personal issue. Ultimately, we were able to coordinate the care of her injuries, as well as the support for her safety at home.

On that day, I learned that to be a good physician, one must realize that the human qualities of medicine are just as im-portant as the clinical aspects. I believe that my patient’s will-ingness to disclose her issues with domestic violence stemmed from a level of mutual trust that we were able to develop over the course of our conversation. I could have simply stuck with my rehearsed lines and tried to extract as much information from her as possible, but that would have reduced her to mere numbers and facts.

Instead, what my patient sought was the sense of knowing that I truly cared about her as a human being and not simply as a set of vital signs and lab values. When we as future phy-sicians lose sight of the fact that we are simply fellow human beings, we begin to forget how important it is to pay atten-tion to the human qualities of the doctor-patient relationship: empathy, compassion, and understanding. !ough my lesson that day was simple, it is something I believe many healthcare providers still struggle with each day.

Every patient is unique, and each is deserving of the same autonomy, understanding, and respect we would like to be given ourselves. A%er all, doctors are patients, too.

Doctors Are Patients TooDaniel Mangels


PERSPECTIVESA Boston Man: Sir Oliver Wendell HolmesBailey Fitzgerald

History of Medicine is a course taken by every "rst year medical student at New York Medical College. It is taught by the chancellor, Dr. Edward C. Halperin. !e course begins by exploring medicine practiced by the ancient Egyptians, Greeks, and Romans, and delves into major medical inno-vations. Students also learn of controversial events that have occurred throughout medical history, including physicians’ role in the slave trade and discrimination against medical school applicants of Jewish descent. As a "nal project, His-tory of Medicine requires students to write a paper on a his-torical medical "gure. !e following is Bailey Fitzgerald’s account of the life of Dr. Oliver Wendell Holmes:

I chose to write about Oliver Wendell Holmes, Sr. because I loved that his genius spread tentacles out of the #eld of medi-cine into writing, poetry, and policy. In my undergraduate edu-cation, I studied both English and Biochemistry. I have always been passionate about literature, so it felt important to me to have some balance built into my curriculum even into med-ical school. Most of the time, when people #nd out about my dual degrees, the reaction I encounter is surprise. It is not that people do not see how I could like both, but it seems generally counter-culture to give equal weight to a humanities subject and a hard science. However, to me, not only does the concept make perfect sense, I cannot imagine having one without the other. In medicine, we are the progeny of a long line of physi-cian scientists who were also consummate humanists. "us, I chose to write about Oliver Wendell Holmes, Sr. because I love his writing.

“Boston State-House is the hub of the solar system. You couldn’t pry that out of a Boston man, if you had the tire of all creation straightened out for a crowbar.”1

“[A] Boston man” Oliver Wendell Holmes most certainly was. He was very arguably born that way, and if he was not, by the time he penned those lines in 1857 he had become the consummate Bostonian, the toast of Boston medical societ-ies and literary societies alike. It seems unlikely that Holmes truly believed, in the most objective sense, that Boston really was “the hub of the solar system” when he inserted the line into the mouth of a character from his most famous work, “!e Autocrat of the Breakfast-Table”. !e United States that Holmes lived in was becoming increasingly cognizant of a wider world, a shi% away from the colonial centers of Boston to the more and more prominently problematic South and ever-expanding West. It seemed that the future of the Unit-ed States would lie in the expanding western border and the addictive promise of a manifest destiny, fueled by technolog-ical innovation. For the #rst time, railroads were surpassing canals, and in the year Holmes published the collection, “!e Autocrat of the Breakfast-Table”, Minnesota was admitted to the Union. But as the Union was expanding, it was also tenu-

ous. Kansas was precipitously dissolved into con$icts between its pro and anti-slavery citizens known collectively as “Bleed-ing Kansas”, ominously foreshadowing the civil war to follow. !e newspapers announcing the (in)famous Supreme court decision of Dred Scott v. Sandford circulated contemporary to the #rst issues of Holmes’ magazine, Atlantic Monthly.2

For Holmes, however, controversy reached him only when it reached the heart of Boston. Boston was by all accounts, in both practice and feeling, the center of Holmes’ solar system.3 He was in many ways the embodiment of isolated privilege within the turbulent context. !e circumstances of his birth and career both led him to be so ensconced in the embrace of the oldest and highest Boston society as to be widely cred-ited with neologizing the concept of the Boston “Brahmin Caste”.†,3 His family was an old, moneyed, and eminently re-spectable one. He was born on the 29th of August 1809 to a minister of the First Church, the Reverend Abiel Holmes, and to Sarah Wendell Holmes, whose merchant family could be proudly traced to the earliest settlers of Boston4. His child-hood home and birthplace in Cambridge, Massachusetts, was the furthest place from the center of Boston that Holmes ever meaningfully called home.3

Education played an important and well-emphasized role in Holmes’ upbringing. He studied at the Phillips Academy in Andover as preparation for entering Harvard, where he ma-triculated in 1829. Ironically, Holmes did not intend to study medicine, and actually studied law for a year before switching to a course of medical studies. In furtherance of his medi-cal education, Holmes embarked for Paris in 1833, where he studied under a number of illustrious physicians including Pierre Louis (who was in turn a student of René Laennec).4 While in Paris, Holmes was an attentive student, writing home that he spent more than “#ve hours in the day… at the bedside of patients,” and that such time was always spent, “with my note-book in my hand”.5 However, the biggest in-$uence of Louis on the education of the young Holmes was not the hours spent in learning clinical skills in the hospital, but rather the hours spent outside the hospital where, under the mentorship of Louis, Holmes became a member of the Société d’Observation Médicale.

!ere, Holmes was encouraged to undergo a “laborious ex-amination of all the organs of the body in such cases as are

† It is perhaps worth noting that Holmes’ concept of these New England “Brahmins”, referring to those lineages of educated professionals and prominent o"cials, was opposed to those from “the huckleberry districts”, a rather snotty turn of phrase that managed to imply innocent geography while insinuating inferiority. !is was an era where the virtue inherent to an elevated class was both keenly felt and continuously asserted. As for Holmes, “[h]is own social position was as secure as a German who has a ‘von’ before his name”.3


fatal” and to examine thoroughly the facts of every case, looking for similarities between groups of cases while scru-pulously documenting the e&ects of treatment.5 While seem-ingly routine to a modern reader, this orderly emphasis on databases of carefully garnered facts within a medical com-munity constituted the beginnings of the modern concept of evidence-based medicine.

When Holmes returned home to Boston, he sat for his ex-ams and was granted his M.D. from Harvard in 1836. Diplo-ma in hand, the twenty-six-year-old Holmes was unleashed upon the medical societies of Boston, by all accounts raring to implement all that he had learned in Paris at his practice in Boston, and thus becoming one of Boston’s most prominent physicians.5 To this end, Holmes wrote for (and won) three consecutive prizes in the prestigious Harvard Boylston Dis-sertation competition.‡, §

Although initially embarked on a course of private practice, the focus of Holmes’ medical career quickly shi%ed toward teaching. Over the next twenty years, Holmes held teaching positions at Dartmouth College (to which he commuted four-teen weeks out of the year) and at Tremont Street Medical College, a school he helped establish in Boston. He also ed-ited a version of Hall’s "e "eory and Practice of Medicine. However, the inspiration for Holmes’ next, and most famous, contribution to medical reform came during his tenure on the sta& of the Boston Dispensary, to which he was appointed in 1837.4

While on sta& at the dispensary, Holmes helped found a so-ciety known as the Boston Society for Medical Improvement. !rough reports at society meetings and his own observa-tions at the dispensary, Holmes began to notice patterns of puerperal fever concentrated in particular obstetric practices and was particularly struck by an anecdote of a physician who had died a%er sustaining a cut while performing an autopsy on a woman who had died of the disease. Curious, Holmes decided to examine available medical literature and to inves-tigate the causes of this disease pattern.4

On February 13, 1843, Holmes presented his essay on puer-peral fever to the members of the Boston Society for Medical Improvement. Combining his considerable scienti#c intel-lect, his learned talent for survey of evidence, and his gi%ed literary skills, the essay was a damning report that argued that the transmission of puerperal fever was actually accom-plished by the physicians assisting in the deliveries. Holmes

‡ Interestingly, at this time, the world record for most Boylston Prizes ever won by an individual was the 4 consecutive prizes that had been won by Holmes’ brother-in-law, Dr. Usher Parsons5.

§ One of the prizes, which he split with two other authors, was written in response to the query, “How far are the external means of exploring this conditions of the internal organs to be considered useful and important in medical practice?” Here, Holmes submitted an impassioned treatise advocating for the expanded use of the stethoscope in United States clin-ical practice. !is advocacy appears to be a manifestation of his Parisian training, and of the in$uence of René Laennec as an intellectual grandfa-ther of sorts10.

called for a reform of the protocols involved in dealing with this disease. He cautioned that a “physician holding himself in readiness to attend cases of midwifery, should never take any active part in the post-mortem examination of cases of puerperal fever” and that “if within a short period two cases of puerperal fever happen close to each other… [the physi-cian attending the cases] would do wisely to relinquish his ob-stetrical practice for at least one month, and endeavor to free himself by every available means from any noxious in$uence he may carry about him.” What made these observations and recommendations truly prescient was that they were made six years before the famous studies by Ignaz Semmelweis on the subject and well before Lister’s work in antisepsis was broad-casted.4

His work proved a zeitgeist for the popularization of sanitary medical practices in the United States, but not for a number of years a%er it was published. It was in fact, a ridicule of the work published by several obstetricians, Hugh Hodge and Charles Meigs, that revived the paper. !eir opposition to Holmes’ conclusion(s) spawned a republishing of the work, which gained a much wider audience in 1855 than the origi-nal publication ever had. When the work of Pasteur and List-er was popularized in the 1860s and 70s, Holmes was vindi-cated.¶, 4

In 1847, Holmes joined the faculty of Harvard Medical School where he served as a professor of anatomy and physiology for the next thirty-#ve years. For the #rst six of these, he served as a dean of the Harvard Medical Faculty.4 It was during his tenure as dean that the turmoil of the outside world #rst be-gan to encroach into Holmes’ Boston medical sphere. In the area of slavery and civil rights, Holmes seemingly displayed what might fairly be characterized as a remarkable ambiva-lence. In 1850, Martin Delaney** and two other young African American men applied to join the incoming medical class, and Holmes admitted the students. However, a%er the stu-dent body registered a number of protests, Holmes asked the students to leave the college a year later.††, 6

!is stringent policy of appeasement in Holmes’ public views did not go unremarked upon by his friends. Holmes explained himself to his friend James Russell Lowell, who charged Holmes with not taking a properly reformist role in response to issues such as slavery. Holmes responded that al-though he could not deny the heroism of soldiers, his growing distaste for war made him unable to support any cause that seemed likely to lead to it. “Slavery,” in the mind of Holmes, “yielded…to the danger of disunion, and he desired to avert

¶ Holmes is reported to have described the paper as the “most signi#cant contribution of his life”.4

** Despite this setback, Martin Delaney would later become one of the nation’s foremost African nationalists. Undaunted, upon his return home, Mr. Delaney styled himself and began some level of medical practice.

†† Holmes was seemingly equally non-committal on the controversial issue of admitting women to the practice of medicine. When pressed on the subject, he allowed that he “was willing to teach women anatomy, but not in the same classes or dissecting rooms as men”.4


PERSPECTIVESthe catastrophe of civil war”.‡‡, 7

A%er his tenure as dean, Holmes dedicated his time to literary pursuits for which he is at least as equally well remembered as for his medical insights. He became a founding member of the magazine "e Atlantic Monthly, for which he contributed a series of ‘breakfast table’ articles, the most famous of which is his “!e Autocrat of the Breakfast-Table”, one of the mag-azine’s inaugural pieces. Holmes’ literary canon, including articles, books, papers, and poems have earned him a lasting place of honor among the classics of American literature. !e Saturday Club, of which he was a founding member as well, (it was created to support "e Atlantic Monthly), counted among its exclusive ranks such notables as Emerson, Haw-thorne, and Longfellow.4

In 1882, Holmes #nally retired from teaching and once again le% Boston to visit Europe, this time not as a student but as a famous scientist and well-respected elder of the profession. On this second Grand Tour, Holmes was awarded honorary degrees by the universities of Oxford, Cambridge, and Edin-burgh. In his advancing years, Holmes lived in Boston with his daughter and then his son, the o%en overshadowing Jus-tice of the United States Supreme Court. It was there that he died, at the age of 85 on October 7th, 1894.4

!e true legacy of Holmes lies not merely in his literature, or his famous o&spring, or even his essay on puerperal fever. In the essay, “Currents and Counter-Currents in Medical Sci-ence,” Holmes wrote:

"e truth is, that medicine, professedly founded on ob-servation, is as sensitive to outside in!uences, political, religious, philosophical, imaginative, as is the barometer to the changes of atmospheric density. But look a moment while I clash a few facts together, and see if some sparks do not reveal by their light a closer relation between the med-ical sciences and the conditions of society and the general thought of time, than would, at #rst, be suspected.8

He goes on to elaborate that, in his time, the true context shaping the scienti#c inquiry of the time was that of reform and a rejection of traditional practices in favor of soundly re-searched evidence-based approaches. Holmes notes that, in his time, “the more positive knowledge we gain, the more we incline to question all that has been received without absolute proof.8 In Holmes, medicine received an articulate, dogged, and extremely knowledgeable advocate for what Neuhauser calls “!e Logic of Medicine”.9 Holmes’ logical prescription of treatment based on facts alone, accrued through a commu-nity of evidence-based societies of clinicians, is the tradition of modern medicine in which physicians are still taught, and in which they still practice today.

‡‡ Oliver Wendell Holmes Jr. (Holmes’ son, and later Justice of the United States Supreme Court) and Amelia Jackson Holmes (Dr. Holmes’ wife) had no such compunctions when it came to slavery as casus belli. Both Dr. Holmes’ wife and son had an early interest in the abolitionist movement, and his son later joined the Army and served as a union soldier in the Civil War.11

REFERENCES

1. Holmes OW. "e Autocrat of the Breakfast Table: Every Man His Own Boswell. Boston: Houghton Mi'in; 1891.

2. Campbell, D. Brief Timeline of American Literature and Events:1850s. !e American Literature website. http://public.wsu.edu/~campbelld/amlit/1850.htm Accessed December 30, 2012.

3. Ballantine WG. Oliver Wendell Holmes. !e North Amer-ican Review. 1909; 190(645):178-93.

4. Dunn PM. Oliver Wendell Holmes (1809-1894) and His Essay on Pueperal Fever. Archives of Disease in Childhood. Fetal and Neonatal. 2007; 92:325-27.

5. Fitz R. My Dr. Oliver Wendell Holmes. Bulletin of the New York Academy of Medicine. 1943; 19(8):540-54.

6. Kinshasa KW. African American Chronology: Chronologies of the American Mosaic. Westport, CT: Greenwood; 2006.

7. Dole NH. Oliver Wendell Holmes. In: Holmes OW, "e Early Poems of Oliver Wendell Holmes. New York: T.Y. Crow-ell & Company; 1899:xi-xxv.

8. Holmes OW. Medical Essays, 1842-1882. Boston: Hough-ton, Mi'in and Company; 1891.

9. Neuhauser D. Oliver Wendell Holmes MD 1809-94 and the Logic of Medicine. In: Quality and Safety in Health Care. 2006; 15(4):302-04.

10. Baas JH. Outlines of the History of Medicine and the Med-ical Profession. Huntington, NY: Krieger; 1971.

11. White GE. Oliver Wendell Holmes, Jr. Oxford: Oxford UP; 2006.


As of 2012, 69% of primary care physicians in the Unit-ed States were documenting on electronic medical records (EMRs), and as EMR systems continue to roll out to hospitals across the country, we can expect this number to continue to rise.1

Needless to say, EMRs have great potential to provide bene-#ts to both healthcare providers and patients alike. Allowing for patient records to be accessed across the country—or even across the globe—improves the continuity of care for patients and gives them greater access to and responsibility over their own health records. At the same time, it can be argued that EMR companies are the true bene#ciaries of the EMR incen-tive program that was enacted in 2009 as part of the American Recovery and Reinvestment Act, and that the drop in produc-tivity and the steep learning curves faced by healthcare pro-viders in the initial stages of EMR implementation actually hinder the overall ability of healthcare providers to provide the highest quality of care possible.

As a former EMR implementer, a patient, and now soon-to-be physician, I have experienced the EMR phenomenon from di&erent ends and angles of the spectrum. Although my outlook on EMRs and their true bene#t to the American healthcare system has undergone a gradual shi%, I cannot say that my perspective has become any clearer. In fact, it is now much murkier than it was initially.

As a newly-hired implementer, I was sent around the country to support healthcare providers during the #rst few days that the EMR system was introduced at their hospitals, a period of time the EMR industry a&ectionately refers to as the ‘go-live’. Physicians and nurses alike complained that the so%ware was ‘clunky’ and a hindrance to their work$ow. Nurses were con-cerned that they were spending more time staring at the com-puter screen than doing actual patient care. Surgeons were concerned that nurses would not be able to #nd their Signed and Held orders a%er hours. At one hospital, providers who had previously used other electronic data collection systems were so unimpressed with the new EMR system that they threatened to go back to documenting on paper.

At the time, I attributed the healthcare providers’ frustrations to a general opposition to change and irritation with the hos-pital administration for forcing the system overhaul. Having grown up around computers, working with our EMR system was second nature to me. I could open a document, input the necessary data, save the information in a folder, and then retrieve the data whenever I needed it. I found the so%ware intuitive and the interface user-friendly. !ese were, a%er all, two of the major selling points of our company’s so%ware, and I endorsed them completely.

Furthermore, at every company meeting, we were reminded of the bene#ts that our EMR imparted on the quality and con-tinuity of care for patients. Our CEO o%en used one example in particular to illustrate the bene#ts of an integrated EMR system: A patient went on vacation to Europe and forgot an important medication at home. Since her health records were kept digitally in our EMR system, a local doctor was able to access her prescription records online and subsequently pre-scribe her the same medication in Europe in much less time than it would have taken for the European physician to call the woman’s primary care physician to obtain the necessary information. !is woman was so a&ected by this incident that she wrote a letter to our CEO expressing her gratitude. Un-fortunately, this excitement and gratitude never seemed to translate to the healthcare providers who were the true end users of our so%ware.

My #rst experience with an EMR system as a patient came not during a hospital visit, but during a checkup with a new dentist. I remember sitting reclined in the dentist chair with my mouth open as one of the dental assistants examined my teeth and read o& her examination to a colleague who was sta-tioned in front of the computer, documenting all of the infor-mation in my #le. !e entire experience was impersonal, and not at all like the dentist appointments that I was accustomed to during which my dentist made the e&ort to ask about my family or my job. It seemed like they were more worried about #lling in all of the necessary #elds on the computer screen than explaining to me what exactly they were looking for or what they had found on examination of my teeth. I le% that appointment with a bad impression and never went back. Since that day, I have only had positive experiences with EMR as a patient. Nevertheless, that #rst encounter always comes to mind when someone asks me about my thoughts on EMRs.

My view on EMRs continued to evolve as the possibility of becoming a physician became less of a dream and more of a reality. As I started to imagine myself in the role of a health-care provider, I began to empathize more with the surgeon who struggled to place electronic orders for his patients, the nurse who was hindered by the many required questions on the patient history questionnaire, and even the registrar who could not locate the insurance information for a newly ar-rived patient. I began to think about what I might do if I was in their situation. As I re$ected further, I considered all of the possible mistakes that I could make using an EMR system—especially as a young, inexperienced doctor.

A study done by the Emergency Care Research Institute (ECRI)†, which included 36 voluntarily participating hospi-

† !e ECRI institute is an independent, nonpro#t organization that pro-motes safety, quality, and cost-e&ectiveness in healthcare through research, education, and consultation.

Electronic Medical Records: !e Good and the BadSherry Liou


PERSPECTIVEStals, provided results demonstrating a total of 171 health in-formation technology (HIT) malfunctions over a nine-week period. Of these 171 HIT malfunctions, 25% involved a com-puterized order entry system, 17% were caused by clinical documentation system errors, and 13% were caused by er-rors in the lab information systems.2 !e analysis proceeded to show that the errors caused by EMRs are partially due to human error in using the systems, but are also caused by the computer systems themselves. Unfortunately, the number of reported incidents is only a small percentage of the total number of adverse events that are related to the implemen-tation of EMRs.

Now, as a medical student experiencing my #rst patient en-counters, I no longer feel comfortable wholeheartedly endors-ing the usage of EMR in hospitals. !ere is no doubt that with experience, I will master the ability to balance face-time with the patient with time spent on the computer, but I have to ask myself, “How many mistakes—potentially even life-threaten-ing mistakes—will I make before then?” Fortunately for me, by the time I start my clinical years, EMRs will be common-place at most of the large healthcare institutions, so I will have an advantage compared to the physicians who have had to ex-perience this EMR overhaul in the prime of their careers. Un-fortunately, because there is not a standardized EMR across all hospitals, I know that there will still be a steep learning curve with retraining in di&erent EMR systems, leaving room for error.

Furthermore, many academic medical centers are still strug-gling with how to appropriately incorporate EMR training into the medical school curriculum. !ere are mixed feelings about whether or not access to EMR as a medical student is bene#cial. Although there are numerous clinical bene#ts for giving medical students access to EMR—including the ability to enable evidence-based medical training, early exposure to best practices consistent with clinical recommendations, and facilitation of critical clinical thinking early on in training—it has also been shown that “a lack of computer navigation skills may contribute to limited provider–patient communi-cation” and thus a diminished learning of interpersonal skills by medical students.3 !ere is also concern that the clinician decision support component of the EMR systems may actu-ally compromise the medical student’s ability to learn how to make critical decisions. !erefore, the implication of EMRs on the training of future physicians is still unclear.

While EMRs o&er a spectrum of bene#ts—empowering pa-tients to take charge of their own health, increasing the con-tinuity of care, as well as catching human error—they also have their downsides. Contrary to the heroic stories of EMRs helping healthcare providers identify deadly allergies before the incorrect drugs are given, there are also stories of EMRs incorrectly interpreting the time of midnight, resulting in the delayed administration of vital antibiotics to a newborn or the doubling of the administration of a potent drug. One of the more severe errors that have been documented include the failure of EMRs to link lab results to transplant surgery records, leading to organ rejection and subsequent patient

death.2 Furthermore, the implementation of an EMR system comes at a huge cost: the #nan-cial impact of purchasing new hardware and so%ware, as well as training and maintenance costs, are daunting. It will be years before we know if the re-turn on interest for EMR so%ware is worth the cost.

Because the EMR industry is still a relatively nascent one, in my opinion, it is di"cult to say de#nitively if the bene#ts of electronic medical documentation outweigh the costs of im-plementing these systems. I believe that it will take a few more years for the EMR frenzy to settle before we can determine if further development of EMR systems can better accom-modate the needs of healthcare providers and if healthcare providers can fully adjust to these electronic documentation systems.

REFERENCES

1. Porter M. Adoption of Electronic Health Records in the United States. https://www.google.com/search?client=sa-fari&rls=en&q=Adoption+of+Electronic+Health+Re-cords+in+the+United+States&ie=UTF-8&oe=UTF-8#q=-Adoption+of+Electronic+Health+Records+in+the+Unit-ed+States+Molly+Porter&rls=en. Published February 2013. Accessed December 15, 2013.

2. Clark C. HIT Errors ‘Tip of the Iceberg,’ Says ECRI. HealthLeaders Media. April 5, 2013. http://www.healthlead-ersmedia.com/content/TEC-290834/HIT-Errors-Tip-of-the-Iceberg-Says-ECRI##. Accessed April 20, 2014.

3. Tierney JM, Pageler NM, Kahana M, Pantoleoni JL, and Longhurst CA. Medical Education in the Electronic Medical Record (EMR) Era: Bene#ts, Challenges, and Future Direc-tions. Acad Med. 2004; 88: 748-752.

4. King R. How Kaiser Permanente Went Paperless. Business-week. April 7, 2009. http://www.businessweek.com/technolo-gy/content/apr2009/tc2009047_562738.htm. Accessed April 20, 2014.

5. Sparnon ME, Marella WM. !e Role of the Electronic Health Record in Patient Safety Events. Pa Patient Saf Advis. 2012; 9(4): 113-121.


Inspiring Compassion for Rare DiseasesColton Margus

When I was asked to contribute to this volume of Quill & Scope, I was thrilled to have the opportunity to introduce Stu-dent Advocates for Neglected Diseases (STAND), the new student group that I started here at New York Medical Col-lege to spur greater student engagement with this small and most in-need patient community.

Despite what we learn in the classroom, many medical stu-dents across the country are not su"ciently exposed to and thus not fully appreciative of the deeper burdens that patients and families with rare and neglected diseases face. I want STAND to address that, because I believe doing so will lead to more informed and compassionate physicians.

Rare diseases are o%en life-threatening or chronically debili-tating, and each rare disease a&ects a very small portion of the population (fewer than 200,000 people in the United States).1 Neglected or orphan diseases include both rare inherited dis-orders as well as neglected infectious diseases a&ecting the global poor. Such diseases are traditionally not given a high priority for prevention or treatment and, as a result, lack suf-#cient attention from governments, healthcare professionals, news media, and drug developers.

!e Orphan Drug Act of 1983 and the subsequent Rare Dis-eases Act of 2002 exemplify laudable e&orts to “promote the development of drugs and devices for rare diseases” through establishing a national o"ce, increasing research funding, and improving incentives for development of new thera-pies.1 However, the complexities of rare and neglected dis-ease diagnosis at the level of individual patients and families are still underappreciated within the medical profession. At the heart of the matter is the belief that all patients should matter. Neglected conditions have a harder time attracting funding and support, and patients o%en su&er from that oversight. Tens of millions of Americans are a&ected by near-ly seven thousand rare diseases, most of which lack any treat-ment or cure. !eir need for a helping hand does not depend on disease prevalence—and neither should our compassion. What should be great news for busy medical professionals and students is that the smallest e&ort for the smallest com-munities can o%en make the biggest di&erence. Having an impact on a rare disease does not necessarily mean #nding a cure. Coping with a rare disease can be incredibly isolating, and an outstretched hand from the medical community can mean the world. Just spending one-to-one time with the pa-tients and their families and showing genuine interest in what life is like for them can provide tremendous encouragement. It can alleviate their feelings of being forgotten and provide encouragement that the next generation of physicians will be sensitive to their needs.

Even beyond the orphan communities themselves, progress on behalf of neglected diseases helps to advance the medi-cal #eld more broadly. A substantial part of today’s medical knowledge originated in the pursuit of an overlooked ques-tion or with a rare disease model.2 Future physicians must ap-preciate that neglected diseases can o&er fertile opportunities to advance innovative new research strategies and treatment methods for more common disorders. In fact, as healthcare management shi%s toward personalized medicine targeting smaller and smaller subsets of the general population,3 one could argue that our research models developed on behalf of rare disease communities will be all the more relevant.

I am admittedly biased—two of my younger brothers su&er from a rare genetic disease called ataxia telangiectasia (A-T). At a birth frequency of 1 in 300,000, my brothers’ auto-somal recessive truncation of the ataxia telangiectasia mu-tated (ATM) gene is extremely rare, but no less devastating in its stunted growth, progeric aging, cancer predisposition, immune de#ciency, and cerebellar degeneration.4 On top of coping with their sons’ diminishing quality of life, my parents have had to #ght indi&erent insurance companies and navi-gate enormous bureaucracies for support. I have seen doctors misdiagnose and misguide treatment, but I have also seen wonderful physicians listen carefully to my family’s concerns and recognize the importance of collaborating with patients and their families in managing a disease. I have seen the enor-mous di&erence a good physician can make to families like mine, even when there is no cure.

Now that I am in medical school myself, I want to take the opportunity to convince receptive future doctors of the value in championing and understanding rare diseases just as they begin their careers. I hope to plant the seed in the next gener-ation of healthcare professionals by getting medical students to think about and to engage with patient communities that they might never come across otherwise.

STAND is busy organizing several events on campus to bring attention to rare disease patients and their families. For ex-ample, following our introduction to the DNA-repair dis-order xeroderma pigmentosum (XP) in our biochemistry course last spring, we invited Caren Mahar, patient mother and founder of the XP Society and Camp Sundown, to vis-it New York Medical College. It was a great opportunity for students to hear a more personal perspective on the disorder, and to better understand the o%en overlooked burdens on families diagnosed with incurable diseases they cannot even pronounce.

Still, as much as lectures and presentations raise awareness, nothing compares to the e&ect that direct, individually-driv-en interactions can have on one’s outlook, investment, and


PERSPECTIVESpropensity for future engagement. !at is why STAND is brainstorming more creative ways to get the student body di-rectly involved with patients, both on campus and at other medical institutions.

Our newly created “David R. Cox Prize for Rare Compassion” will recognize the essays of student doctors who have most inspiringly engaged a rare or neglected patient community that they have encountered. Participating students will meet with an unfamiliar patient, family, or advocate a&ected by a rare disease, and share their newfound insights a%erwards in a short essay. Beyond that, it is also my hope that with help from the Global Genes Project, an international organization, we will be able to facilitate Rare Disease Day activities at med-ical schools around the country. !ere are a lot of exciting directions we can go in.

!roughout this process, it has been overwhelming to see how many people have come out of the woodwork for some-thing meaningful. Even in the group’s infancy, we have al-ready garnered the support of students, administrators, and faculty alike, and their collective response has been more than I could have hoped for.

I feel incredibly fortunate and look forward to seeing the inte-gration of our classroom foundations with rare disease advo-cacy and patient engagement. I am optimistic that our doing so will make a positive di&erence in our community and in how at least one doctor approaches patients and their families somewhere down the road.

Author’s note: Associate Dean Tony Sozzo’s support has been invaluable in the success of this student group, and a meeting in January 2014 organized by Dr. Jennifer Koestler reiterated the school’s commitment not only to supporting student initia-tives but also to adapting the New York Medical College curric-ulum and learning experience in a way that will produce even better doctors.

REFERENCES

1. U.S. Government Printing O"ce. Rare Dis-eases Act of 2002. November 6, 2002. http://www.gpo.gov/fdsys/pkg/PLAW-107publ280/html/PLAW-107publ280.htm. Accessed February 4, 2014.

2. European Organization for Rare Diseases (EURORDIS). Position Paper: Why Research on Rare Diseases? October 2010. http://download.eurordis.org/documents/pdf/why_rare_disease_research.pdf. Accessed February 4, 2014.

3. U.S. Food and Drug Administration (FDA). Paving the Way for Personalized Medicine: FDA’s Role in a New Era of Medical Product Development. October 2013. http://www.fda.gov/downloads/scienceresearch/specialtopics/personal-izedmedicine/ucm372421.pdf. Accessed February 4, 2014.

4. Taylor AM, Byrd PJ. Molecular pathology of ataxia telangi-ectasia. J Clin Pathol. 2005 Oct;58(10):1009-15.


Stephanie, a good friend of mine, experienced her #rst mi-graine on her twel%h birthday. From then on, she had mi-graines at least once a month, sometimes with additional symptoms such as a partial loss of vision, as well as nausea and numbness. In high school, she was an active girl and an ace on the tennis court. I remember that her headaches were sometimes so debilitating that she missed class and fainted once during a varsity game. Her mother, May, o%en consult-ed her family doctors about her migraines. However, despite her more concerning episodes, the doctors never suspected an underlying cause.

Looking back, May tells me she wishes she had listened to her motherly instincts and had urged more adamantly for a brain scan, which the doctors deemed unnecessary given that Stephanie only had a few other symptoms and that she had recovered from her spells a%er just a few hours of sleep. Stephanie remembers being reassured that migraines like hers were not too uncommon for teenage girls.

In September of her senior year of college, Stephanie went on vacation to Las Vegas. I had kept in touch with her since high school, but it had been a month since we last talked. I did not know that it would be another month before I heard from her again. A week prior to her vacation, she had experienced an unusual episode in which she had awoken unable to move her neck. Concerned, May had taken her to the doctor, but no conclusions were made that day. Stephanie later found out that she had su&ered a transient ischemic attack (TIA), fre-quently referred to as a “mini-stroke”. On her last day in Las Vegas, Stephanie began to feel an oncoming migraine, which was exacerbated by the smoke-#lled lobby of her hotel. She collapsed and was taken to the hospital in a dire condition.

At the hospital, it was determined that she had su&ered a hem-orrhagic stroke, and her parents were noti#ed immediately. !ey were given an extremely grave prognosis and asked to make a choice between two equally unbearable ends: the #rst was to let their daughter die peacefully; the second was to drill a hole into her skull and induce a coma. !ey declined medical intervention and prayed by Stephanie’s bedside. As May recalls, her daughter’s brain was swollen and under great pressure inside the skull; it wouldn’t be long before she was brain-dead. However, when the doctor arrived for his #nal round, he noticed signs that prompted a reevaluation of her mental status. It seemed like a miracle—Stephanie’s body re-fused to succumb to death.

At this point, the necessary brain scans and angiogram were ordered, and the evidence viewed. Speculations about Steph-anie’s condition began to surface in the minds of those treat-ing her. Moyamoya disease (MMD) is a rare and relatively unknown disorder. Her doctors had heard of it but had never

seen it, nor were they sure she even had it. In fact, I doubt I will ever come across this disease in my studies as a med-ical student. Moyamoya is characterized by the progressive occlusion of both internal carotid arteries due to excessive growth of smooth muscle cells and luminal blood clot forma-tion.1,2 As a compensatory reaction to the lack of blood $ow to the brain, numerous tiny and tortuous collateral arteries are formed. !ese are o%en thin, dilated, and subjected to high $ow stress, increasing the risk of microaneurysms.1,2 Patients o%en present with cerebrovascular problems such as TIAs, ischemic stroke, intracranial hemorrhage, migraines, or sei-zures.

!e disease was #rst described in Japan, and its appearance on diagnostic angiograms was likened to a “pu& of smoke,” or “moyamoya”, in Japanese.2 !is telling arrangement of tiny blood vessels was revealed in Stephanie’s angiogram.

An analysis of patients in the western United States revealed an overall prevalence of 0.086 per 100,000.1 However, a four-fold greater incidence was found in Asian-Americans than in Caucasian Americans, supporting the possibility of a genetic etiology. Stephanie, who is Chinese-American, #ts this high-er-risk pro#le. It has also been observed that the incidence of this disease is almost two times higher in females as in males. Furthermore, the incidence of the disease peaks in children around the age of 5, as well as in adults in their mid-40s.1,2

As is the case with many rare diseases, proper diagnosis is o%en hindered by many factors. Because Moyamoya is rela-tively unknown, it is o%en misdiagnosed as multiple sclerosis or simply as migraines, as in Stephanie’s case.3 A delay in di-agnosis can mean a delay in proper treatment and ultimately a higher risk of life-changing implications from stroke. !e situation is made worse when doctors attempt to treat the symptoms rather than work toward unveiling the underlying cause.

!ere is no cure for Moyamoya, but current treatments are successful in reducing the risk of future strokes by surgical revascularization of the cerebral hemispheres.1 Stephanie was lucky to be treated at Stanford University Medical Center, one of the few places in the country that specializes in Moyamoya.

!e #rst time I talked to Stephanie a%er her Las Vegas inci-dent was during her recovery from surgery. I spoke to her as I would have on any other day, listening as she stumbled on words and repeated thoughts that she had voiced just minutes before.

May once told me her greatest fear was that when her daugh-ter came back, she would not be the same Stephanie. It was a strangely emotional experience for me, knowing that she

An Introduction to Moyamoya DiseaseMichael Shen


PERSPECTIVESwould most likely live free of risk a%er surgery, yet wondering if her mother’s fears could somehow prevail.

Today, the most di"cult challenges of Moyamoya seem to be behind her. Stephanie has had no cognitive or motor im-pairments as a result of the stroke and brain surgery. She has bounced back magni#cently. From my conversations with Stephanie and her family, I feel that the events of the past year have laid upon them a new lens through which they view their existence. Having experienced the darkest and bright-est moments of death and of life, they now live with a secret spirituality that I do not know but can only presume. And there is nothing more that I can be or feel, than thankful for Stephanie’s full recovery—personality and all.

REFERENCES

1. Achrol AS, Guzman R, Lee M, Steinberg GK. Pathophysiology and genetic factors in moyamoya disease. Neurosurg Focus. 2009;26 (4):E4.

2. Scott RM, Smith ER. Moyamoya Disease and Moyamoya Syndrome. N Engl J Med. 2009;360:1226-37.

3. Stevens, K. Making moyamoya known. !e Advocate. December 4, 2012. http://theadvocate.com/features/peo-ple/4360446-123/making-moyamoya-known.


Emerging Justi"cations for Placebic TreatmentTejas Pulisetty

I spent the summer of 2011 collecting data for my glob-al health research in the urban and rural locales of eastern Ghana. Besides learning how to say “Do you have any organic chicken le%?” in the native Twi dialects, and how not to dance to the music of the pop star Amako, I learned of the depth of an inveterate ethical dilemma.

During the daily eye health outreaches in the rural villages where I volunteered, one of the Ghanaian ophthalmologists would routinely prescribe tetracycline ointments for patients, despite believing that the patients were perfectly healthy. When we asked why, he responded, “!ey come here because they feel that they need a checkup. When they go home with something in their hands, they feel satis#ed and happy that they received a tangible treatment from the clinic.”

!e reader may sense something amiss here, but at the mo-ment, I didn’t think much of it. Perhaps it was merely a cul-tural di&erence that I was unaware of—or perhaps the doctor was on to something.

It turns out that clinicians routinely prescribe unnecessary medications much more frequently than was previously known—and this occurs not only in Ghana, but also in devel-oped countries.

For instance, in the United States, it is not entirely impossible to imagine a scenario in which a patient walks into a clinic and the doctor has a diagnosis that is so di"cult to make that the doctor ends up giving the patient a medication that they know will not biochemically or physically address the patient’s condition. !is is con#rmed statistically—an investigation of 3,848 patient visits over a one year period to an established general practice revealed that in roughly half of all initial gen-eral practice patient-doctor consultations, a #rm diagnosis could not be made as a result of the patient presenting with vague symptoms instead of a speci#c chief complaint.1 Why, then, would the doctor choose to provide the patient with a medication that is not biochemically or physically proven to address the symptoms? Because such treatments have been shown to work for many decades in a variety of scenarios.

A 1987 British study divided a collection of 200 patients, for whom no clinical diagnoses could be made, into separate groups. One group received honest feedback and was told that the clinician did not know what caused their problems. A second group received false feedback and was not only given a speci#c diagnosis, but was also told that they would de#nitely get better in the next several days. Interestingly, this second group was more than 64% more likely to experience an im-provement in symptoms than the other group.2 If this is the case, why doesn’t every caregiver do this?

In real clinical scenarios, placebic treatment is a controver-sial grappling between the bioethical principles of autonomy and bene#cence. Placebos are inert substances or treatments that are prescribed for psychological rather than physiological bene#t. In order for placebos to work, the personal interac-tions between a caregiver and a patient must somehow convey to the patient a suggestion of a positive outcome. If the sug-gestion is unintentional on the part of the caregiver, it is not considered a form of deception.3 !e suggestion may also be honest and intentional yet incomplete. For instance, the phy-sician may say to the patient, “I am prescribing a pill which research suggests can be of bene#t to you. In your circum-stances, I have reason to believe that it will work with minimal side e&ects.”4 !is can be considered a mild form of deception because the patient is intentionally led to believe that he or she is getting a real physiological treatment instead of a placebo. In this situation, the deception clearly prioritizes bene#cence and violates patient autonomy. Or does it?

It can be argued that the decision to give the patient an honest and informed de#nition of the placebic treatment could po-tentially dissuade the patient from receiving the placebo, thus leading the patient to choose to go untreated and e&ectively eliminating the option to be treated. Ultimately, this would re-sult in a paradoxical loss of autonomy from the patient’s per-spective.4 Bennet Foddy, a senior research fellow at the Ox-ford Institute for Science and Ethics, notes that “whether the patient takes the placebo or refuses it, the pharmacological outcome is the same,” considering that a placebo is inert. Fur-thermore, Foddy states that “the only di&erence is that in one case, the patient forms a self-bene#ting false belief.”4 By this logic, it would seem that prescribing a placebo results in a net gain for the patient. Indeed, the theme here is that the patient’s right to refuse a thoroughly-explained and unveiled placebic treatment is overridden by the potential bene#ts a patient can receive from a placebo and the drug’s inert nature.4

In further support of placebo use, Professor Foddy provoca-tively adds:

Doctors have a duty to do the best they can to relieve a patient’s symptoms. If that means they prescribe a placebo, or even conduct a séance…then there is a duty to do these things. If a doctor can really suggest to a patient that a chant will cure his headache, then it very likely will, and she should ululate it at the top of her lungs…It is a type of deception that patients ought to be thankful for, just as we are thankful when we receive a mendacious compliment from a friend.4

Overall the support for placebic treatments is argumenta-tively diverse, and the umbrella argument of proponents for placebos is that physicians are obligated to do the best they


PERSPECTIVEScan to relieve a patient’s symptoms.5 An interesting observa-tion is that placebic treatments may, in certain cases, be one of the best possible treatments. For example, placebos have been shown to be unusually e&ective in psychiatric depres-sion as well as irritable bowel syndrome (which may involve a substantial psychiatric component).5 Proponents also point out that placebic treatments are o%en signi#cantly less costly than treatments such as antibiotics or diagnostic tools such as MRI, both of which are not always deemed necessary in initial patient-physician encounters.

However, the opposition is just as robust on the other side. Even though placebic treatments are currently less costly than true pharmacological treatments or diagnostic tools, pre-scription drugs in general add to a national burden of drug costs, and placebic drugs may further contribute to this bur-den in the future. In fact, it was recently shown that the more expensive a placebo is, the stronger its therapeutic e&ect may become.6 Furthermore, prescription drugs, via incorrect dos-age or unintended use, have been shown statistically to kill 106,000 Americans per year, and prescribing excessive, cost-ly, and physically unnecessary medications is an obviously condemnable habit.7,8 Additionally, while emphasizing the violation of basic principles of the doctor-patient relation-ship, those who oppose and question placebic treatments also contend that such treatments indirectly lead to hazardous results. !ese opponents further believe that placebic treat-ment should not be used in a real clinical setting but should be strictly limited to laboratory clinical trials. A%er all, resorting to clinically unsubstantiated treatments may delay a proper diagnosis of a serious illness.7 !us, there exists a solid body of opposition to such behavior by doctors. In fact, the American Medical Association delineated an ethical policy that prohib-its the deceptive use of placebos in clinical practice, in which physicians are barred from giving patients “a substance…that the physician believes has no speci#c pharmacological e&ect upon the condition being treated.”9 Additional data is needed to better describe the relative amount of opposition and sup-port of placebos by professionals.

One survey revealed that approximately “half of [all] internists and rheumatologists” in the U.S. routinely prescribe placebic treatments for patients with debilitating chronic conditions.10

In an Israeli hospital, a retrospective questionnaire revealed that 37% of physicians prescribed placebos at least once per month, and 94% of all placebo-prescribers believed they were e&ective.11 A Danish survey estimated that 48% of Danish cli-nicians prescribed placebos more than ten times in a given year, and that 46% believed that placebic treatments are ethi-cally acceptable.12 A Canadian survey found that 80% of clini-cians in one hospital admitted to using placebos at least once in a given year.13 Finally, a New Zealand survey “indicated that almost all [general practitioners] surveyed would deliberately use a [placebic] treatment under some circumstances.”14

Regardless of the interpretations of modern data, the strength of the support, or the force of the opposition, placebic treat-ment will remain an option that is very useful for some pa-tients and less useful to others. Although this debate has

historically been level, the modern ethical ar-guments presented here, in combination with the evidence of positive support by health pro-fessionals and students, seems to show substan-tial ethical rationale and professional support for the use of placebos in clinical practice. Placebos are “the most common-ly prescribed drug across cultures and throughout history,” and as aforementioned, there is violation of neither patient autonomy nor bene#cence in the use of placebos.2 Although one cannot assert with certainty that the Ghanaian ophthal-mologist who prescribed tetracycline that summer should be commended for his behavior, it is apparent that he has done no harm and has not strayed from the societal nor profession-al guidelines of modern medicine.

REFERENCES

1. !omas KB. Temporarily dependent patient in general practice. Br Med J. 1974;1(5908):625-626

2. !omas KB. General practice consultations: is there any point in being positive? Br Med J (Clin Res Ed). 1987;294(6581):1200-1202.

3. Gold A, Lichtenberg P. !e moral case for the clinical place-bo. J Med Ethics. 2014;40(4):219-224.

4. Foddy B. Response to open peer commentaries on “A duty to deceive: placebos in clinical practice.” Am J Bioeth. 2009;9(12):W1-W2.

5. Foddy B. A duty to deceive: placebos in clinical practice. Am J Bioeth. 2009;9(12):4-12.

6. Ariely D. Predictably Irrational: "e Hidden Forces "at Shape Our Decisions. New York, NY: HarperCollins; 2008.

7. Braillon A. Placebo is far from benign: it is disease-monger-ing. Am J Bioeth. 2009;9(12):36-38.

8. Institute for Safe Medication Practices. QuarterWatch—Monitoring FDA MedWatch Reports. http://www.ismp.org/quarterwatch/pdfs/2011Q4.pdf. Published May 31, 2012. Ac-cessed December 26, 2013.

9. Bostick NA, Sade R, Levine MA, Steward DM. Placebo use in clinical practice: Report of the American Medical Asso-ciation Council on Ethics and Judicial A&airs. J Clin Ethics. 2008;19(1):59-61.

10. Tilburt JC, Emanuel EJ, Kaptchuk TJ, Curlin FA, Miller FG. Prescribing “placebo treatments”: results of national sur-vey of US internists and rheumatologists. BMJ. 2008;337.

11. Nitzan U, Lichtenberg P. Questionnaire survey on use of placebo. BMJ. 2004;329(7472):944-946.

12. Hróbjartsson A, Norup M. !e use of placebo interven-tions in medical practice—a national questionnaire survey of Danish clinicians. Eval Health Prof. 2003;26(2):153-165.


13. Gray G, Flynn P. A survey of placebo use in a general hos-pital. Gen Hosp Psychiatry. 1981;3(3):199-203.

14. !omson RJ, Buchanan WJ. Placebos and general prac-tice: attitudes to, and the use of, the placebo e&ect. N Z Med J. 1982;95(712):492-494.

TruceMichael Shen (Linocut)


Vitamin D de!ciency is an important health problem for refugees. Vitamin D de!ciency can have serious implica-tions on morbidity and mortality, as the literature shows that it is a risk factor for rickets, osteomalacia, cardiovas-cular disease, some cancers, and diabetes. To assess the problem of vitamin D de!ciency among refugees, litera-ture reviews of relevant research were conducted. Databas-es searched include PubMed, Cochrane Library, Trip da-tabase and relevant grey literature. "e United States (US) welcomes many refugees and provides them with health-care for their !rst eight months. Refugees, however, face barriers in accessing healthcare, especially a#er their initial months in the US. Currently refugees in the US are tested for vitamin D de!ciency during the Domestic Medical Ex-amination only if the physician identi!es clinical signs and symptoms. Further research should be conducted about vitamin D de!ciency in refugees entering the US since most studies have previously been conducted in Australia, New Zealand, and the Netherlands. Systematic de!ciency screening and vitamin D supplementation could alleviate the burden of vitamin D de!ciency among refugees. Fur-ther research is needed to determine whether these strate-gies would be acceptable to refugees and cost-e$ective.

INTRODUCTION

!rough the United States Refugee Admission Program, the US has granted asylum to almost 3 million refugees since 1975 and currently welcomes more refugees than any other country.1,2 Furthermore, the US accepts more than half of all refugees who settle in a country other than the country to which they initially $ed (also known as a “third country”). !ese refugees are at the highest risk of persecution.1 In 2012, refugees arriving in the US came from: Africa (18.2%), East Asia (24.7%), the Near East/South Asia (51.6%), Latin Amer-ica (3.6%), and Eastern Europe (1.9%).3

!e following article demonstrates that vitamin D de#ciency is a commonly reported issue among refugee populations.4,5

Vitamin D de#ciency is an important health issue as it is as-sociated with many pathologies such as rickets and osteoma-lacia.6 Additionally, there is growing evidence linking vitamin D de#ciency or insu"ciency to bone fractures,7 periodonti-tis,8 cardiovascular disease,9 poor immune function, certain cancers, diabetes mellitus, osteoporosis, and impaired muscle function.10 !us, signi#cant health gains could result from addressing vitamin D de#ciency and insu"ciency among ref-ugees.

!e US Centers for Disease Control (CDC) considers vitamin D de#ciency as a serum level of less than 30 nmol/L, while vitamin D insu"ciency occurs at serum levels of 30-50 nmo-l/L.11 However, there is some debate in the literature about the

appropriate serum values associated with de#ciency and in-su"ciency. As a result, researchers o%en use di&erent values to de#ne vitamin D de#ciency and insu"ciency.

Vitamin D is normally produced in the skin as a result of sun-light exposure, although it can also be derived from the diet.11 For individuals with limited sunlight exposure, !e National Institutes of Health O"ce of Dietary Supplements recom-mends taking dietary supplements.12 Table 1 lists the suggest-ed Vitamin D intake by age group.

!e healthcare needs of newly arriving refugees, including vitamin de#ciencies, are provided for by US government ser-vices. !e US Department of State; US Centers for Disease Control and Prevention; the US Immigrant, Refugee and Migrant Health Branch; and the US O"ce of Refugee Reset-tlement coordinate the processing of refugees and healthcare provisions for these individuals. !e literature shows, how-ever, that refugees underutilize healthcare services a%er the initial US government medical support provided during the eight months a%er they enter the US. Furthermore, refugees struggle at all points of healthcare access because of the lan-guage barrier, stress, and isolation resulting from accultura-tion.13

METHODS

A review of the relevant scienti#c literature and grey litera-ture policy documents was conducted. PubMed, Trip, and !e Cochrane Library were searched to identify relevant studies and review articles. Speci#c search terms and their results are listed in Table 2. !e search results regarding vita-min D de#ciency in refugees were limited to scienti#c papers that reported on human studies and were published in En-glish before June 2012. Studies were individually assessed to determine whether they were relevant to the vitamin D bur-den among refugees. !is narrowed search identi#ed eleven papers meeting the inclusion criteria.

RESULTS

VITAMIN D DEFICIENCY IN REFUGEES

Eight results returned by PubMed, Cochrane Library, and Trip databases were descriptive epidemiological studies that

Addressing the Health of Refugees: Vitamin DLaura B. Madsen

Table 1. Vitamin D Intake Recommendations by Age Group11

Age Group (years) Recommendation (IU or mg)

0-1 years 400 IU or 10 mg

1-70 years 600 IU or 15 mg

70+ years 800 IU or 20 mgNote: This table was constructed using recommendations from the “Second National Report on Biochemical Indicators of Diet and Nutrition in the US Population.”


PERSPECTIVES

sought to measure the burden of vitamin D de#ciency among refugees. All found that a large proportion of the refugee pop-ulation were vitamin D de#cient or insu"cient, with a range of 29-88% of refugee sample populations being classi#ed as either de#cient or insu"cient. !e #ndings from these stud-ies are summarized in Table 3.

!ree other studies provided further information about the burden of vitamin D de#ciency and insu"ciency among ref-ugees. A study by Paul Benitez-Aguirre et al. tested 93 dark skinned refugees in Australia for vitamin D de#ciency at the end of winter and the end of the summer. Although vitamin D levels increased on average during the summer (from 19 nmol/L to 36 nmol/L, p<0.0001), 87% of the subjects (n=79) were still vitamin D de#cient at the end of the summer.14

Another study examined eleven cases of female refugees in Switzerland su&ering from vitamin D de#ciency. !e authors focused on the manner in which women presented their symptoms in primary care settings and the steps doctors used to make their diagnoses. !e women presented with histo-ries of “bone pain, proximal muscular weakness, and change in gait or fatigue.”15 Nine of the eleven women wore a veil, which greatly restricted their exposure to sunlight. Four of the women were from Bosnia, four were from Somalia, one was from Afghanistan, one was from Albania, and another was from Ethiopia. !e authors identi#ed two points that were extremely relevant to this review:15

• Vitamin D de#ciency can be di"cult to identify in a clin-ical setting despite its characteristic pattern of pain. !e doctors in the study #rst attributed the women’s pain to somatization disorder, chronic back pain, or unexplained somatic symptoms. In only one case did the doctor ini-tially consider vitamin D de#ciency.

• Pain associated with vitamin D de#ciency has been shown to resolve in three to six months with treatment. For ten of the women, the symptoms resolved in one to three months with treatment for vitamin D de#ciency. For the

last woman, her symptoms resolved in sev-en months.

Furthermore, a review by Benson and Skull provided insight into the characteristics that are associated with a higher risk of vitamin D de#ciency or insu"ciency in refugees.8 For example, vitamin D de#ciency is likely to oc-cur in individuals who are dark-skinned, have limited sun-light exposure, have di"culty absorbing vitamin D, or have a diet that is de#cient of vitamin D—such as a strict vegetarian diet.8,15 !ese characteristics are common in refugee popula-tions.

Within the refugee population, the studies identi#ed several groups that were at an even greater risk of vitamin D de#cien-cy than the general refugee population: women of child-bear-ing age, men age 46 and older,16 East African refugees,4,17 Mid-dle Eastern refugees, children with precocious puberty, and populations with increased time in hiding.17

CURRENT US POLICY ADDRESSING VITAMIN D DEFI-CIENCY IN REFUGEES

!e Refugee Act of 1980 established !e Federal Refugee Resettlement Program as a division of the Department of Health and Human Services. !e legislation delineated that healthcare provisions for newly arriving refugees would be part of the resettlement process.18 A%er arriving in the US, refugees are provided with Medicaid or Refugee Medical As-sistance (summarized in Table 4) as a form of medical insur-ance during their #rst eight months in the country. Refugees are strongly encouraged to undergo a free health screening within 90 days of arrival.19 !e primary purpose of evaluat-ing the refugee’s health is to prevent transmission of com-municable diseases within the US. During the course of the medical screening, patients with communicable diseases or other health issues are referred to the appropriate physicians for proper treatment. A%erward, refugees are encouraged to seek follow-up treatment while their healthcare costs are still covered by Medicaid or Refugee Medical Assistance.19

!e US Centers for Disease Control’s (CDC) Immigrant, Ref-ugee, and Migrant Health Branch provides clinical guidelines for the Domestic Medical Examination for Newly Arriving Refugees.20 !ese guidelines, however, are only recommen-dations and are not prescriptive or mandatory.21 To date, the Summary Checklist for Domestic Medical Examination for Newly Arriving Refugees does not contain an explicit general recommendation for testing refugees for vitamin D de#cien-cy, and a comprehensive approach for addressing vitamin D de#ciency in the refugee population is lacking. !at being said, the CDC’s Guidelines for Evaluation of the Nutritional Status and Growth in Refugee Children During the Domes-tic Medical Screening Examination does include an advisory statement stating that most immigrants are a&ected by vita-min D de#ciency. !e CDC advises that many risk factors for vitamin D de#ciency are o%en seen in refugees and that vitamin D de#ciency is most common among veiled, dark-skinned immigrant women.22

Table 2. Search Terms on Medical Databases and Results

Database Search Terms Number of Results

PubMed (vitamin D insufficiency OR vitamin D deficiency OR vitamin D deficient

OR vit D insufficiency OR vit D deficiency OR vit D deficient OR

hypovitaminosis D3) AND (refugee OR asylum seeker)

20

Trip (vitamin D insufficiency OR vitamin D deficiency OR vitamin D deficient



5

The Cochrane Library

(vitamin D insufficiency OR vitamin D deficiency OR vitamin D deficient



1


!e US domestic medical examination focuses on commu-nicable disease control, explicitly testing for communicable diseases and administering immunizations.21 !e Summary Checklist for Domestic Medical Examination for Newly Arriv-ing Refugees provides a number of conditions that physicians should test for even if clinical signs are not present. !ese include tuberculosis, lead levels, malaria, syphilis, chlamyd-ia, gonococcus, HIV, and viral hepatitis. Physicians are also asked to obtain a complete blood count, glucose and serum chemistries, pregnancy test, dietary history and anthropo-metric indices. Testing for most other conditions, including vitamin D de#ciency, is at the discretion of the physician con-ducting the examination on a case-by-case basis.23

From an international perspective, the World Health Orga-nization (WHO) makes recommendations about emergency nutrition for refugees, speci#cally about how to avoid de#-ciencies in vitamins B1, B3 and C during humanitarian emer-

gencies including periods of con$ict, natural disasters, and food insecurity.24 !ough the WHO has made no recommen-dations to date about vitamin D speci#c to refugees in the re-settlement process, the international body does indicate that vitamin D supplementation may decrease the incidence and severity of respiratory infections in children, prevent rickets in infants, and reduce the risk of pre-eclampsia in pregnant women.25,26,27

DISCUSSION

!e #ndings show that vitamin D de#ciency is widespread among refugee populations. Six of the eight studies found that the majority of their study population of refugees was vitamin D de#cient or insu"cient. !e remaining two studies found that a substantial proportion of the refugee population was de#cient, with average vitamin D de#ciency rates among the refugee population being higher than the reference rates for de#ciency in the US population (31% of non-Hispanic

Table 3. Descriptive Studies of Vitamin D Deficiency and Insufficiency Among Refugees

Author(s)

Number of

Subjects Study Population Details

Proportion Vitamin D

Deficient or Insufficient

Level of Severity of

Vitamin D Deficiency

Chaves et al, 2009.34

156 • Burmese refugees• Age range 16-86 years• Median age 30 years• Attending a clinic at a hospital in Melbourne,

Australia

37% deficient(<50 nmol/L)

N/A

Huntington et al, 2010.33

153 • Sub-Saharan and South Asia refugees• Age range 6 months – 57 years• 97% Pediatric patients• Attending new refugee examinations by

Sioux Falls Health Dept in South Dakota, USA

64% deficient (<32 ng/mL)a

6% severely deficient (<15 ng/mL)b

58% mildly deficient (15-32 ng/mL)

Renzaho et al, 2011.5

49 • Sub-Saharan migrants and refugees• Age 20+ • Mean age 41.5 years • Living in Melbourne, Australia

88% deficient (<50 nmol/L)

N/A

Sheikh et al, 2009.35

239 • Newly arrived refugees, mostly from Africa • Age range 1-17 years • 36% age 0-7 years; 45% age 8-12 years;

19% age 13-17 years• Attending clinic in Sydney, Australia


N/A

Sheikh et al, 2011.17

251 • Refugees, mostly from Africa• Age range 0-17 years • Mean age 8 years• Attending outpatient general health clinic in

Sydney, Australia


2% severely deficient (<13 nmol/L)

19% moderately deficient (13-25 nmol/L)

40% mildly deficient(26-50 nmol/L)

Stellinga- Boelen et al, 2007.36

112 • Refugees from Africa, Central Asia or Eastern Europe living in The Netherlands

• Age range 2-12 years• Median age 7.1 years

55% deficient or hypovitaminosis D


42% hypovitaminosis D (30-50 nmol/L)

Tiong et al, 2006.4

258 • African refugees attending general practice clinics in Melbourne, Australia

• 57% Sudanese• 17% Liberian• 50% <15 years old


N/A

Wishart et al, 2007.16

869 • Refugees arriving at the national refugee resettlement center in New Zealand

54% deficient or insufficient

(<50 nmol/L)


37% insufficient (25-50 nmol/L)c

Note: Table constructed using data from the scientific papers specified in the table. a. 32 ng/mL is equivalent to 80 nmol/L. The conversion factor is 1ng/mL = 2.5 nmol/L.11 b. 15 ng/mL is equivalent to 37.5 nmol/L. c. Wishart et al. use these values because they argue that <25nmol/L is a “frank deficiency” and 25-50 nmol/L is when bone health becomes negatively affected.


PERSPECTIVES

Blacks, 12% of Mexican Americans, and 3% non-Hispanic whites).28 A signi#cant limitation to this project is that the studies were primarily conducted in Australia and New Zea-land. Additional research should be conducted to determine the rates in the US context.

!e evidence provides convincing support that preventative measures should be taken to address vitamin D de#ciency among refugees—both to eliminate health disparities and to provide protection for a vulnerable population.

!e de Torrente de la Jara et al. study highlights several key factors related to addressing vitamin D de#ciency among refugees. Under the current policy, refugees are to be treated for vitamin D de#ciency if they are identi#ed as being de#-cient. Currently, the responsibility falls on their physicians to identify relevant symptoms as possible indicators of the de#-ciency and then testing for vitamin D levels. However, as the paper argues, physicians o%en incorrectly attribute the pain symptoms to other conditions.15 As a result, refugee patients o%en remain untested for vitamin D de#ciency during their domestic medical examination, missing a crucial opportunity to address the de#ciency, which can be easily corrected using supplements or by providing educational information about vitamin D. Furthermore, since refugees are unfamiliar with the healthcare system in the US, they are less likely to seek medical care during the #rst eight months a%er their arrival. A%er that time, they may be uninsured if they do not apply for Medicaid or health insurance under the A&ordable Care Act, which o%en occurs due to language or cultural barriers or an unfamiliarity with the US healthcare system.29,30

Since the US domestic medical examination is highly encour-aged for all refugees, it is an ideal time to intervene in an e&ort to improve the vitamin D status of the patients. A systematic de#ciency screening and vitamin D supplementation policy could alleviate the burden of vitamin D de#ciency among ref-ugees.

CONCLUSION

Vitamin D de#ciency is a major health issue among refugees worldwide.4,5 A policy is needed to systematically improve

vitamin D status in the refugee population during the initial period of medical provision by the US government, in order to prevent and mitigate the e&ects of vitamin D de#ciency from the beginning of the refugees’ time in the US. !is is likely to be best accomplished by testing for vitamin D de#-ciency and providing interventions during refugees’ domestic medical examination. In addition, further research should be conducted about the speci#c population of refugees entering the US since much of the research to date has been conducted in Australia, New Zealand, and !e Netherlands.

REFERENCES

1. US Department of State. Refugee Admissions. http://www.state.gov/j/prm/releases/statistics/206319.htm. Updated 2013. Accessed 2014.

2. US Department of State. Refugee Admissions Reception and Placement Program Fact Sheet. http://www.state.gov/j/prm/releases/factsheets/2011/181029.htm. Published 17 Oc-tober 2011. Accessed June 2012.

3. US Department of State. FY11 Refugee Admissions Statis-tics. http://www.state.gov/j/prm/releases/statistics/184843.htm. Updated 2012. Accessed June 2012.

4. Tiong AC, Patel MS, Gardiner J, Ryan R, Linton KS, Walk-er KA, et al. Health issues in newly arrived African refugees attending general practice clinics in Melbourne. Med J Aust. 2006;185(11-12):602-6.

5. Renzaho AM, Nowson C, Kaur A, Halliday JA, Fong D, Desilva J. Prevalence of vitamin D insu"ciency and risk fac-tors for type 2 diabetes and cardiovascular disease among Af-rican migrant and refugee adults in Melbourne: a pilot study. Asia Pac J Clin Nutr. 2011;20(3):397-403.

6. Mayo Clinic. Vitamin D. http://www.mayoclinic.com/health/vitamin-d/NS_patient-vitamind. Updated 2011. Acessed 2012.

7. Souberbielle JC, Body JJ, Lappe JM, Plebani M, Shoenfeld Y, Wang TJ, et al. Vitamin D and musculoskeletal health, car-diovascular disease, autoimmunity and cancer: Recommen-dations for clinical practice. Autoimmun Rev. 2010;9(11):709-15.

8. Benson J, Skull S. Hiding from the sun - vitamin D de#cien-cy in refugees. Aust Fam Physician. 2007;36(5):355-7.

9. Reid IR, Bolland MJ. Role of vitamin D de#ciency in car-diovascular disease. Heart. 2012;98(8):609-14.

10. Hanley DA, Cranney A, Jones G, Whiting SJ, Leslie WD. Vitamin D in adult health and disease: a review and guide-line statement from Osteoporosis Canada (summary). CMAJ. 2010;182(12):1315-9.

Table 4. Types of Healthcare Assistance Offered to Refugees

Type of Healthcare

Assistance Description

Refugee Medical Assistance20

A federal insurance program for refugees provided for the first eight months after the date of arrival as a refugee or the date on which asylum was granted.

Medicaid20,30,31 An insurance program that is provided to all individuals meeting eligibility criteria as part of a state-federal partnership. The Medicaid program is provided nationally, but is admin-istered by the individual states. Healthcare services are either provided at reduced cost or for free. Eligible individuals must meet income requirements. Medicaid is NOT a refugee specific program.


11. National Center for Environmental Health, Centers for Disease Control and Prevention. Second National Report on Biochemical Indicators of Diet and Nutrition in the US Pop-ulation. 2012.

12. O"ce of Dietary Supplements. Dietary Supplement Fact Sheet: Vitamin D. National Institutes of Health. http://ods.od.nih.gov/factsheets/VitaminD-QuickFacts/. Updated June 2011. Accessed 2014.

13. Morris MD, Popper ST, Rodwell TC, Brodine SK, Brou-wer KC. Healthcare barriers of refugees post-resettlement. J Community Health. 2009;34(6):529-38.

14. Benitez-Aguirre PZ, Wood NJ, Biesheuvel C, Moreira C, Munns CF. !e natural history of vitamin D de#ciency in Af-rican refugees living in Sydney. Med J Aust. 2009;190(8):426-8.

15. de Torrente de la Jara G, Pecoud A, Favrat B. Musculo-skeletal pain in female asylum seekers and hypovitaminosis D3. BMJ. 04;329(7458):156-7.

16. Wishart HD, Reeve AM, Grant CC. Vitamin D de#-ciency in a multinational refugee population. Intern Med J. 2007;37(12):792-7.

17. Sheikh M, Wang S, Pal A, MacIntyre CR, Wood N, Gunesekera H. Vitamin D de#ciency in refugee children from con$ict zones. J Immigr Minor Health. 2011;13(1):87-93.

18. US Congress. !e Refugee Act. Immigration and Nation-ality Act. Washington, DC. 1980.

19. Florida Department of Health Division of Disease Con-trol. Health Care Guide for Florida’s Refugees. 2012.

20. Centers for Disease Control and Prevention. Immigrant, Refugee, and Migrant Health Branch. http://www.cdc.gov/ncezid/dgmq/irmh-fact-sheet.html. Updated June 2013. Ac-cessed July 14 ,2014.

21. Centers for Disease Control and Prevention. Guidelines for the U.S. Domestic Medical Examination for Newly Arriv-ing Refugees. http://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/domestic-guidelines.html. Updated February 2014. Accessed 2014.

22. Centers for Disease Control and Prevention. Guidelines for Evaluation of the Nutritional Status and Growth in Refu-gee Children During the Domestic Medical Screening Exam-ination. http://www.cdc.gov/immigrantrefugeehealth/pdf/nutrition-and-growth-guidelines.pdf. Updated November 2013. Accessed 2014.

23. Centers for Disease Control and Prevention. Summa-ry Checklist for Domestic Medical Examination for Newly Arriving Refugees. 2012. http://www.cdc.gov/immigrantref-ugeehealth/pdf/checklist-refugee-health.pdf. Updated July 2012. Accessed July 14 2014.

24. World Health Organization. Nutrition in Emergencies.http://www.who.int/nutrition/topics/emergencies_work/en/. Updated 2014. Accessed July 14, 2014.

25. World Health Organization. Vitamin D Supplementation in Children with Respiratory Infections. http://www.who.int/elena/titles/vitamind_pneumonia_children/en/. Updated 2014. Accessed July 14, 2014.

26. World Health Organization. Vitamin D Supplementation in Infants. http://www.who.int/elena/titles/vitamind_infants/en/. Updated 2014. Accessed July 14, 2014.

27. World Health Organization. Vitamin D Supplementation during Pregnancy for the Prevention of Pre-eclampsia. http://www.who.int/elena/titles/vitamind_pregnancy/en/. Updated 2014. Accessed July 14, 2014.

28. Centers for Disease Control and Prevention. CDC re-port #nds U.S. population has good levels of some essential vitamins and nutrients. http://www.cdc.gov/media/releas-es/2012/p0402_vitamins_nutrients.html. Updated 2012. Ac-cessed 2012.

29. O"ce of the Assistant Secretary for Planning and Evalua-tion, US Department of Health and Human Services. Barriers to Immigrants’ Access to Health and Human Srvices Pro-grams. http://aspe.hhs.gov/hsp/11/ImmigrantAccess/Barri-ers/rb.pdf. Published May 2012. Acessed August 23, 2014.

30. Bustamante AV and Van der Wees PJ. Integrating Im-migrants into the U.S. Health System. Virtual Mentor. 2012;14(4): 318-323.

31. US Department of Health and Human Services. Medic-aid. Washington, DC. http://www.healthcare.gov/using-in-surance/low-cost-care/medicaid/index.html. Updated 2012. Accessed 2012.

32. Centers for Medicare & Medicaid Services. Premiums, Copayments, & other Cost Sharing. Baltimore, MD. http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Cost-Sharing/Cost-Sharing.html. Updated 2012. Accessed 2012.

33. Huntington MK, Shafer CW, Pudwill R, Boer L, Kendall J. Prevalence of vitamin D de#ciency among immigrants to South Dakota. S D Med. 2010;63(2):51-5.

34. Chaves NJ, Gibney KB, Leder K, O’Brien DP, Mar-shall C, Biggs BA. Screening practices for infectious diseas-es among Burmese refugees in Australia. Emerg Infect Dis. 2009;15(11):1769-72.

35. Sheikh M, Pal A, Wang S, MacIntyre CR, Wood NJ, Isaa-cs D, et al. !e epidemiology of health conditions of newly arrived refugee children: a review of patients attending a specialist health clinic in Sydney. J Paediatr Child Health. 2009;45(9):509-13.


PERSPECTIVES36. Stellinga-Boelen AA, Wiegersma PA, Storm H, Bijleveld CM, Verkade HJ. Vitamin D levels in children of asylum seekers in !e Netherlands in relation to season and dietary intake. Eur J Pediatr. 2007;166(3):201-6.

37. O"ce of Refugee Resettlement, U.S. Department of Health and Human Services. About Cash and Medical Assis-tance.http://www.acf.hhs.gov/programs/orr/programs/cma/about. Accessed August 4, 2014.

Photographer credits listed on the contributors page

A

B

C

D


NYMC STUDENT PHOTGRAPHY

E F

G H

I J


K

N

L

M O


NYMC STUDENT PHOTGRAPHY

P

Q

R S

T

Path by Sunshine CottageMichael Shen (Watercolor)


REFLECTIONSPOEMSWaterParvati Singh

Standing at the edge of the oceanLooking towards the deceptively clear blue water

Waves rapidly crashing over and engul#ng each otherOnto the sandy shore

Pulling back into the blue envelope!e water’s rhythmic yet irregular motion is hypnotic

Beckoning me to walk in!e #rst step is hesitant,

Full of doubt and insecurity!e next few steps are tinged with excitement,

!inking of the possibilities and glorySoon the water is up to my neck

Fear has crept in as the water beats against my chestResilience sets in and fades

!e water level is right below my lower lipFear has returned with doubt and insecurity

And a tinge of regretFinally deciding to drop the anchors of fear and romantic notions

I take a deep breathJump into the water, swimming with the currents

Becoming part of the waterFlowing with it towards the edge of the earth,

Joining in with the horizon


!e sound of giggles and laughterEchoed across the rolling green landscape

My siblings and I were taking turnsWielding our homemade bow and arrows

Shooting arrows against gravityTo pierce the cloudy evening sky

And provoke the Indian god IndraInto sending showers of cool raindrops

Across our summer oasis

No raindrops cameOur attempts ceasing

A%er my mother shouted at usTo stop trying to reenact scenes

From Hindu mythology

One day a thunderbolt did come downWith such high velocity

!at it hit my grandfather multiple timesLeaving him paralyzed from a stroke

Seeing the sad looks on my parents facesI o%en visited my grandfatherExuding infectious enthusiasm

Trying to make my parents and grandfather laugh

Each time I saw my grandfather, my BabaWe would play our tic-tac-toe game

He beat me a few timesOn those occasions, I proudly told my parents

!at Baba’s cognition was still presentTrying to awaken hope and elicit faint smiles

CrossroadsParvati Singh


REFLECTIONS

!en one day a tactless idiotClaimed my Baba barely had a sliver of comprehension

!is information shattered my spiritAnd le% me standing at a crossroads

Time seemed to have bifurcatedIn the distance, life appeared to be rapidly accelerating

Except in my personal bubbleWhere everything slowed down

Almost to the point of suspensionAs I contemplated the paths that lay before me

One of avoidanceOne of oblivion and fake energyOr one of acceptance and action

!e sharp wailing cries of my motherWoke me from my trance

I saw the grief painted across my parents’ facesAnd it dawned on me that as I stood at my crossroads

A life had literally passed me by

Since then, I have hoped to do something bigger than myselfAnd to make a positive impact in this world

Maybe it is out of regretOr it is out of a desire to emulate my grandfather’s sel$essness

Or maybe it is from seeking redemption

Either way, the next time a thunderboltShoots down from the skyI will not make the mistake

Of being paralyzed at my next crossroads

*Submitted as an entry in the 2014 Pharos Poetry Competition


CONVOCATION OF THANKS

Our Tree of Enlightenment Nidhi Shah (Oil Painting)!rough this painting, I wanted to show how much the donors meant to us. !ey will always be the roots of our knowledge that nourish our education. Without the roots, the rest of our branches would remain bare. !e fruits of our knowledge come from them, and for that we will always be grateful.

!e appreciation is not mine alone to give. !e words my classmates used to express our collective grati-tude have been embedded into the branches of the tree. !ey include humility, eye-opening, enlightened, thankful, humbling, grateful, self-less, unforgettable, inspirational, a gi% that keeps on giving.


REFLECTIONS

!e Convocation of !anks ceremony has been a tradition at the New York Medical College School of Medicine for the past 26 years. Every spring, the #rst year medical students compile a program of musical pieces, artistic representations, and spoken words in an attempt to demonstrate their appreciation to the family and friends of the individuals who sel$essly donated their bodies to science in a #nal act of giving.

During the process of preparing for the ceremony, many of our classmates, ourselves included, came to realize that it is very di"cult to put into words the appreciation that we, as #rst year medical students, feel for the generous donations from our donors and their families. We can say, though, that we accepted their gi% with profound grat-itude, and we hope that even in their absence we were able to honor their #nal wishes with the utmost respect.

We hope that by including a collection of speeches from the Convocation of !anks ceremony, we can further honor those who have sacri#ced so that we can become well-trained physicians. We wish to immortalize the words spoken by our classmates, which will continue to resonate with us throughout the course of our career.

Sincerely,Sherry LiouMargaret NguyenQuill & Scope Managing EditorsClass of 2017

About the Convocation of !anks



I’d like to start by sharing that I love stories. Romantic or dark, dramatic or adventurous, comedic or tragic—it doesn’t mat-ter. So long as there are characters being tested by challenges, I can’t get enough. I think this was part of the draw for me to practice medicine, because there is no better #eld for stories. And we get them all: lifelong epics, acute disasters, miracles, tragedies. Every patient has a story and it is our job to unravel it. One of the #rst things we learn in medical school is how to take a history—how to get the patient to tell you their story. But like a bad anthropologist, we try to help the people we study—to change how their stories will end.

As is o%en quipped when you enter med school, your #rst patient is already dead. But there is more to this saying than wit and morbid humor. !ese cadavers are not just an educa-tional tool, a collection of organs and tissues, a body; these are people—people who have lived long, rich interesting lives—lives that have le% their mark on their bodies. So even though the deceased could no longer tell us their story directly, my classmates and I had the privilege of spending several months unraveling each story as told by the very bodies in which they experienced them.

I’d like to remind you that the vast majority of us had nev-er seen a dead body before our #rst anatomy session at this school. !at #rst incision was very hard, at least for me. My parents can be proud that they raised a child who, if nothing else, is uncomfortable cutting people with knives. At #rst, to push through my discomfort I think I objecti#ed the person

on my dissection table. She was an “it,” not a “she” for the #rst couple weeks. I had enough on my mind trying to stay a$oat through the deluge of information poured on us in those #rst days of medical school without trying to riddle out the meta-physics of death and identity.

!ough it didn’t happen all at once, my perspective did even-tually change. Anatomical curiosities became possible symp-toms. “!ese bones seem brittle” turned into “I wonder if she had osteoporosis?” Or “I wonder when he had that pacemak-er put in?” “Do you think this #broid tumor caused her any pain?” “I bet his heart anomaly gave every one of his doctors a scare! Maybe he had fun watching them freak out listen-ing through a stethoscope before letting them know that they should hear a murmur.” I think what really got to me were the tattoos and #nger nail polish. !ese were some of the only clues to the personalities of our patients. By the end of gross anatomy, we wanted to know more about these people—not medically, not because we wanted to #x them, but because we had spent time with them and had glimpsed some of their story.

If I could thank our donors, who we honor today, I would thank them not just for helping future doctors unravel the tangled paths of the portal triad or brachial plexus, nor for giving hopeful surgeons practice with a scalpel. I would thank them for being our #rst patients, for teaching us our #rst les-sons in humanistic medicine, and for sharing some of their life with us even a%er it had ended.

Convocation of !anks RemarksChristopher Monson


REFLECTIONS

It is an honor to stand before you—the friends and family of those who generously donated their bodies to the Class of 2017—to have the opportunity to express gratitude on behalf of myself and my colleagues for the tremendous gi% that you all have given us. Today I want to take a few minutes to share an experience that I had in anatomy lab that I consider to be a pivotal moment in my life.

In preparation for our #rst anatomy lab practical exam, a group of friends and I decided to head to the lab to practice identifying structures a few days before the exam. Unfortu-nately, near the time of the exam, I was under the weather and could not accompany them. A night later, I decided to go by myself. Picture a dark, stormy night. In the middle of the rain, I was wearing a hooded sweatshirt, running to the building, and wiping o& the water as I walked up the stairs to the fourth $oor anatomy lab. !e lab is about the size of this auditorium, full of occupied dissection tables and model skel-etons interspersed between—certainly not where I envisioned myself in the middle of the night. Although my #rst instinct was to leave and come back in the morning when I would not feel so jittery, I decided to stay and I am so glad that I did.

I pulled out my books and sat down next to my dissection ta-ble. However, unlike previous times, I took a couple minutes before starting to look at the body lying out before me on the table, not as a cadaver, but as a person. I was instantly over-

whelmed by regret. She was allowing me to learn the ancient science of anatomy by giving up her right to a traditional buri-al—a tremendous gi%—and as I sat next to her, I realized that I had never even said a simple thank you. It was probably the #rst time in my life that I had received something on such a grand scale without the opportunity to express my gratitude.

However, as I searched for meaning in her face, I truly felt that she was trying to tell me something. And in that mo-ment, it was clear that she wanted me to question this new-found regret. She had donated her body in hopes of making my classmates and me better doctors, so that we could pass along her sentiment of unconditional love and generosity to our patients. Her contribution required no thanks, but rather, instilled in me a sense of purpose.

!at late night in the anatomy lab rede#ned my purpose in life: to truly give without keeping score. I have no doubt that each and every one of my classmates experienced a similar feeling during his or her time in the anatomy lab. To my col-leagues and future physicians, I challenge each and every one of you to not only carry this sentiment to your practice, but also to embody this sense of unconditional giving in your day to day lives.

On behalf of the Class of 2017, I would like to thank all of you again for the gi%s of your loved ones.

Convocation of !anks RemarksVinod Ravikumar



My friends, family members, and prospective students o%en ask me about the transition to medical school. Early on, my response focused on the importance of time management; there is a heavy workload and I now have less time with fam-ily and friends. But at a certain point during the year I devel-oped a di&erent perspective. !e things we are learning now matter.

I took calculus in my senior year of college because I noticed that many medical schools required or “highly recommend-ed” it. It’s like when Mom says, “I highly recommend you take out the garbage.” I took the course to satisfy the requirement and have never looked back. But the lessons we learn during these formative years of medical school have profound sig-ni#cance, whether it’s learning about a disease or how to be a compassionate and caring clinician. All of a sudden we are not just focused on getting correct answers on exams but we are asking ourselves, “What can I learn from this?”

I recently spoke with Dr. Pravetz, who informed me that many—if not all of the donors—actually contacted him about making the donation. I had thought perhaps Dr. Pravetz would have to go around trying to procure donations, be-cause that is how most donations work. O%en when dona-tions are made, it includes some self-serving purpose. I know that to get us to donate blood the blood bank has to o&er us tickets to baseball games. It’s not solely about giving but also about our own personal gain.

When people are moving on in years or perhaps are not well, they begin to discuss their plans concerning what should be done when they pass on. Is there a greater time for them to think about themselves? !ey can be givers for their whole lives, but now? !ey should think about themselves. Instead the generous donors asked, “What can I give?” !ey gave not just when it was convenient. Not just when it was easy. !ey gave without any expectation of fanfare or accolades. It was giving in its purest sense.

What did they give? !ere are many seasoned physicians in this room and they have experienced the anatomy lab the same number of times as the medical students. One time. It is an experience that most of us will have once, yet it serves to in$uence our practice of medicine forever. Let’s say that of my classmates, even just one of us, one day, is performing emergency surgery and saves a life because of the perspective

we gained in the lab. And let’s say that patient goes on and ends up having children, and they grow up and have children of their own. Generations later we could seat the physician and the donor in the front of the room and #ll the entire audi-torium with people that are alive because of that one generous act which took place years before. Can you imagine?

!is is the logic that is o%en ascribed to a famous quote from the classical Jewish text, the Talmud (an authoritative record of Rabbinic discussions on Jewish law and ethics). !e Tal-mud inquires why G-d would start the world with one person. Why didn’t He create a population of people and place them on Earth? !e Talmud responds in part by saying, “To teach that whoever saves a life, it is as if he or she has saved an entire world.”

I wondered why we end this event with the planting of a tree—perhaps because it is symbolic of today’s honorees. Be-cause every winter the trees lose their leaves, and a child who is observing might even think that the tree is passing on. But in the spring we observe regrowth from that very same tree. !at is what we are recognizing today.

I would like to thank Dr. Pravetz and the other members of the Department of Cell Biology and Anatomy who taught us the didactics of gross anatomy. Just as importantly, he taught us life lessons and provided us with this opportunity to re$ect today. !ank you to all of the members of the school admin-istration, faculty, sta&, and my fellow classmates who have helped organize this event.

I would especially like to thank the families and friends who have honored us by coming today. We acknowledge that you have also sacri#ced—be it cultural, religious or family funeral traditions, or the sense of closure that was perhaps compro-mised. I hope that today’s event provides an added sense of comfort.

And #nally to our donors: any words of gratitude that I could try and express would surely ring hollow. I want to thank you, and I want to leave you with an assurance—an assurance that a valuable lesson was learned by this year’s Class of 2017. A lesson about science—sure—but also a lesson about giving. A lesson that we will hopefully carry wherever the practice of medicine may take us. !ank you.

Convocation of !anks RemarksIsrael Ackerman


REFLECTIONS

Beyond My WindowAnastasiya Holubyeva


ORAL PRESENTATION WINNERSFirst Place (Basic Science)

PURPOSE

Multipotent adult stem cells (MASCs) are undi&erentiated cells that can be extracted from adult tissues and have the ability to di&erentiate into endodermal, mesodermal, and ec-todermal phenotypes. MASCs were seeded onto polyglycolic acid (PGA) polymer and surgically implanted to regenerate damaged tissue, including articular cartilage, meniscus, bone, and peritoneum. Obtaining su"cient tissue coverage is o%en a signi#cant clinical challenge for open tibial fractures. !e purpose of this study was to determine if MASCs, seeded into PGA felt matrices, would di&erentiate into periosteum, dermal, and epidermal structures in order to treat open tibia fractures.

METHODS

PGA mesh was cut into 20 x 5 mm squares and infused with rat MASCs (rMASCs) transduced with green $uorescent protein, at passage 29. !e polymer was seeded with 20 x 106 cells/ 100 μl and allowed to culture for 14 days. A%er the 14-day culture period, surgeries were performed on adult rats to expose the tibia, to remove the periosteum in order to mimic a human compound tibial fracture, and to cover the wound with the PGA plus rMASCs. !ere were three di&erent exper-imental groups: 1) control rats with an empty wound without PGA, 2) rats with PGA alone without rMASCs, and 3) rats with PGA infused with rMASCs. Each group had three ani-mals. !e rats were euthanized 28 days post surgery, and the lower legs were dissected and #xed with formalin. !e sur-gical defects were further dissected and processed for paraf-#n histology. !e tissue samples on the slides were stained with an antibody to green $uorescent protein to distinguish between stem cell di&erentiated tissue and native rat tissue. Tissue samples were then visualized under a $uorescent mi-croscope and photographed.

RESULTS

!e control rats that did not receive rMASCs (those with ei-ther an empty wound or a wound with PGA) did not stain positive for GFP. Upon gross examination 28 days post sur-gery, the wounds were completely closed with skin and hair regrowth covering the surgical incision. However, the tibia had no periosteum and scar tissue was present under the dermis. Samples from the experimental rats that received PGA with rMASCs were also completely closed. Tissue slices throughout the sample showed cells of stem cell origin with the morphology of periosteum, blood vessels, skeletal muscle, dermis, and epidermis. !e epidermis had an intact basal lay-er and hair follicles with GFP-staining.

CONCLUSION

When GFP-labeled undi&erentiated MASCs in PGA polymer were surgically implanted in a rat model of a compound tib-ial fracture, GFP positive cells were observed with the mor-phology of periosteum, blood vessels, dermis, and epidermis. !is preliminary study suggests MASCs can respond to local signals to di&erentiate into a number of separate phenotypes. !us, the MASCs may be able to provide so% tissue coverage over open tibial fractures.

Multipotent Adult Stem Cells (MASCs) for Tibial Exposure RegenerationRachel Talley-Bruns, Azlyn Go%, Robert M. Koch, Paul A. LucusDepartments of Chemistry and Biomedical Engineering, Boston University


NYMC STUDENT RESEARCH FORUM

Functionalized Nanoparticles: Old Drugs, New TricksJ. Henry Feng, Aaron Colby, Mark W. Grinsta%Departments of Chemistry and Biomedical Engineering, Boston University

INTRODUCTION

Translational medicine involves taking new discoveries with-in the lab and applying them as solutions to clinical and pub-lic health problems. One major health issue that a&ects mil-lions of individuals worldwide is cancer, which is projected to claim 13.1 million lives worldwide by 2030.† In addition to the lives a&ected by cancer, the increased #nancial burden on citizen and state ought not to be overlooked. !erefore, the development of novel, cost-e&ective, and targeted cancer therapies should be investigated. Current standard of care re-lies on resection of the tumor growth for bulk removal and systemic administration of chemotherapy; the chemotherapy is usually a cocktail-blend, containing the active chemothera-py agent plus a solubilizer, such as Cremaphor EL. However, the e"ciency of the administered dosage is very low: relative-ly very little drug reaches the cancer cell’s interstitium, and an even lower concentration is internalized by the cell com-pared to the amount of active agent administered. !e photo-sensitive expansile nanoparticle (eNP) is a novel and elegant drug delivery system, which not only increases the solubility of a chemotherapy agent but also may have implications of increasing the e"ciency of the chemotherapy payload. In ad-dition, the payload release of the drug can be triggered by the volition of the administering physician with a long-wave UV source, and thus break the paradigm of a typical drug’s phar-macokinetics in the body.

METHODS

!e photosensitive monomer and photosensitive polymeric nanoparticle were #rst synthesized using a novel convergent organic synthesis scheme.‡ Dynamic light scattering (DLS), zeta potential measurements, and scanning electron micros-copy (SEM) were used to characterize the physical nature of the functionalized nanoparticle. Chromophore-conjugated nanoparticles were synthesized and subjected to irradiation, and characterized with 0.05 mg of PolyFluor™ 570 (Methacry-loxyethyl Tricarbonyl Rhodamine B; Polysciences, Inc.) Cy-totoxicity and cell uptake assays were performed.

† World Health Organization, published 2012.

‡ Feng J and Grinsta& MW. Synthesis and Characterization of Functional Polymeric Nanoparticles. "e Nucleus NESACS. 2011;139: 8-10.

RESULTS

DLS and zeta potential measurements indicate that nanopar-ticles undergo expansion upon irradiation with long-wave UV light within 2 minutes. SEM images show a clear expansion of the particle structure. Time-lapsed $uorescent microscopy showed expansion of particles on a microscope slide, indicat-ed by increased light signal with time of irradiation. Further cell testing of empty nanoparticles showed excellent internal-ization with no cytotoxicity.

CONCLUSION

Stimuli-responsive nanoparticles may provide signi#cant bene#ts in the #eld of drug delivery. In this work we have described the design and synthesis of a new type of trigger-re-sponsive nanoparticle embodying improved spatio-temporal control over triggering of the release mechanism. Various characterization techniques have demonstrated the unique expansile function of these particles while in vitro assays have demonstrated signi#cant particle uptake and internalization by cancer cells. Building o& these proof-of-concept results, in future studies, we will encapsulate a range of therapeutic drugs to determine how UV-responsive eNPs and their asso-ciated external triggering system may be utilized to improve drug e"cacy.

Second Place (Basic Science)


ORAL PRESENTATION WINNERS!ird Place (Basic Science)

INTRODUCTION

Partial nephrectomy (PN) for renal cortical neoplasms has demonstrated superior long-term renal functional outcomes when compared to radical nephrectomy (RN). Minimizing the distance between surgical margin and tumor reduces the non-neoplastic parenchymal volume (NNPV) removed in the surgical specimen. As the role of NNPV on postoperative outcomes has produced varying results in preliminary inves-tigations, we sought to determine the association between NNPV removed and postoperative chronic kidney disease (CKD) staging at our institution.

METHODS

Our Urologic Oncology database was queried for patients undergoing PN from 1990-2012. Demographics and patho-logical data were collected. !e ellipsoid formula was used to calculate surgical specimen volumes (VS) and tumor volumes (VT), which were then subtracted from each other (VS - VT) to determine the NNPV removed. Estimated glomerular #l-tration rate (eGFR) values were calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) for-mula. A binary logistic regression was utilized to determine predictors of postoperative CKD upstaging based on eGFR values.

RESULTS

A total of 584 patients meeting inclusion criteria underwent PN. On binary logistic regression analysis (with age, tumor volume, surgical modality, and pre-operative CKD con-trolled) increasing NNPV removed in the surgical specimen was independently associated with postoperative CKD up-staging (OR: 1.005, p = 0.006).

CONCLUSION

Increasing NNPV removed during PN is correlated with CKD upstaging based on eGFR values; therefore, further emphasis should be placed on healthy parenchymal preservation with long-term follow-up to ensure adequate oncologic outcomes.

Increasing Volume of Non-Neoplastic Parenchyma in Partial Nephrec-tomy Specimens Is Associated with Chronic Kidney Disease Upstaging Michael B. Rothberg, Srinath Kotamarti, Matthew Danzig, Jared Levinson, Shumaila Saad, Ruslan Korets, James M. McKiernan, and Ketan K. BadaniDepartment of Urology, Columbia University Medical Center


NYMC STUDENT RESEARCH FORUMFourth Place (Basic Science)

PURPOSE

Glioblastoma (GBM) is a treatment-refractory primary brain malignancy characterized by exceptional genetic heteroge-neity. Most GBMs feature dysregulation of receptor tyrosine kinase (RTK) signaling via gene ampli#cation and/or muta-tional activation. However, small-molecule inhibitors target-ing speci#c RTKs have not been shown to be successful in treating GBM. One possible mechanism for resistance is the expression and activation of multiple RTKs within individual GBMs. Seven percent of GBMs are found to co-amplify epi-dermal growth factor receptor (EGFR) and platelet-derived growth factor receptor α (PDGFRA), both RTKs, and preva-lent co-expression of PDGFRA and EGFR appears to not be limited to co-ampli#ed tumors alone. Previous studies have demonstrated interaction between EGFR and PDGFRA in a tumorsphere cell line derived from a co-ampli#ed GBM tu-mor sample. !e objectives of the present study were to es-tablish whether EGFR and PDGFRA interaction occurs in non-co-ampli#ed tumors and to assess the downstream e&ect of EFGR and PDGFRA on temporal- and ligand-mediated Akt response heterogeneity in GBM.

METHODS

!ese objectives were addressed via several cell and molecular biology techniques, including immuno$uorescence, proxim-ity ligation assay (PLA), co-immunoprecipitation (Co-IP), and phospho-$ow cytometry using cultured tumorsphere cell lines derived from two non-co-ampli#ed GBM patient samples. Conditions were manipulated with EGF and PDG-FB ligands as well as ge#tinib and imatinib, small-molecule inhibitors of EGFR and PDGRA, respectively.

RESULTS

PLA in a non-co-ampli#ed GBM tumorsphere cell line re-vealed that an EGFR-PDGFRA interaction occurred upon stimulation with EGF that disappeared in the presence of ge-#tinib. Co-IP experiments further clari#ed this interaction, demonstrating that PDGFRA was transactivated by EGFR following stimulation with EGF. As with the PLA, this trans-activation e&ect was reversed by ge#tinib. Phospho-$ow ex-periments showed that activation levels of RTK downstream phospho-Akt occurred as a function of total EGFR and PDG-FRA expression and changed with application of di&erent li-gands and duration of ligand exposure in both tumorsphere lines.

CONCLUSION

EGFR and PDGFRA were highly expressed and interacted in non-co-ampli#ed tumorsphere lines. Heterogeneity of RTK downstream phospho-Akt activation levels occurred as a function of total EGFR and PDGFRA expression and changed with application of di&erent ligands and duration of ligand exposure. Taken together, these results provide pre-liminary data on the interaction between EGFR and PDGFRA in non-co-ampli#ed GBM, suggesting a more complicated mechanism at work than expected based on co-expression alone. More information on the interaction between EGFR and PDGFRA is needed to truly understand its contribution to GBM oncogenesis and treatment resistance.

EGFR and PDGFRA expression heterogeneity and interaction in glioblastoma oncogenesisDiana V. Punko, Debyani Chakravarty, Alicia Pedraza, Cameron W. BrennanMemorial Sloan-Kettering Cancer Center


POSTER PRESENTATION WINNERS

Homeostatic Response to Hepatic Lipid Metabolism in the Absence of ApoBChristina Wang, Donna Conlon, Dr. Henry GinsbergColumbia University Medical Center, NIH NIDDK Medical Student Research Program in Diabetes Summer of 2013

INTRODUCTION

Apolipoprotein B (apoB) is an essential component in the assembly and secretion of very-low-density lipoprotein (VLDL); the abnormal increase in plasma VLDL is directly associated with the progression of atherosclerosis. !e knock-down of apoB using antisense oligonucleotides (ASO) results in decreased VLDL secretion a%er six weeks of treatment in mice maintained on a high fat diet. Despite this decrease in triglyceride secretion with apoB ASO-treatment, there is no hepatic steatosis as compared to control ASO-treated mice. An increase in macroautophagy of the ER was observed, as well as an increase in fatty acid oxidation of lipids that be-come trapped in the ER and are delivered to the lysosome by autophagy, thus preventing the accumulation of lipid.

METHODS

Using HuH-7 cells, a human hepatoma cell line, in which apoB had been genetically knocked out (a gi% from Kiran Musunuru, Harvard University), we attempted to create an in vitro model in which to further study the e&ects on hepatic lipid metabolism that were observed in the mice a%er 6 weeks of apoB knockdown. !e HuH-7 cell lines studied includ-ed a control (B10) and two apoB knockout (KO) (D9- and C1-) lines. To #rst con#rm that apoB is not being synthesized or secreted, an apoB label experiment was conducted using 35S-methionine to label newly synthesized apoB, where cells were treated with 0.4 mM oleic acid (OA) or BSA only. A fatty acid oxidation study in these cell lines using a 16-hour label (14C-OA) sought to measure the quantity of 14C CO2 and acid soluble metabolites produced at the end of the label.

RESULTS

As expected, there was apoB secretion observed in the control cells that increased with the addition of OA, while the apoB KO lines produced no apoB in the presence or absence of OA. Measurements of triglyceride cell mass showed no signi#cant di&erence among the three cell lines in either growth media or in the presence of 1 mM OA, similar to what was observed in the apoB ASO model. Fatty acid oxidation a%er the 16-hour label yielded a signi#cant increase in 14C CO2 and acid soluble metabolites in both apoB KO lines as compared to the control.

CONCLUSION

!ese data suggest that the increased oxidation of lipid in the apoB KO lines contributes to the lack of accumulation of tri-glyceride cell mass. Further studies seek to investigate wheth-er the observed results can be explained by an upregulation of autophagy in the ER, thus providing an in vitro model that examines the path of hepatic lipid metabolism in the absence of apoB.

First Place (Basic Science)



Mechanism of Sinus Node Activation in Cardiac TissueVinod K. Ravikumar1, Hye Jin Hwang1,2, Di Lang1, Ajit H. Janardhan3, Kath-erine Holzem1, Bum-Rak Choi5, Richard B. Schuessler1,4, Igor R. E#mov1

1Department of Biomedical Engineering, Washington University, St. Louis2Division of Cardiology, Cardiovascular Research Institute, Yonsei University College of Medicine3Department of Medicine, Cardiovascular Division, Washington University School of Medicine4Department of Surgery, Cardiothoracic Division, Washington University School of Medicine, St. Louis5Rhode Island Hospital and Warren Alpert Medical School of Brown University

PURPOSE

Currently, there exists a debate as to whether the sinus node (SN) incorporates many spatially separated sinus node cells, which can all independently produce a heartbeat, or if the SN is actually an insulated composite body that possesses many exit sites to the atrium. Since there is a lack of de#nitive evi-dence both in animal and human models, our group investi-gated the mechanism of SN heartbeat generation.

METHODS

Optical mapping experimentation was performed on the Canine Right Atrium (n=5 hearts), which were mapped uti-lizing ANBDQBS voltage-sensitive infrared dye in hopes of recording action potentials from the transmural layers. In or-der to accurately track wave movement through the tissue, a three-dimensional isosurface map was produced to depict the precise activity. Furthermore, we overlaid histological images with the electrical data of SN atrial-paced activity to paint a vivid picture of the exact location of the activation site.

RESULTS

Our experimentation showed that there was a singular sinus group that was responsible for producing electrical signals throughout the cardiac tissue. When the tissue was treated with acetylcholine and isoproterenol, the overlaid images showed pacemaker signals emanating from the histological outline of the SN. !e electrical signals not only originated from the SN, but also possessed the largest slope as well as the earliest initiating cycle length, which are both indicative of a dominant pacemaker.

Atrial pacing was subsequently initiated to temporarily cause the SN to rest, during which time we noticed many di&erent groups with sinus activity emerge. Isoproterenol administra-tion (0.5μM) enabled competition between atrial ectopic foci and the dominant sinus group of cells.

CONCLUSION

We concluded that during the typical production of a heart-beat, there is an underlying #ght for dominance between groups of sinus cells within the area of tissue we refer to as the SN. Furthermore, these groupings of cells not only compete amongst themselves, but also with atrial electrical currents, to establish what we observe to be a functional heartbeat.

Second Place (Basic Science)


POSTER PRESENTATION WINNERS

Tension Band Plating for Anterior Tibial Stress Fractures in High- Performance AthletesRobert M. Zbeda1, Peter K. Sculco2, Lionel E. Lazaro2, Riley J. Williams2, David S. Wellman2, David L. Helfet2 1New York Medical College2Hospital for Special Surgery, New York

BACKGROUND

Anterior tibial stress fracture is a sports-related injury that can be exceedingly di"cult to manage and treat. !is is espe-cially true for professional and collegiate athletes who require rapid return to high-level competition in order to preserve their sports careers. Anterior tension band plating is a nov-el and biomechanically sound surgical approach for treating these fractures. !e senior author previously published a case report on this operative technique.† We now have a larger number of athletes treated using this surgical technique and are better able to assess outcomes. To our knowledge, our case series will be the largest described in the literature thus far.

PURPOSE

To describe a case series utilizing tension band plating in the treatment of anterior tibial stress fractures in high-perfor-mance athletes and to provide outcomes following this pro-cedure.

METHODS

Between 2002 and 2010, eight professional or collegiate ath-letes underwent tension band plating to treat anterior tibial stress fracture a%er unsuccessful non-operative management. !e anterolateral aspect of tibia was plated at the fracture site using either a 2.7mm or 3.5mm locking plate and bone gra%. O"ce charts, imaging studies, and operative reports were retrospectively reviewed to gather details regarding patient demographics, injury history, and surgical management. Postoperative radiographs were used to determine the date of union for each stress fracture. Follow-up visits were used to determine each patient’s follow-up time, return to training, and return to competition.

† Borens O, Sen MK, Huang RC, et al. Anterior tension band plating for anterior tibial stress fractures in high-performance female athletes: a report of 4 cases. J Orthop Trauma. 2006;20(6):425-430.

RESULTS

In our case series, there were seven females and one male. Four patients were track and #eld athletes, two patients were basketball players, and two patients played volleyball. Four patients were Division I collegiate athletes and four patients were professional/Olympic athletes. !e average age at time of surgery was 22.8 years (20 to 27 years). Patients were on average symptomatic for 57 weeks (26 to 106 weeks) before surgery. !e date of fracture union occurred on average 9.2 weeks (5 to 15 weeks) a%er surgery. Patients returned to train-ing on average 9.4 weeks (5 to 19 weeks) a%er surgery. Seven out of eight patients eventually returned to their pre-injury level of competition. !ere were no complications of infec-tion, nonunion, or malunion.

CONCLUSION

Tension band plating for anterior tibial stress fractures in high-level athletes allows for an earlier return to both train-ing and competition relative to non-operative management. !is approach should be strongly considered in athletes who have failed non-operative management. In addition, this ap-proach may be preferred in athletes who wish to avoid the longer healing time associated with nonoperative treatment or knee pain associated with intramedullary nailing.

First Place (Clinical Science)



Subgroups of Bladder Cancer Patients Prior to Radical Cystectomy: A Cluster AnalysisBradley Morganstern1, Michael Feuerstein2, Michael Goltzman2, Nicole Roberts2, Sara Blass2, Guido Dalbagni2, Yuelin Li2, Bernard Bochner2, Bruce Rapkin3

1North Shore-LIJ Health System2Memorial Sloan-Kettering Cancer Center3Monte#ore Medical Center

PURPOSE

With a dearth of prospective studies exploring health-re-lated quality of life (HRQOL) in bladder cancer (BCa), we began a comprehensive study examining patients pre- and post-radical cystectomy (RC). Here we present a novel ap-proach, a cluster analysis, to identify subgroups (clusters) of BCa patients derived from baseline European Organization for Research and Treatment of Cancer Quality of Life Ques-tionnaire-C30 (EORTC) scores. We hypothesized the clusters would have signi#cant di&erences when compared to other validated HRQOL measures and demographics.

METHODS

!is study includes 12 questionnaires completed within one month prior to RC. Using the EORTC scores, a hierarchical cluster analysis was carried out to identify clusters. Stopping rules were explored based on the recommended number of clusters; a%er considerations we opted for a 3-cluster solu-tion. Clusters were then compared for demographic, clinical, BCa-speci#c and psychological di&erences.

RESULTS

154 of 249 (62%) patients were evaluable based on a com-pleted EORTC. A cluster analysis of three distinct groups was completed. Group 1 patients reported signi#cantly worse scores in all function and symptom domains on the EORTC. !is group reported more urinary symptoms (p_0.001), wor-ry (p_0.001), gastrointestinal symptoms (p_0.001), and body image anxiety (p_0.001). In addition, it was noted to have the lowest Satisfaction with Life scores (p_0.001) and Mental Health Inventory scores (p_0.001). Group 3 reported better function and symptom scores then the other groups. It was associated with lower body mass index (p_0.001), fewer co-morbidities (p_0.010), male gender (p_0.009), fewer trans-urethral resections prior to cystectomy (p_0.007) and better scores on the EORTC QLQ-BLM30, a BCa-speci#c survey. Group 2 represented an intermediate cohort.

CONCLUSION

Cluster analysis provides a systematic method to identify clusters of BCa patients based on patient-reported HRQOL rather than clinical assumptions. !is statistical strategy helps identify di&erential risk groups of patients who may necessi-tate di&erent treatments or more targeted interventions.

Second Place (Clinical Science)


DEAN’S RESEARCH AWARD WINNER

Hydrogel delivery of co-embedded EPC-MSC for treatment of AKI and modulation of macrophage cytokine/chemokine releaseJoseph A. Zullo, Ellen Nadel, May Rabadi, Matthew Baskind, Maharshi Rajdev, Camer-on Demaree, Radovan Vasko, Savneek Chugh, Michael S. Goligorsky, Brian B. Ratli%Departments of Medicine, Pharmacology and Physiology, Renal Research Institute New York Medical College

PURPOSE

Reconstitute renal function and promote angiogenesis during sepsis-induced acute kidney injury (AKI) through targeted stem cell therapy.

METHODS

Endothelial progenitor stem cells (EPC) and mesenchymal stem cells (MSC) were co-embedded in hyaluronic-acid hy-drogels (HA-hydrogel) in vitro and in vivo at 20,000 cells/µL. HA-hydrogel delivery of stem cells to LPS-induced (intraper-itoneal 3.5 µg/kg lipopolysaccharide injection) AKI mice (age >16 weeks, inbred C57/B6 mice) was assessed for e&ects on mean arterial pressure (MAP), renal blood perfusion (RBP), serum creatinine, proteinuria, and angiogenesis using non-in-vasive oscillometric blood pressure monitors, Laser-Doppler $owmetry, and ELISA kits, respectively. A%er exposure to 5 µg/mL LPS or 100 µM H2O2, live/dead assays determined in vitro survival of embedded stem cells; luminex multiplex as-says examined the release of 27 cyto-/chemokines from both embedded stem cells and macrophages; FACS and Real-Time PCR examined e&ects of stem cells on macrophage polariza-tion in vitro and in vivo.

RESULTS

Co-embedding EPC-MSC in HA-hydrogels improves stem cell viability (K 72%) during LPS exposure. Delivery of co-em-bedded EPC-MSC to AKI mice demonstrates signi#cant im-provement in proteinuria (L 58%), serum creatinine (L 45%), MAP (K 50%), RBP (K 25%), and angiogenesis (K 30%). Ex-posing co-embedded EPC-MSC hydrogels to pro-in$am-matory M1 macrophages results in a signi#cant polarization shi% to anti-in$ammatory M2 macrophages in vitro (K 80%) and in vivo (K 14%). In addition, in vivo studies demonstrate a four-fold increase in circulating macrophages in AKI mice receiving co-embedded EPC-MSC hydrogels. Incubation of co-embedded EPC-MSC with macrophages signi#cantly en-hances the release of anti-in$ammatory cyto-/chemokines IL-4 and IL-10 from macrophages.

CONCLUSION

Treating sepsis-induced AKI mice with co-embedded EPC-MSC hydrogels signi#cantly improves renal and vascular dysfunction, and alters macrophage polarization to anti-in-$ammatory M2s. In vitro studies demonstrate improvement in cellular resistance to endotoxins when EPCs and MSCs are co-embedded in hydrogels. In addition, in vitro studies suggest paracrine mechanisms between stem cells and mac-rophages that increase anti-in$ammatory cyto-/chemokines from macrophages, opening additional avenues towards ther-apy and our understanding of the multifactorial mechanisms of sepsis-induced AKI.

(Basic Science)

AuscultationsAndrew Staron


Quill and Scope Sta#Anthony Casabianca (NYMC Class of 2017): Anthony grew up in New York and received a BS in Biology and Psychol-ogy from Stony Brook University. Later he received his MS from New York Medical College before joining the MD class of 2017. He enjoys music production and cooking. Anthony is also vice-president of student scribes.

Elliot Chan (New York Medical College, Class of 2017): Elliot graduated with a degree in integrative biology from the Uni-versity of California, Berkeley in 2011. A%er graduation, he worked as a research associate at the University of California, San Francisco Medical Center in Ophthalmology. He is an ac-tive member of the NYMC community, and spends his time between the Science and Technology Entry Program and the Wood#eld Detention Center. He is also currently co-presi-dent of both the Rock Climbing Club and Ultimate-Frisbee Team. During Elliot’s free time, he enjoys hiking New York State parks and exploring New York City for its culinary trea-sures.

Julia Cooperman (New York Medical College, Class of 2016): Julia is a co-Editor-in-Chief of Quill & Scope. She grew up in Ohio and completed her BA in History at the University of Michigan. She spent three years as an English as a Second Language teacher in New York City as part of the New York City Teaching Fellows, completing her MS in Education at CUNY, Lehman College. She then completed a post-bacca-laureate pre-med program at New York University and con-ducted public health research at Mount Sinai School of Med-icine before matriculating at New York Medical College. In her free time she enjoys eating her way through NYC.

Bailey Fitzgerald (New York Medical College, Class of 2016): Bailey is a co-Editor-in-Chief of Quill & Scope. She gradu-ated in 2012 from Syracuse University, where she received degrees in both biochemistry and English & textual studies. At NYMC, she is also co-President of the American Medical Student Association, with particular interests in health policy.

Natalie Frassica (New York Medical College, Class of 2017): Natalie is currently an MD candidate. She graduated from Boston University in 2013 with a bachelor’s degree in biol-ogy and a minor in public health. During her undergraduate career she assisted with clinical research in the Pediatric In-tensive Care Unit at Massachusetts General Hospital for Chil-dren. Additionally, she served as a peer tutor and a student DJ at the college’s radio station, WTBU.

Meghan Kiley (New York Medical College, Class of 2015)

Sherry Liou (New York Medical College, Class of 2017): Sherry is a co-managing editor of Quill & Scope. She was born and raised in Northern California and graduated from UC Berkeley in the fall of 2011 with a dual degree in Business Ad-ministration and Molecular and Cell Biology. Prior to matric-

ulating at NYMC, she worked as a project manager for Epic, an electronic medical record company based out of Madison, Wisconsin, where she developed an interest in anesthesia. In the future, she hopes to eventually transition into hospital administration. In her spare time, Sherry enjoys doing barre yoga, using her roommates as guinea pigs for new recipes, and holding onto her Yelp Elite status.

Ellen Liu (New York Medical College, Class of 2016)

Joanne Liu (New York Medical College, Class of 2016): Jo-anne is a co-Editor-in-Chief of Quill & Scope. She received her BS from MIT in 2011, and completed her MS in 2012 at Columbia University. While studying at Columbia, she con-ducted clinical research at the New York State Psychiatric In-stitute on the potential role of omega-3 polyunsaturated fatty acid status in neuropsychiatric disease. In her spare time, Jo-anne makes messes and sometimes she makes movies.

Margaret Nguyen (New York Medical College, Class of 2017): Margaret is a co-managing editor of Quill & Scope. She earned her BA in Neuroscience from Pomona College in 2010. A%er graduating, she worked as a research assistant in Developmental Neurobiology for two years, investigating sig-naling molecules involved in synapse formation. A%erward, she became the managing editor of diaTribe, a patient-focused newsletter that reports on diabetes and obesity research. At New York Medical College, Margaret is involved in various campus activities including volunteering at La Casita and the Wood#eld Detention Center. She also enjoys teaching high school students from low-income communities through the Science and Technology Entry Program.

Chandana Peddu (New York Medical College, PhD pro-gram): Chandana is the graduate student liaison for Quill & Scope. She grew up in India and holds a BS in Biotechnology from Amity University, Rajasthan. Following her undergrad-uate studies, she steered towards research, which landed her at NYMC. She is currently pursuing a PhD in biochemistry with a pivoted interest in enzymology and DNA polymerases. In her spare time, she enjoys traveling, spending time with her friends and family, and reading #ction.

Oded Tal (New York Medical College, Class of 2016): Oded grew up in Queens, NY, attended LaGuardia High School of Performing Arts as an art major, and then graduated from Stony Brook University with a BS in Biology and Chemistry. He continued research at the Department of Urology at Co-lumbia Medical Center during a gap year, along with tutor-ing inner-city children and traveling before continuing on to New York Medical College. In his spare time, Oded enjoys traveling, painting, and cooking. His work can be seen at www.bydueprivilege.blogspot.com.


QUILL & SCOPE STAFF

Sangeeta Ramani (New York Medical College, Class of 2017): Sangeeta graduated from Johns Hopkins University in 2013 with a B.A. in Public Health Studies. During her senior year at JHU, Sangeeta took graduate public health courses at the Bloomberg School of Public Health, with a focus in interna-tional and reproductive health. At NYMC, she is also Curric-ulum Coordinator for La Casita and the Community Health Representative for the Obstetrics/Gynecology Interest group.

Eric Routen (New York Medical College, Class of 2016): Eric is a co-Editor-in-Chief of Quill & Scope. He is a 2011 gradu-ate of the University of Notre Dame, equipped with a degree in psychology and a passion for social justice. Always one to marry passion and service, he has worked with people su&er-ing from mental illness and homelessness in Sacramento and individuals living with HIV/AIDS in Baltimore. Last summer, he completed research in Music !erapy with cancer patients undergoing radiation therapy in Manhattan. His interests in-clude the sound of the cello, non-#ction books, and fast-food sustainability. He looks forward to entering a residency pro-gram that allows him to combine music, homelessness issues, and a 9-5 workday.

David Shottland (New York Medical College, Class of 2016)

Parvati Singh (New York Medical College, Class of 2015)

Jane Song (New York Medical College, Class of 2015): Jane was born in Seoul, Korea but has lived all over the states during her childhood, including LA, Albuquerque, Austin, and Bos-ton. Jane studied biology and English at Emory University in Atlanta, GA, and took two years o& to work in pediatric neu-roscience research at the NIH before starting medical school. In her free time, she enjoys traveling, running, photography, brunching, and exploring new cities through food.


ContributorsIsrael Ackerman (New York Medical College, Class of 2017)

Henry Feng (New York Medical College, Class of 2017)

Anastasiya Holubyeva (New York Medical College, Class of 2017)

Sherry Liou (New York Medical College, Class of 2017)

Laura B. Madsen (New York Medical College, Class of 2016): Laura grew up in West Palm Beach, FL. She received her Bach-elor of Arts in History and Science from Harvard University and her Master of Science in Public Health from !e London School of Hygiene and Tropical Medicine in England. She has an interest in health care delivery to underserved popula-tions in the United States. Her undergraduate thesis was titled “Caring for the Uninsured: Faith-Based Free Health Clinics in South Florida, 1980-present.” At NYMC, she holds leader-ship roles in the Latino Medical Student Association and the Christian Medical Dental Association.

Daniel Mangels (New York Medical College, Class of 2017): Daniel received his undergraduate education from the Uni-versity of California at Berkeley and his Master’s Degree in Physiology from Georgetown University.

Colton Margus (New York Medical College, Class of 2017): Colton is an MD candidate. He previously worked with the Bill & Melinda Gates Foundation in Beijing and as an analyst at 5AM Ventures, a life science venture capital #rm. He has additional experience in clinical neurology and cell biology laboratory-based research, as well as Chinese education re-form advocacy. Originally from Florida, Colton earned his BA in International Relations at Stanford University, com-pleted pre-medical coursework at the University of Pennsyl-vania, and studied advanced Chinese language at National Taiwan University.

Christopher Monson (New York Medical College, Class of 2017)

Tejas Pulisetty (New York Medical College, Class of 2017): Tejas recently studied statistical science at Duke University. He has been involved in many activities in biomedical re-search, public health, journalism, and intramural athletics.

Michael Shen (New York Medical College, Class of 2017): Michael obtained his Bachelor of Arts degree from Cornell University, with a major in Biological Sciences cum laude, a concentration in Microbiology, and a minor in Music. He is involved with the AMSA PharmFree Committee and con-ducts research at the Renal Institute.

Vinod Ravikumar (New York Medical College, Class of 2017)

Parvati Singh (New York Medical College, Class of 2015): Parvati received her BA from Colgate University, where she majored in molecular biology and minored in political sci-ence. She also received a Master of Science from Columbia University. Additionally, Parvati has done research at the NIH, Columbia University, and Albert Einstein on topics dealing with esophageal cancer, cardiomyopathy, and Toxo-plasma gondii.

Nidhi Shah (New York Medical College, Class of 2017)

Andrew Staron (New York Medical College, Class of 2015): Andrew is a former leader of the Art Club at NYMC. He par-ticipates in a potpourri of artistic endeavors including pho-tography, painting, music, and dance.

NYMC Student Research Forum Abstract Contributors:Rachel Talley-BrunsHenry FengMichael RothbergDiana PunkoChristina WangVinod RavikumarRobert ZbedaMichael GoltzmanJoseph Zullo

Photography Collage Contributors (center spread):A, K, T. Johnathan Ly (NYMC, Class of 2015)B. Sherry Liou (NYMC, Class of 2017)C, M. Anastasiya Holubyeva (NYMC, Class of 2017)D. Bianca Patel (NYMC, Class of 2017)E. Rima Bishar (NYMC, Class of 2014)F. O. Lindsey Olsen (NYMC, SLP, Class of 2015)G. James Rini (NYMC, Class of 2015)H. Steven Palmer (NYMC, Class of 2016)I. Rita Anderman (IACUC Administrator at NYMC)J, R. Justin Nowell (NYMC, Class of 2017)L. Ashley DavisN. Melodye Brant (Program Coordinator at NYMC)P. Robert Fekete (Assistant Professor at NYMC)Q. Matt Cannistraci (MS at NYMC, Class of 2015)S. Shravan Cheruku (NYMC, Class of 2014)

O!ce of Student A"airsNew York Medical CollegeAdministration Building

40 Sunshine Cottage RoadValhalla, New York 10595

www.nymc.edu/clubs/quill_and_scope

Quill & Scope

Documents

Quill & Scope Fall 2014