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William Robert Jenkins, MD RES’85

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William Jenkins, 75, of Millinocket, ME, died February 27, 2015. He grew up in the Bangor, ME, area and, after attending the University of Maine, he served in the US Army for several years, including two years in Vietnam, where he earned two Bronze Stars; he retired from the Army Reserve as a lieutenant colonel. Having resolved to become a family physician while in Vietnam, he graduated from George Washington University School of Medicine in 1982 and, after his residency at Memorial Hospital of Rhode Island, opened a private practice in the Katahdin area of Maine.

Bill was board certified in geriatrics and served as medical director of the Millinocket Regional Hospital emergency room and of the Katahdin Nursing Home. For several years he traveled to Vietnam with Vets With A Mission to provide medical care. His many recognitions included Maine Family Doctor of the Year in 1999 and the Maine Primary Care Association Clinical Excellence Award in 2007.

A layreader and member of the vestry at St. Andrew’s Episcopal Church, he loved music, nonfiction books, photography, and the natural beauty of Maine. Survivors include his wife of 40 years, Leslie, and their two sons, Mark and David.

Donations in his memory may be made to Vets With A Mission, 1307 Caldwell St., 3rd Floor, Newberry, SC 29108; St. Andrew’s Episcopal Church, 40 Highland Ave., Millinocket, ME 04462; or Millinocket Regional Hospital, 200 Somerset St., Millinocket, ME 04462.


Healing Thoughts

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A new research fund will test the science behind ancient health traditions.

Anecdotal evidence abounds to suggest that mind-body exercises help sick people heal. Now scientists are trying to figure out why.

Some studies have found that contemplative practices like mindfulness or tai chi exert specific effects on body-related areas in the brain; others suggest they can enhance immune function.

“But what nobody has done,” says Catherine Kerr, PhD, an assistant professor (research) of medicine and family medicine, “is bring these two sets of findings together to look at whether body awareness and underlying brain mechanisms in contemplative practice are actively involved in changing the immune system and decreasing inflammation.”

With backing from the new Berkman Landis Family Fund, Kerr will explore how qigong, a traditional Chinese meditation and movement exercise, affects breast cancer survivors struggling with fatigue, depressed mood, and sleeplessness after chemotherapy. Her multidisciplinary team—which includes Brown’s Contemplative Studies Initiative, of which Kerr is director of translational neuroscience research—will measure neural and immune responses in breast cancer survivors enrolled in a qigong trial at the Women’s Medicine Collaborative in Providence.

One of the study’s broader goals is to test pre-scientific folk theories of self care described in traditional Chinese texts. “The ancient literature states that when you cultivate the ability to directly and clearly lead the mind to focus on different parts of the body during qigong and tai chi practice, you also cultivate improved immune function,” Kerr says.

Mara Berkman Landis ’89 says her own experience with alternative medicine, which finally gave her relief after a years-long illness, prompted her and her husband, Dean Landis, to establish the research fund. “If an Ivy League institution could work toward validating experiences people like me have had, that would be the best way to effect change in the medical world,” she says.

The seven-figure gift also will provide research opportunities for Alpert medical students and establish a “Day of Mindfulness and Self-Care,” a healing symposium at which students will meet patients who use mind-body therapies—people whom physicians otherwise might never encounter because, Kerr says, they are managing their own care. “There’s a bias [in medical practice]toward people having the most suffering, who are repetitively seeking help,” she says.

The symposium will show medical students how to incorporate self care into their own lives, Kerr adds. “Frankly, they’re in the red zone of stress,” she says. “By stepping back from stressful thoughts and emotions, taking a mindful pause—there are good data showing that this can be really helpful.”

The prospect of student participation thrills Landis. “I would love for medical students to understand the difference between surviving and healing,” she says.

Medical Maverick

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An emergency medicine doc traces the evolution of the specialty.

Who is the prototypical emergency medicine doctor? An adrenalin junkie who enjoys lots of stress and never knowing what will happen next, and who can work in a fast-paced, information-poor environment, according to emergency physicians interviewed in the documentary 24|7|365, which was written and produced by Mark Brady, MPH MD’09. Brady is himself an emergency physician, living in Memphis, TN, and practicing with Baptist Memorial Health Care and the Methodist Hospital systems.

Inspired by the book Anyone, Anything, Anytime: A History of Emergency Medicine—written by Brian Zink, MD, Frances Weeden Gibson–Edward A. Iannuccilli, MD, Professor and chair of the Department of Emergency Medicine at Alpert Medical School and Brady’s former professor—Brady wanted to capture the voices of the aging founders of the field before it was too late.

Each year more than 130 million people receive care in emergency departments, but that health safety net is relatively new. Emergency medicine became a board-certified specialty in 1979. “Today, we are basically a full generation removed,” Brady says. “The people who started it knew why they did it, where it came from, what it was like before, and why it was important to do. I wanted people to know why we do what we do.”

Brady does it, he says, out of a desire to care for underserved populations. “We are the only place anyone can go when they are sick, regardless of their ability to pay,” he says. “If you don’t have money, we still take care of you”—a service that was legislated in 1986 by the Emergency Medical Treatment and Active Labor Act. “I am personally proud of the fact that the average emergency provider delivers about $140,000 of unreimbursed care per year,” he says.

The film describes the founders of the field as mavericks. “That’s built into the DNA of an emergency physician. We fight for the patients that need care,” Brady says. “If a patient needs surgery, it is our job to convince the surgeons to take them to the OR. Sometimes you have to wake the CEO up in the middle of the night to free up hospital beds. We have to be advocates for the patients.”

After earning his Master of Public Health at Harvard, followed by an NIH fellowship in infectious diseases in South America, Brady did a medical writing internship at the Discovery Health Channel. “That’s how I learned about the media industry and really learned how to write accessible medical content,” he says. “When I heard about an idea from some emergency medicine residents to do interviews of the founders of our specialty, I convinced them that we could do something bigger—and I knew how to go about it.” After 24|7|365 Brady teamed up with director Dave Thomas and other emergency physicians to establish a small independent
film company that focuses on socially relevant medical documentaries.

Brady’s next ventures include international travel with the Navy Reserve and joining the faculty of Memphis’s first emergency medicine residency, at the University of Tennessee, in July. His next film, he says, “is about end-of-life care. We are horrible at it and we can do better.”

Visit 247365doc.com to watch 24/7/365: The Evolution of Emergency Medicine. See the trailer for Brady’s new documentary at neversaydiefilm.com.

Phone Consult

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Need a summary of a landmark journal article? There’s an app for that.

Manuel Lam ’04 MMS’09 MD’09 recalls the endless clinical trials his attending physicians referenced during rounds when he was a resident at Stanford. “AFFIRM, ACCORD—we would try to jot down all the acronyms to look up later, but there were just so many,” he says.

Now residents can pull out their phones and consult an app, Journal Club, when their attending mentions an unknown trial. Journal Club is the result of collaboration among Lam and colleagues David Iberri, MD, of Stanford and Timothy Plant, MD, of Johns Hopkins.

The app focuses on the top articles in medicine, summarizing the main points and outcomes. Written by physicians, these summaries are designed to be easily read and understood quickly. “Think of it as CliffsNotes for medical research,” Lam says.

Authors and editors are recruited directly though wikijournalclub.org, an independent, online journal club built upon MediaWiki, the open-source software engine that powers Wikipedia. The wiki software allows for collaborative editing of the website’s pages. From this site, important summaries are selected for inclusion in the read-only app.

Journal Club first hit the Apple App Store in April 2012. It boasted 100 articles just months after its debut; three years later that number has more than doubled.

Lam, who concentrated in computer science as a PLME, is one of the curators of Journal Club, selecting which summaries on the website should be included in the app. In his day job, he’s an internist at the Facebook Health Center in Menlo Park, CA, and hospitalist for the Palo Alto Medical Foundation at Stanford Hospital. Some of the residents there use Journal Club, he says: “It brings smiles to our faces when we hear residents and interns talking about Journal Club.”

Both the app and website have grown quickly—since the Android app debuted in March 2013, downloads and revenue have almost tripled, the iPhone app has grown 72 percent, and the website is nearing 1 million views. The app sells for $4.99.

“It’s definitely an upward trajectory,” Lam says. “Everyone assumes that doctors know everything about everything. That’s not true. But now, in one minute, you can whip out your phone, access the article, and absorb the major details.”

The Second Power

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Frustrated by the education system, an alumna founds a school for exceptional students.

Year after year, Kimberly Busi MD’97 watched in frustration as her son fell deeper down the rabbit hole. When he was 18 months old, she and her husband suspected that he might have some developmental challenges. By age 8, they knew he had Asperger syndrome and would be classified as a “twice-exceptional” student (gifted in one area but with special needs in another).

“While my son excelled academically, he was becoming increasingly anxious and sad about school,” Busi says. “His traditional school environment, despite its vigorous academic standards, had little understanding about how to provide the support he needed.”

In 2009, Busi took matters into her own hands. She left behind an academic appointment in psychiatry at New York University School of Medicine to organize a parents’ group and found and direct an after-school program and a 10-week summer camp for twice-gifted children. Her goal—to evolve the program into an alternative college preparatory school—was realized when the Quad Preparatory School opened its doors in September 2014 for students ages 10 to 14.

“My medical education at Brown emphasized thinking outside the box, and I leaned on that philosophy to reconstruct all the pieces that go into figuring out what school means,” Busi says.

She brought in other clinicians with twice-gifted educational experience to design individual, customized instruction. They came up with a plan in which half a student’s time is devoted to one-on-one training in four core academic areas, and the other half to collaborative projects in a group setting. “If you solely provide tutoring, your students will never learn the skills to work in a world where collaboration and social awareness are often required,” Busi says.

Located in a synagogue on the Lower East Side of Manhattan, the school is designed with flexible walls and a large, open, and well-lit area to facilitate movement and energy, as well as quieter space that’s available as needed. Cross-curricular inquiry projects and off-site trips build self-esteem and foster social interaction—areas generally neglected for special needs students in traditional school settings.

Busi and her supportive advisory board want to grow by eight to 10 students a year, find a permanent home, and expand to K-12. Staying solvent has become a complicated, never-ending challenge that ties into families receiving special needs financial assistance from the New York City Department of Education and state and federal agencies in accordance with the federal Individuals with Disabilities Education Act.

Despite the hard work that it will take to accommodate more students in what she calls “a vastly underserved population,” Busi takes comfort in knowing that her son, now age 14, looks forward to school every day. That he and so many of his classmates are meeting their potential has made her more fully appreciate one mantra she continually heard while she was at Brown: go out into the world and make it a better place.

Bio’s Big Day

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The life sciences at Brown go under the microscope.

From climate change to the microbiome, from aging to brain science, the mysteries, discoveries, and revolutions in life sciences research at Brown were on full display one Saturday in early March at the Day of Biology. The event, part of Brown’s year-long 250th anniversary celebration, drew alumni, students, and faculty together to showcase their work and share ideas at colloquia, TED-style talks, and a keynote by Nobel laureate Craig Mello, PhD ’82.

Day of Biology Photo Gallery

Walter J. Kenworthy Keynote Address by Dr. Craig Mello

TED(style) Talks: Lucy Spelman, Joshua Cohen, Justin Klee, and Jeffrey Morgan

 

Inbox

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Equal Exchange

As a reader from the South and a former Harlem science teacher, respectively, we took interest in the recent article on Brown’s relationship with Tougaloo College (“Closing the Gap,” Winter 2015). The perspective of our classmates who hail from this important linkage has been an invaluable component of our medical education, yet we are concerned that the exchange may not go both ways, as the piece points out. Specifically, we wonder why the elective clerkship that once sent Alpert Medical School students to Jackson Memorial Hospital to learn medicine and explore health disparities in Mississippi has fallen by the wayside. Considering the experiences of our classmates, Alpert Medical School students are eager to learn outside of Rhode Island. Many pursue research or engage in volunteer activities overseas; still more complete away electives at prestigious academic medical centers around the country. Why does nobody want to go to Jackson? Just in the past year, Alpert students launched the Ferguson Decoded Project, hosted a “die-in” to protest police brutality, and have taken to social media to post #BlackLivesMatter.

In the spirit of the Brown-Tougaloo Partnership, we would like to encourage our classmates to leverage this momentum by considering a rotation in Jackson. And Brown, known for supporting students, should step forward to re-open the elective. Where better to learn and advocate for patients than in a state that was at the epicenter of the civil rights movement and has long ranked as having the least equitable health care in the country?

Sean R. Love MD’17 and
Linnea Sanderson ’06 MD’17
Providence, RI

In the recent article “Closing the Gap,” by Phoebe Hall, the author states that a “significant number of Americans may not find a doctor who looks like them.” This statement is both ill con-ceived and offensive. Perhaps Ms. Hall can explain how being the same age, sex, or race as a patient improves my ability to care for them? As a white, male physician in his 50s, does this prevent me from practicing obstetrics, pediatrics, or in areas with mostly minority residents?

In the spirit of Martin Luther King, I would hope that I am judged not by the color of my skin but by the content of my character. It is dangerous to label individuals by age, race, sex, or sexual orientation. It is further dangerous to assign behaviors to an individual based on that individual’s membership in a certain demographic. To do so encourages intolerance of others and of our differences. Let people show you what they are about.

Nicholas G. Carras, MD ScM’87
Long Island, NY

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The Fighter

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A longtime local advocate for kids’ mental health care gets a national stage.

A large tarpon can measure up to 8 feet long and weigh well over 200 pounds. Called the silver king for the shimmering scales that plate its sides, it’s legendary among sportfishermen for its stamina and fighting spirit. Once hooked, those hundreds of pounds of muscle launch into the air, throwing the hook again and again. But the battle’s only begun when the hook finally sets; even a veteran angler can take hours to reel it in, with patience and strategy, applying the right amounts of pressure and slack until he wears down his formidable opponent and pulls it on board.

It may be that Gregory Fritz, MD ’67, a “fanatic fisherman” by his own description, is uniquely qualified to tackle some of health care’s most entrenched problems. The director of child psychiatry at Hasbro Children’s Hospital and at Alpert Medical School, he has been fighting for mental health parity—equal coverage for mental and physical health conditions—for much of his four-decade career.

His most recent catch took Fritz eight years to reel in. In March, a provision went into effect that requires federal funding for pediatric residency programs to include children’s psychiatric hospitals such as Bradley Hospital in East Providence, where he is academic director. Closing that loophole involved maneuvers that made Fritz “very unpopular” nationally, says Bradley’s medical director, Henry Sachs III MD’88 RES’92 F’93.

“He took the heat,” Sachs says. “I have no doubt this would not have happened without Greg’s persistence. …

“But that encapsulates Greg. When he believes in something, he advocates incredibly effectively for it,” Sachs adds. “If you don’t have patience, you’ll get frustrated and give up. Greg will see the long-term view of things and follow them out.”


A Gentleman and Scholar

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We say farewell to the Medical School’s founding dean.

On a frigid January day, the Brown community woke to nearly two feet of snow and the news that the founding dean of its Medical School, Stanley M. Aronson, MD, MPH, had died, at the age of 92. Aronson was born, educated, trained as a physician, and employed as a doctor and professor in New York City, but in 1969 he and his wife, Betty, decided to raise their children outside the city and he accepted a job as chief of pathology at Brown and The Miriam Hospital.

Aronson’s decision was contingent upon the University pursuing plans to establish a medical school. He worked tirelessly with then-Provost Merton Stoltz and others to achieve that goal, advocating for the idea within Brown and around the state to build support. The School launched in 1972 with modest means—43 faculty members, 16 students, and little research infrastructure—but during his years as dean, 1973 to 1981, Aronson guided it through its crucial first accreditation and blazed the trail of its growth.

“We had a group of graduate students at Brown,” Aronson recalled in an interview last year. “We asked them, ‘Your records are excellent, you could probably get into Harvard or Boston University immediately. Would you gamble on a school that does not even have a building, has a faculty so small in number that we could fit the entire faculty in one classroom? We don’t have permission from the federal government to go ahead. Are you willing to gamble?’”

Sixteen students did gamble, and Aronson credited them for their courage. During his tenure, he created one of the nation’s first departments of family medicine, in 1978. He also inaugurated the Early Identification Program, a special route of ad mission for college students from Rhode Island as well as from
Tougaloo College (see Brown Medicine, Winter 2015).

Aronson intended for Brown’s medical school to be different from others; unlike the mid-century model that espoused detachment and aloofness, Brown’s would emphasize modesty and compassion. In a recent interview he recalled telling state legislators, “I tried to explain that we’re going to train men and women to be individual physicians, to learn both responsibility and humility, and a long-term commitment in a profession that is intensely imperfect.”

After stepping down from the deanship, Aronson served as editor of Medicine & Health Rhode Island, he penned a weekly column for the Providence Journal, and remained active at the Medical School, meeting and advising students. He was an advocate for palliative medicine, having helped to found Home & Hospice Care of Rhode Island in the 1970s.

Aronson is survived by his wife, Gale; his daughter, Sarah ’83 MD’87; his stepdaughter, Susan Symons; five grandchildren; and six great-grandchildren.

The following are some of the remembrances shared by alumni, faculty, and friends.

A Dark Cloud

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The fight against TB carries on in Ukraine.
The twins ran up to me, dressed identically in blue plaid shirts and tan shorts, excited to see a new face. They took turns counting to 17 in English, skipping numbers and laughing, eager to show off their skills to a native speaker. I asked them how long they had been in the tuberculosis hospital and they weren’t sure, but agreed it was a long time, and they were going home on Friday!

Later that day the medical team told me the 5-year-old boys had been in the hospital for more than five months. One boy was admitted and subsequently diagnosed with active tuberculosis disease, prompting his brother to be admitted and evaluated for TB. He was determined to have latent TB infection, which means his body was exposed to TB but he was not sick from it. However, he remained in the hospital with his brother for the full five months, as it was the safest place for him; their family members at home were deemed infectious or unsuitable caregivers.

These boys were just a few of the children I met at a Ukrainian pediatric TB hospital. Other children had been there longer: one 16-year-old boy admitted 20 months earlier was finishing up a lengthy treatment for multidrug-resistant tuberculosis (MDR-TB), which he acquired from his uncle. On the playground—where the children go every day at 11 a.m. while the hospital is disinfected with ultraviolet light, tinging the halls an eerie blue—I chatted with two giggling little girls as they shared a small bench swing. One had been diagnosed with HIV and active TB after both of her parents died of those diseases; thankfully, she is doing well now.

Pediatric tuberculosis patients are a barometer for the success of a country’s TB program. Children under age 1 have about a 50-percent risk of becoming ill with active tuberculosis if exposed. They are infected with the strains around them, often from caregivers, and in Ukraine these strains may be multidrug resistant. The treatment for MDR-TB can last two years and cause severe side effects, including hearing loss. Young patients spend many critical months of normal development in a hospital, taking multiple crushed and measured pills and receiving painful injections. And this is the best of scenarios for those who have access to lifesaving anti-tuberculosis medicines.

TAKING THE HISTORY

Ukraine is geographically the largest country in Europe, and has 45 million people. It’s a country of passionate and resilient people living within a transition zone between Russia and Europe, living up to the name “Ukraina,” which is sometimes translated as “border country.” It became independent from the former Soviet Union in 1991, and since then it has struggled to maintain independence and succeed economically. Over the last two years, mismanaged government and widespread corruption fomented revolution and now war in the eastern regions with Russia. This situation, layered over a weak and crumbling health care system, has taken a significant toll on the health infrastructure of Ukraine.

Ukraine is one of the world’s highest-burden MDR-TB countries. Its antiquated Soviet health care system allows little cooperation between multiple specialized hospitals, making it impossible to navigate for many patients. TB management is very vulnerable in this setting, as it requires strict adherence to multiple drugs for a minimum of six months. When some of the drugs are not available or patients are not supported through the length of treatment, drug resistance starts to develop. MDR-TB can be very difficult and expensive to treat, sometimes costing 25 to 100 times as much as sensitive TB.

The Brown University Ukraine Collaboration, which includes Timothy Flanigan, MD, professor of medicine; Boris Skurkovich, MD, clinical professor of pediatric infectious disease; and Mariya Bachmaha MPH’16, aims to bridge research expertise in the US with colleagues in Ukraine, to improve that country’s HIV and TB clinical research capacity, in hopes it will translate to improved patient outcomes and contribute to the foundation of a new generation of researchers and caregivers.

I liken our collaboration to a snowball rolling down a hill, picking up speed and size. We have gathered a remarkable group of researchers and clinicians, such as Allyson Garcia MD’16, who was a Peace Corps volunteer in Ukraine and joined our collaboration as a first-year medical student. She is one of many Alpert medical students to have participated in projects in Ukraine through our collaboration.

There is a long road ahead, but I am certain that snowball will eventually knock out the burden of TB in Ukraine.

Stirring the Pot

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What do we really know about medical marijuana?

Ellen Smith P’05 thought her doctor was crazy.

Two years earlier, he’d finally put a name to the source of the pain that had plagued her for 54 years: Ehlers-Danlos syndrome, a connective tissue disorder that stretches her ligaments and tendons and leaves her prone to frequent subluxations.

They’d tried to alleviate the pain with pharmaceutical painkillers, with no luck—Smith can’t metabolize them. She underwent 22 surgeries. As the pain progressively worsened, she had to give up her career as a middle school history teacher, and quit swimming. She spent four years in a wheelchair. She barely slept.

In 2006, Rhode Island legalized medical marijuana. Smith’s physician thought it might help. She’d smoked pot in college, “and I hated the feeling,” she says. “But here’s a doctor saying, go try this because there is nothing else to give you for pain.”

So she tried it. “The next thing I knew, it was morning,” she says. “I slept the entire night.”

Weeding out the truth

Marijuana didn’t cure Smith, but it changed her life. Now 65, she rarely needs her wheelchair anymore. She sleeps most nights, and most days the only drug in her system is a low dose of cannabis, delivered in an olive oil infusion that she cooks herself, in her kitchen. Holding up the bottle, she says, “This is what keeps me alive.”

More than 1 million Americans are legal medical marijuana patients. The drug has been said to work for just about any condition you can think of, from cancer and HIV/AIDS to glaucoma to Alzheimer’s. The growing body of anecdotal evidence has persuaded more than three-quarters of the public, and nearly half of US states and the District of Columbia, that cannabis is a legitimate medical treatment and should be legal.

But physicians considering it for their patients have few peer-reviewed studies or clinical trials to guide their decisions. That’s because marijuana’s classification by the US Drug Enforcement Agency as a Schedule I substance—meaning it has “a high potential for abuse” and “no currently accepted medical treatment use”—discourages scientists, who must endure a lengthy federal approval process to conduct research, and then struggle to get funding, a legal supply of the drug, and, finally, patients for their studies.

In March, a bipartisan group of US senators introduced a bill that would reclassify marijuana as Schedule II, grouping it with cocaine and oxycodone, and lowering the barrier for research. It’s a move that both supporters and opponents say is long overdue.

“Whenever you choose a therapy, you choose it based on risks and benefits,” says Professor of Medicine Peter Friedmann, MD, MPH, who directs the Brown/Rhode Island Hospital Fellowship in Addiction Medicine. “The benefits [of marijuana]are unknown, and the risks are known. … There are people who believe it works for them, but we really don’t have the studies to show if that is an effective therapy.” By rescheduling cannabis, he says, “we would be able to do those kind of studies.”

James Crowley, MD, professor emeritus of medicine and a retired hematologist-oncologist, is more direct. “The Schedule I designation has been deadly,” he says. “In the future people may well say, ‘Do you know at one time this lifesaving drug was illegal?’”

What are they smoking?

Over the decades there has been lots of federally funded research on marijuana, but most of it has focused on negative effects, among them addiction, abnormal brain development, and mental illness, especially among people who began using in adolescence. That intrinsic bias bothers many scientists, perhaps even some at the National Institute on Drug Abuse; in a 2014 paper in the New England Journal of Medicine, NIDA authors noted that most studies focused on heavy, long-term users and that confounding factors, such as concurrent use of other drugs, “detract from our ability to establish causality.” The authors continued, “There is also a need to improve our understanding of how to harness the potential medical benefits of the marijuana plant without exposing people who are sick to its intrinsic risks.”

It’s only within the past 50 years that we’ve begun to understand marijuana’s physiology and why it affects humans and other animals the way it does. The two species used recreationally and medicinally—Cannabis sativa and C. indica—produce hundreds of chemical compounds, more than 80 of which are cannabinoids, which appear to play a role in the plant’s self-defense. In the early 1960s the Israeli chemist Raphael Mechoulam, PhD, sometimes called “the father of marijuana research,” identified the two most abundant cannabinoids: tetrahydrocannabinol (THC), which is responsible for marijuana’s psychotropic properties; and cannabidiol (CBD), its principle non-psychoactive compound.

It took another quarter-century for researchers to figure out that animals have our own, endogenous cannabinoids. Like neurotransmitters, endocannabinoids have receptors throughout the brain and nervous system. But, whereas the brain uses neurotransmitters to send messages to postsynaptic neurons—I’m cold, I’m hot, that hurts—and trigger a reaction—shiver, sweat, flinch—endocannabinoids are produced on demand, when those messages are received, and travel “upstream” to the presynaptic neuron, where their receptors are located. This serves to moderate the body’s initial reaction to a stimulus—dulling pain to tolerable levels, for example.

The elucidation of the endocannabinoid system “has been wonderful to watch from the perspective of a GP who’s been recommending [marijuana]to patients since the ’70s,” says Jeffrey Hergenrather MD’75, the president of the Society of Cannabis Clinicians. “It has this modulating role, this way of helping us to eat, sleep, relax, forget, and protect—all the things we need to do to stay healthy and centered.” He recalls reading the scant medical literature about marijuana while he was at Brown, and “marveling at the polarization and inconsistencies” in the findings. Early in his practice, Hergenrather says, he had patients who swore cannabis helped them with myriad ailments, from pain to seizures, and he gave his tacit blessing.

THC and CBD indeed can have beneficial effects when they bind to humans’ cannabinoid receptors, moderating pain as well as anxiety and nausea, and stimulating appetite. But that’s not all they do, of course. THC, in particular, overwhelms the endocannabinoid system, dampening too many processes in sometimes adverse ways. Judgment, reaction time, and coordination may be impaired; users may experience panic or paranoia.

Effects on the memory are a larger concern, especially among adolescents, as the endocannabinoid system appears to play an important role in brain development. “Repeated cannabis use with high THC appears to affect the formation of the prefrontal cortex, the stress response systems, and dopamine neural activity, probably through impairment of the connectivity of neurons,” says Jeffrey Hunt, MD, professor of psychiatry and human behavior. Furthermore, he adds, “the earlier you use, the more risk you have to become addicted.”

Right now doctors considering medical marijuana for their patients must balance concerns about these adverse effects with anecdotal evidence and their own observations. Most of the physicians interviewed for this article reported decidedly mixed results using cannabis for nausea. Crowley says marijuana helped some of his patients cope with the anxiety of living with cancer; Hergenrather says he’s seen it alleviate symptoms of Crohn’s disease and of Alzheimer’s, and that it may have shrunk a child’s glioma. Stories of epileptic kids whose seizures have slowed or ceased with cannabis treatment have become staples in the popular media, from National Geographic to Wired to CNN.

But few high-quality clinical trials of medical marijuana have been done in the US. Better established research programs exist elsewhere in the world, notably Israel and Europe, yet worldwide, the most conclusive evidence supports its use only for pain and complications related to multiple sclerosis. Studies on glaucoma, nausea, appetite stimulation, insomnia, and Tourette syndrome have been less clear; its effectiveness treating pediatric seizure disorders is unproved.

Thomas Trikalinos, MD, PhD, director of the Center for Evidence-Based Medicine in the Brown School of Public Health, says drug research is needed to “disentangle the signal from the noise.” The “gold standard” for addressing causal questions, such as whether medical marijuana works, is randomized trials, with enough people to achieve statistically significant results, he says. When those aren’t possible, observational studies may take their place—but those findings may be difficult to interpret. “Some may self-select to take medical marijuana; others may be more resistant,” he says. “Those who self-select may have a more severe disease and have tried everything, or may like to experiment.” So it’s hard to tease out whether different outcomes are due to the treatment, or the patients themselves.

“Let’s assume medical marijuana works to alleviate pain in people with chronic pain who have tried several treatments and not responded. So do you recommend everyone take it? Hardly,” Trikalinos says. Though some people swear cannabis works for them, at this point their results are subjective. “But if you are in pain,” he says, “a subjective outcome is the most important outcome.”

Learning curve

Ellen Smith insists that visitors go down to the basement ahead of her. “I’m slow,” she says, as she folds down the seat of her stair lift. “It’s embarrassing.”

As a registered caregiver for five other Rhode Island patients, Smith grows marijuana in the basement of her North Scituate home, where she and her husband, Stuart, have lived since 1992 and raised four sons. After riding down the stairs, Smith leads the way to the first of two warm, bright, aromatic rooms, where she clones, nurtures, and harvests 15 varieties of cannabis; another door leads to a greenhouse, where the plants grow taller than her. Back upstairs, she concentrates the dried flowers into tinctures, salves, lozenges, and oils, tailored to each patient’s needs, including her own.

Smith grows so many different plants, and offers it in so many different forms, because marijuana affects each person in different ways, she says. “You can’t tell someone with MS, ‘this is the strain that works for you.’ It just doesn’t work that way,” Smith says. “It’s not like going to a pharmacy and one size fits all.”

Fifteen strains of marijuana are but a fraction of the hundreds out there, created through selective breeding and hybridization of the two species, Cannabis sativa and C. indica. Each species has different effects, on nausea, suppressed appetite, pain, and other conditions, as do the plant’s two most abundant compounds, THC and CBD; furthermore some people don’t want to get high. Finding the strain that works for each patient is an art, though some in the field are trying to make it a science.

The Thomas C. Slater Compassion Center in Providence is one of Rhode Island’s three state-regulated dispensaries. A former US Postal Service processing center, only the letters “TCS” on one side of the beige, low-slung building distinguish it from its similarly drab neighbors on a busy industrial stretch north of downtown. After passing through security, where a guard checks identification and medical marijuana cards, patients walk by a display with the requisite Bob Marley, John Lennon, and pot leaf images into a cavernous space that’s more hip lounge than waiting room: exposed brick, sleek stainless steel counters, paper lanterns, and comfortable chairs.

The patients, for the most part, look like any you’d see standing in line at Walgreen’s; behind the counter, the patient advisers may fit certain stereotypes in their appearance—dreadlocks, tattoos—but they try to offer the same discretion and assistance that a customer of any commercial pharmacy would expect. “The patient advisers do a really good job of pointing people in the right direction,” says Melissa Bouchard, the Slater Center’s patient outreach coordinator. They keep files for each patient, and use the data they amass as well as any available studies to make their recommendations. It can be a slow and sometimes frustrating process, Bouchard admits. “It’s trial and error at first to find the strains that work,” she says.

The Slater Center offers about 50 different strains, and each is clearly marked, on acrylic display shelves in the waiting room, with the percentages of C. sativaC. indica, THC, and CBD. Steve Doyle, the director of cultivation, says cloning and consistent growing methods help ensure consistent products. Still, “it’s not a widget on a production line. It’s a living plant,” he says. An outside laboratory confirms each product’s contents.

As for determining dosage, caregivers tell patients to start “low and slow,” Bouchard says. “We want them to build a tolerance so they don’t have an adverse reaction.” Advisers help guide patients toward the most effective products, Bouchard says, but ultimately they “have to find what works for them.” Smith says, “You really have to be your own doctor on this. You really have to be your own pharmacist.”

It’s a statement that makes some health professionals cringe; but Daniel Harrop, MBA ’76 MD’79 RES’83 acknowledges parallels to his psychiatry practice in Providence. “The dosage range [of pharmaceuticals]is incredible as well,” he says. “There are people who need one-quarter mg of Xanax a day, there are people who need 8 mg a day, and both seem to work. … But we’re able to do that because it’s legal and people can pick it up at the pharmacy and know they’re getting the legal stuff.” Harrop says he’s “on the fence” about the therapeutic benefits of cannabis, but because of the compassion centers, “I’d be a little more at ease writing a medical marijuana prescription because now I would know the stuff is clean and there is some investigational research into its contents.”

Discomfort with marijuana’s quasi-legal status, concerns about side effects, and uncertainty about the contents of some products deter many patients and physicians. But putting it in pill form may not be the answer. The FDA has approved two drugs synthesized from THC, dronabinol (Marinol) and nabilone, to treat nausea and suppressed appetite; though they show some promise for chemotherapy and AIDS patients for whom other drugs have failed, they were “superseded almost right away by better agents,” says Crowley, who prescribed Marinol when it was first introduced, in the 1980s. A UK firm has developed an antiepileptic for children that is 98-percent pure CBD; clinical trials, which are ongoing, suggest just moderate improvement.

Some researchers suspect that the hundreds of compounds in cannabis work together in what is called the entourage effect. “The whole is greater than the sum of its parts,” Hergenrather says. “I think there’s such a variability in the genome of the cannabinoid receptors and the way they work, and what’s nice for one person won’t be nice for another. … It would be wonderful to get a closer look at these things, but the feds won’t let us.”

If the laws governing marijuana research ease up, the Slater Center is ready to collaborate. “We’re this little petri dish of patients coming here,” says Christopher Reilly, the center’s spokesman. “We have data on who comes here, what they use, what their symptoms are.” But they can offer only anecdotal evidence to guide their patients. “We need studies to show how this is all working, to corroborate the work we do,” Bouchard says.

Clear the air

The recreational use of marijuana is now legal in four states and decriminalized in many others, and more than half of the public supports legalization. That the popularization of pot as medicine may have eased the path for recreational weed does not sit well with some MDs. In an editorial in the Journal of the American Medical Association in June, the authors wrote, “if the states’ initiative to legalize medical marijuana is merely a veiled step toward allowing access to recreational marijuana, then the medical community should be left out of the process, and instead marijuana should be decriminalized.” Harrop, who has seen many more patients struggle with the effects of criminal marijuana convictions than with the effects of the drug, says, “It would be better to have recreational marijuana than to adulterate the medical system.”

Most people can drink alcohol responsibly, and most should be able to use marijuana responsibly, too, says John Femino ’71 MD’76, the medical director of Meadows Edge Recovery Center in North Kingstown, RI. But at least 10 percent of the population, when exposed to any drug, including alcohol, will have problems, he says. “I’m not a prohibitionist,” Femino says. “But people are missing the big point. I’ve practiced addiction medicine for almost 40 years. If we focus our energy on ‘is the drug safe?’, we can never get to the key question, which is, ‘safe for whom?’”

Research, Femino says, needs to focus not only on whether, how, and for what conditions medical marijuana works, but also on its safety for individual patients. He’s concerned about interactions with other drugs, such as opiates, and about patients with substance abuse histories. Several states authorize medical marijuana for post-traumatic stress disorder, even though no research yet supports its use, and since many patients with PTSD have addiction issues, he says, “it’s exactly the opposite treatment you want to do.” And Femino worries about the safety and variability of a natural product, even one grown organically, in controlled conditions. The development of morphine from opium was “a godsend,” he says. “The history of medicine is to get away from natural products because they’re so darn dangerous.”

Hergenrather, who has been approving medical marijuana for patients since its legalization in California, in 1996, says unscrupulous suppliers put patients at risk with tainted, mislabeled, and potentially harmful products. “There is a role for the government in helping to create a path for quality medicines that are organically produced, with certain known, measured amounts of [its active ingredients], so you have a product that is clean and you know what you’re getting,” he says. “We owe it to the public to have clean, measured medicine.”

Many physicians have patients who, as Harrop says, “swear by” medical cannabis; but, being scientists, they want to wait and see what the science says. While the cart may be before the horse, as the JAMA authors opined, the horse is very much out of the barn. “No one can stop the use of medical marijuana, so what we should do is try to understand exactly what we know at this point and do a systematic appraisal,” Trikalinos says. “We should not leave this to experimentation. … Advocacy can help move the conversation forward, but it also hurts it if it is thought of as a miracle drug that doesn’t need research or scrutiny.”

Step It Up

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Two alumni are elected to key University posts.
For the first time ever, the president of the Brown Alumni Association will be a Medical School alumnus. Galen Henderson MD’93 is president-elect of the BAA, an organization composed of and serving alumni of all Brown’s degree programs. After his two-year term, he’ll serve another two years as president.

Henderson is director of neurocritical care and the Neuroscience Intensive Care Unit at Brigham and Women’s Hospital. He is an assistant professor at Harvard Medical School. A past president of the Board of the Brown Medical Alumni Association, Henderson is active on the advisory councils for the Brown-Tougaloo Partnership and the Division of Biology and Medicine. He received the Brown Bear Award in 2014.

Jeffrey F. Hines ’83 MD’86

Jeffrey F. Hines ’83 MD’86

Jeffrey F. Hines ’83 MD’86 was elected a trustee of the Brown Corporation in May. He is a gynecologic oncologist with WellStar Health System in Atlanta. He began his career in the US Army Medical Corps, deploying as a battalion surgeon during operations Desert Shield and Desert Storm. For Brown, he has chaired the Alumni Interviewing Program, served on the southeast regional committee for Boldly Brown, and raised funds for undergraduate scholarships, the IPC Endowed Scholarship, and Alpert Medical School. He is a member of the Brown Medical Alumni Association Board and founding chair of its Advancing Diversity committee.

Top Doc

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An alumna and faculty member takes the helm at the Department of Health.

Nicole Alexander-Scott, MD F’09 MPH’11, assistant professor of pediatrics and medicine, was unanimously approved by the state Senate as the director of the Rhode Island Department of Health in May. Originally from New York, Alexander-Scott completed an infectious disease fellowship in medicine and pediatrics at Brown and then her MPH at the Brown School of Public Health. 

Do you remember a particular experience that inspired you to pursue a career in public health?

During the first year of my fellowship in Rhode Island, we were treating a beautiful 4-week-old baby who was subsequently found to be HIV positive and extremely ill. That bothered me because in New York, where I did my med/peds residency, the law was that every pregnant woman should be tested for HIV. If a baby was born and the mother had not been tested, you could automatically test the baby at the time of delivery and start antiretroviral treatment right away if necessary. Because we did not have that law in Rhode Island, that baby missed the opportunity and by 4 weeks of age she became very sick very quickly. I knew this could have been prevented. I worked with Brian Alverson, MD, associate professor of pediatrics, and Rhode Island state Sen. Charles Levesque and Rep. Eileen Naughton to pass legislation so that, today, 100 percent of moms and babies have been tested for HIV at birth in Rhode Island since 2009. This law has made a big difference in the health of our babies and our moms.

Do you think medical students understand and appreciate the importance of public health?

Medical school is one of the best times and opportunities for us to make sure that students understand public health. Becoming a physician is not just about the boards you are studying for or the prescriptions you have to write. Addressing the social and environmental determinants of health are really the keys to being able to make sure your patients are healthy. You can write the prescription but you have to know that patients can read it, and they have transportation to get to the pharmacy, a safe home where they can keep their meds, electricity so they can refrigerate and store their meds, a family support system, adequate education, and adequate food. All of those elements have to be considered for you to be an effective physician.

What kind of relationship would you like to develop between the Medical School, the School of Public Health, and the Rhode Island health department?

We would love to initiate public health research programs so that we could provide opportunities to partner with academic departments that are studying and dealing with the community needs that we want to meet and serve. It would be ideal to develop and conduct our program activities so that faculty and staff can get involved with projects over time and provide longitudinal educational opportunities for interested students. As part of my strategic priorities for the state, I have created a Rhode Island Department of Health Academic Center to strengthen the integration of scholarly activities with public health.

How will you know if you have been successful?

The med/peds in me and the public health mindset with these priorities have made it so I have appreciated that infectious disease is important, but I will have to go beyond that if I want to be an effective public health leader. I know the key will be forging relationships and being a collaborator. The only way we are going to address determinants of health and promote health equity is through partnerships with people who are just as committed.

Making sure our communities, particularly among our underserved and our vulnerable populations, are positively affected is going to be the best way to know if we have been successful.

Suniti Solomon, MD Hon.’06

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Suniti Solomon, 76, of Chennai, India, died July 28, 2015. Globally renowned as the pioneering force in India for treating people with HIV and slowing the rate of infection in that country, Solomon worked closely with Alpert Medical School faculty and students for more than two decades. For her achievements, Brown honored her with a Doctor of Medical Science degree in 2006.

The growth of a tiny clinic with an earthen floor and one examining table to a large in- and outpatient medical center, the YRG Care facility in Chennai, “is all Suniti,” says Susan Cu-Uvin, MD, director of the Brown Global Health Initiative and professor of obstetrics and gynecology and of medicine. Cu-Uvin recalls how Solomon was driven by her embarrassment about how the Indian government was treating HIV issues and patients when the epidemic was first discovered. Solomon also was active in education efforts and worked to break down the stigma of AIDS.

Through a grant from the NIH’s Fogarty International Center and other sources, many doctors from Solomon’s center were able to come to Brown for training. Alpert Medical School faculty and students regularly went to work at YRG Care. “It’s been great bilaterally,” says Charles C.J. Carpenter, MD, professor of medicine and former director of the Lifespan/Tufts/Brown Center for AIDS Research. “She has developed a program that is remarkable and has made a huge difference.”

Rami Kantor, MD, associate professor of medicine (infectious diseases), traveled to YRG Care many times and says Solomon “was a tremendously impressive lady, with unlimited energy, wisdom, and almost visible power.” Of her partnership with Brown, he says, “She greatly valued the clinical care teachings, the research, and the technology transfers that occurred through the years and resulted in numerous publications in the medical literature, new generations of YRG Care students and physicians, and most importantly, better care for HIV-infected patients.”

“She quite simply transformed me, changing the way I view medicine and scientific research,” says Kartik Venkatesh ’06 PhD’11 MD’13, an ob/gyn resident at Brigham and Women’s Hospital. “For many of us who were fortunate to have trained under her guidance, we frankly wouldn’t be who we are today: physicians and researchers always aiming for socially and culturally relevant care.”

Solomon’s work, including active collaboration with Brown, is continuing at YRG Care through the leadership of her son, Sunil, and other colleagues.

Tree of Knowledge

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Who knew?


At the 25th anniversary celebration of Brown’s Medical School, in 2000, attendees received an unusual party favor—a tree sapling. They were the offspring of a plane tree outside of Arnold Lab, the home of the Medical School administration at the time; that tree, in turn, was purportedly a descendant of the tree under which Hippocrates taught in Kos, Greece, some 2,400 years ago. One of those gifts—a sapling no longer, at 8 feet tall—now has taken root at Alpert Medical School. Last spring Pardon Kenney ’72 MM S’75 MD ’75 RE S’80, P’03 and his wife, Kendra P’03, donated one of their trees so that medical students may continue to learn in the shade of its storied boughs.


New website takes the guesswork out of finding a therapist

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Yuri Tomikawa ’12 found herself on the phone with psychologist after psychologist in Providence, asking questions about appointment times, insurance, and therapy strategies. She was not in Providence, however, but in New York City, where she was working as a business analyst. Tomikawa was searching for therapists not for herself, but for friends and acquaintances.

“Yuri was a one-woman concierge service,” says Debbie Lai ’13, a manager for Google’s strategy and policy teams. “Someone would call and say, ‘These are the things I’m looking for in a therapist,’ then Yuri would spend the entire day coming up with a comprehensive list of every therapist who fit their criteria, personally calling and interviewing each one of them, and setting up appointment times. It took a day per patient.”

At the same time, Nick Lemme MD’18 and Ben Johnston PhD, MD’18 were in the psych block of their first year at Alpert Medical School. “We were disappointed by the limits on access to care, and the standards for the quality of care,” Johnston says. “In addition, the ability to check in with your therapist or psychologist was not very good.”

“During those months, a lot of very public psychological emergencies were happening on different college campuses,” Lemme says. “That also gave us that extra push we needed to say that access to mental health care is a huge problem, and it’s one we needed to help solve.”

That lack of access is a national trend. According to the Bureau of Labor Statistics, 89.3 million Americans live in federally designated mental health professional shortage areas, compared to 55.3 million Americans living in similarly designated primary-care shortage areas.

Independently of each other, the two groups began trying to create better way to connect patients to therapists. Lemme, Johnston, and Ben Williams ’16 were working on creating an app. Tomikawa and Lai tried to solve the problem with a website. In March, the two groups found out about each others’ work and decided to collaborate, dubbing the project ZenCare, with Tomikawa and Lai as co-founders and Johnston, Lemme, Williams, and Eliza Lanzillo ’16 as student advisers.

Yuri Tomikawa ’12 is a co-founder of ZenCare.

Yuri Tomikawa ’12 is a co-founder of ZenCare.

ZenCare is Yelp meets online dating. The therapists listed all have been referred by people affiliated with Brown, including students, faculty, and alumni. Each therapist makes a short video in which they introduce themselves and talk about their interests and therapy methods. If the viewer is interested, they can schedule a time online for a phone consultation prior to booking an in-person appointment.

“How many other services do you book online right now?” Tomikawa says. “You order food online, you book hotels online, you schedule your masseuse online, and you register for your yoga class online.”

Tomikawa and Lai say that the phone consultation is key. “So often people go to see a therapist in person, only to realize within the first five minutes this isn’t a good match,” Tomikawa says. The phone consultation allows people to discover this without a copay, without trekking to an office, and without needing to sit through the rest of an hour-long appointment. The phone consultation also allows people to connect to many therapists over a short span of time.

And when someone is in crisis, the minutes matter. “By the time someone finds a therapist who fits, the crisis that they’re in is kind of over but not really dealt with,” Lemme says.

Right now, ZenCare only lists Providence-area therapists, but eventually the team hopes to expand to provide personalized recommendations in all sorts of communities. For instance, there could be a ZenCare network specifically for Google employees, or for other college campuses.

“We want to make finding a great therapist simple,” Tomikawa says. “So many people, when faced with calling several therapists, waiting to hear back from them, and then scheduling several appointments, just give up. If you can see that a therapist can talk to you for 10 minutes tonight or tomorrow night, that confidence goes a long way.”

Hippie to Hippocrates

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Putting on the white coat shouldn’t change the person who wears it.

On October 17, 2015, Clinical Associate Professor of Medicine Jon Elion delivered the Charles O. Cooke, MD, Distinguished Visiting Lecture to the MD Class of 2019 at the annual Ceremony of Commitment to Medicine, where students receive their first white coats. This essay is the text of his speech.

When I was a medical student, I hated any story that started, “When I was a medical student …”

When I was a medical student, I had long hair, a beard, and a collection of tie-dyed scrub shirts. Looking around, I can see that many of you here today know all about this fashion trend popularized by the Grateful Dead, and maybe even owned something similar yourself. For the rest of you, perhaps you have read about this in the history books. My scrub shirts look suspiciously like those that were stocked by the hospital. But I digress. Each day I would put on my tie-dyed scrub shirt, hop on my bicycle, and race to the hospital for my clinical rotations. My hair would stream out behind me, barely kept in check by a leather headband. When I arrived at the hospital, I would change into a dress shirt, tie my hair back in a ponytail (tucked into my shirt), and would put on … my white coat. Donning the mantle. My superhero costume. My own little White Coat Ceremony. For when I was wearing that white coat, I was part of a longstanding tradition, going back hundreds if not thousands of years. I could feel the transformation from hippie to Hippocrates as I slipped on that coat. It gave me a code I could live by.

When I was a medical student, I met a pretty red-haired nurse working in the intensive care unit. Little did I know that ICU nurses had no use for smart-aleck medical students. She hated me right off the bat, even if I did have a white coat. She reported me to the head nurse, and said she never wanted to see me again. We were engaged three months later and married eight months after that. That was more than 41 years ago. Kathy’s here today, sitting in the front row. She still thinks I’m a smart aleck.

When I was a medical student, I worked at WBRU, which at the time was the No. 1 radio station in the Providence market. “You’re listening to 95.5 … just a little left of center on your radio dial … .” Some of you may remember when radios had dials. At the end of the day at the hospital, my personal White Coat Ceremony would reverse. The white coat was carefully stowed away in the saddle bag, the dress shirt was exchanged for the tie-dyed scrub shirt, and I let my hair down, both literally and figuratively. Then I hopped on the bike and raced to the WBRU studio, where I had an evening shift playing “progressive rock” or “album rock.”

Over the years, this mini-ceremony was repeated often, and gained many different variations. Working in the computer research lab, then tucking in my shirt, putting on my shoes and a tie, donning the superhero costume, and going to make rounds on the intensive care unit. From algorithms to cardiac rhythms. Saving lives—it’s a tough job, but hey—somebody has to do it!

For the longest time, I considered my white coat as transformative, covering up and disguising the hippie and turning me into something decidedly more medical. Until one day … I was on the intensive care unit caring for an elderly woman who was at the end of her life. Her organ systems were shutting down one at a time. It was like standing outside of a house at night, watching the lights being turned off one at a time. I was at her bedside with her daughter, Judy. Judy with tears streaming down her face, and me in my white coat. I was terribly saddened by the unfolding events. It would be death with dignity, but it was death nonetheless. Old wounds that I harbored were being torn open, and I knew I was going to start crying, too.

But people in white coats don’t cry. So I turned to walk out of the room so Judy wouldn’t see me crying. To this day, I don’t know why, but I stopped in the doorway instead, turned, and went back to the bedside. I decided it was OK to cry. OK to be seen crying. Perhaps people in white coats should cry.

A few weeks after her mother died, Judy sent me a note that I have kept to this day:

Dear Dr. Elion,

It has taken me this long to write to you because I have been searching for the words to express my profound gratitude for your kindness as my mother was dying. Your intuition is remarkable; you knew what I needed to hear even before I asked the questions. I don’t think anyone could have guided me as gently, as thoughtfully, or as wisely as you did through the waiting, the decisions, and the end of my mother’s life.

I hope you are involved in teaching new, young doctors. They will be privileged to learn more than cardiology from you.

Please accept my thanks from the depths of my heart. I will never forget your kindness.

I am convinced that this unfolded as it did because I did not let the white coat transform who I am, but rather let it augment and enhance who I am. That long-haired hippie in the tie-dyed scrub shirt. The computer geek. The guy with a weird sense of humor, and with his own set of experiences, wounds, and pains.

I think that most of you have guessed by now where this is going. Parents and friends—you should be incredibly proud of the accomplishments to date of these students here today. And students—you should be incredibly proud to be sitting here today, awaiting the opportunity to don your white coat. To take another big step toward joining a centuries-old tradition and profession. But be sure that the white coat adds to who you are, enhances who you are, and does not in any way cover who you are. As the saying goes, “Be yourself; everyone else is already taken.”

Jon Elion adapted ’60s anthem “Teach Your Children” for the first-year students. Watch the video here

The Digital Revolution

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Tech is changing health care as we know it. But can it make it better?

Late one night in the not-so-distant future, a man stumbles into an emergency department with slowed breathing and slurred speech. A triage nurse scans his face with an iPhone camera and records an erratic pulse and low blood pressure. At bedside, a resident dons a Google Glass headset and examines the patient while sending real-time video to a remote toxicology consultant, who confirms an opioid overdose and recommends treatment. After he’s discharged, the patient responds to a few automated text messages checking on his recovery. He also agrees to participate in a treatment monitoring program, taking pills with ingestible biosensors that track medication adherence and wearing a slim wristband that can detect relapse, which his physician oversees from her office.

We may be a long way from the futuristic sickbay of the USS Enterprise, but all of these technologies exist, and they aim to streamline physician workflow, enhance patient engagement, cut wait times and health care costs, increase patient satisfaction, and, the true endgame, help them live longer, healthier lives. This intersection of tech and medicine, known collectively as digital health, is a small but growing field that’s already attracting deep-pocketed venture capitalists along with medical researchers, clinicians, and patients.

“Digital health is reinventing the whole enterprise” of health care, says Megan Ranney, MD RES’08 F’10 MPH’10, assistant professor of emergency medicine and founder of Brown’s Emergency Digital Health Innovation program. “It has the potential to transform the way we provide care and help our patients stay healthy.”

“When you look at the future of what a hospital looks like, it’s going to be fundamentally different from what it is right now,” says Edward Boyer, MD, PhD, a professor of emergency medicine at the University of Massachusetts Medical School and a frequent collaborator with Ranney and others at Brown. “What this line of research does is it blows the walls off the hospital.”

No one denies that health care in the United States is in dire need of tech’s two favorite buzzwords: disruption and innovation. “The way the health care system currently works is broken,” Ranney says. But researchers at Brown are cautious about VC and Silicon Valley’s attention. “You don’t want your grandmother taken care of by something disruptive that’s not been appropriately tested,” Leo Kobayashi ’94 MD’98, associate professor of emergency medicine, says. “You could hurt her.”

That’s why, Ranney says, it’s critical that clinicians as well as patients get in on the ground floor. “This is coming, whether we want to create it within medicine or it’s created from the outside,” Ranney says. “We”—physicians—“have a chance to keep it trustworthy and safe. Business isn’t going to do that. And frankly, government isn’t either.” Successful digital health tools must be tested in the real world, and security, ethical, and privacy issues must be considered. Effective development also depends on inclusiveness—of believers and nonbelievers, even of the technologically impaired. “I’m not a techie. I don’t know how to program,” Ranney says. “But you don’t have to, to work on this and enjoy it.”

I’m sad all the time :(

Nine out of 10 American teens own or have access to a cell phone; texting is far and away their favorite form of communication. Yet it surprises skeptics that automated text messaging programs can be effective health care interventions. How could a computer be as helpful as a real person?

“Teens don’t necessarily want to talk to a counselor,” says Cassandra Duarte MD’18, who is working with Ranney to study iDove, a text-based program for teenagers at risk for depression. “They would rather interact with their phone.”

And it’s not just kids. More than 90 percent of American adults have cell phones, and more than 80 percent of them text. “It’s the most ubiquitous, most stable method of communication,” Beth Bock, PhD, professor of psychiatry and human behavior and of behavioral and social sciences (research), says. Automated text messages—to remind patients to take their medication, check in after a hospitalization, or manage chronic diseases—have repeatedly proved effective and are a regular aspect of care in a few US health systems.

Bock started her career running smoking cessation support groups, and she quickly saw the utility of texting in her work. “It’s fascinating to take a face-to-face intervention and deliver it in little doses with a device they use anyway. We’re worming into people’s lives,” she says. Furthermore, text interventions are cheap, can be delivered any time of day or night, and can help many more patients. “Scaling up a text messaging program is not hard,” she says. “We could reach thousands of people.”

Even though users know messages are automated, Bock stresses they won’t work if they’re too robotic. Her smoking cessation program includes a month of messages to prepare a participant for his or her quit date (which users set themselves) and eight weeks of supportive and educational texts after, but it adapts to individual situations. People who don’t sign up until after they quit, for example, receive different messages. “And if they didn’t quit [on their selected date]and need to start over, the messaging is different,” Bock says. “We don’t want it to seem completely mindless.”

When trying to reach teens, it’s even more important to sound authentic, she says. For a pilot aimed at heavy-drinking college students, Bock and Rochelle Rosen AM’91 PhD’02, assistant professor of behavioral and social sciences, assembled student focus groups to help write the texts, which encourage safe drinking
behavior. “My concern was that text messages written by overeducated PhDs wouldn’t sound appropriate to the age group we were working with,” Bock says.

She was right. Though some of the automated messages, which are sent on Thursdays, Fridays, and Saturdays, are educational (“Never leave your drinks unattended,” “You don’t need to be wasted to have a good time”), others that students helped her develop have an authentic irreverence (“If the room is spinning, the alcohol is winning”). Bock says students advised them, “Don’t tell me how to drink, say you care about how I drink.”

Teens interviewed during the development of iDove, which targets 13- to 17-year-olds with depressive symptoms, echoed this. “[I]t would just be nice, you know, just to get a message, just sayin’ there’s people out there,” one boy told researchers. Faith Birnbaum ’10 MD’16, who also worked on the project, says, “Teens feel like someone’s there, even though they know it’s an automated program.”

ON CALL: Automated texts from iDove may help troubled teens cope.

ON CALL: Automated texts from iDove may help troubled teens cope.

Participants in the iDove feasibility trial, which is ongoing, are recruited in the Hasbro Children’s Hospital emergency department. The intervention group learns some coping skills and takes home a packet with more information; then each day they receive the message, “Hi, this is iDove. How are you feeling today? (1= really bad, 5=great).” Based on the number texted back, the teen gets an automated response. For example, a 1 or 2 will prompt a reply that draws on their skills training, such as, “Remember, when something makes you feel bad, try to think of diff ways to approach the situation.” Users also can write back a word like “sad” or “stressed,” which triggers further automated responses.

iDove enrollees are cautioned that no one is monitoring the texts in real time, Ranney says. Unexpected words or numbers prompt a message advising the user to call a crisis hotline or 911 for immediate help. “We also check the text messages daily for signs of worsening mood or other potentially dangerous messages,” she says. “I have only had to call participants one or two times over more than 130 patients’ enrollment.”

Texting lowers the bar of entry to mental health care, which can carry a negative stigma and be costly or difficult to access besides. Crisis Text Line, founded in 2013 by Nancy Lublin ’93, is a free, nationwide service that connects texters to live counselors. According to anonymized data compiled from the more than 12 million messages exchanged so far, many texters reach out from school—a bathroom stall, or even the cafeteria, where they’re surrounded by people. Bob Filbin, CTL’s chief data scientist, says a text feels more private and anonymous than a phone call. One teen told him, “I like the idea of texting because I wouldn’t want the person on the other end of the phone to hear me crying.”

When people contact CTL, they get an automated reply asking what’s going on. “It’s amazing how quickly they respond with really intense messages,” Filbin says, like “I think I might b pregnant” or “I’m worried I might cut again.” They’re connected with volunteer crisis counselors, who exchange dozens of messages that employ “active listening” and collaborative problem solving, and if necessary refer texters to services. “It turns out most people in crisis just need somebody to talk to,” Filbin says.

Sense and sensibility

Even the most gung-ho digital health advocates stress that texting and other tools are intended to enhance, not replace, the face-to-face clinical relationship. Text messages open the door to services a patient doesn’t have the means to get and a physician doesn’t have time to provide, or allow a doctor to reach more patients, or let a patient play a more active role in his or her own care. As practices become ever busier, texting may actually help clinicians and patients stay more connected. After all, Duarte says, “How big a difference can a 10- to 12-minute encounter with a physician really make?”

Especially in chronic disease management, it can seem like a doctor’s work is never done. Medication adherence is a frequent challenge, but self-reporting is notoriously unreliable, and a text reminder to take a pill doesn’t guarantee the patient will follow through. Even techie tools like “smart” pill bottles that record when the cap is opened offer only indirect evidence. The most reliable technique, direct observation, is expensive and impractical in most cases. It’s a ripe opportunity, says Peter Chai ’06 MMS’07 MD’10 RES’14, for a digital health solution.

Chai, a toxicology fellow at UMass Medical, is working with Ed Boyer, his mentor and the director of toxicology, to study ingestible biosensors—tiny tags attached to gelatin capsules that, when dissolved in the stomach, send a radio signal that’s picked up by a device worn by the patient. “The cool part is,” Chai says, “not only do we know in real time if they took the medication, but we can respond in real time.” The wearable device sends a signal to a HIPAA-compliant, cloud-based server, which the clinician can access and, if needed, send a text reminder or reinforcing message.

Chai and Boyer first tested the technology to monitor HIV medication adherence, but as toxicologists they see applications beyond disease management. “We’re giving this to patients with extremity fractures who are prescribed opioids—some of the most dangerous medications we have in medicine,” Chai says. “But our instructions are to take as needed, so we are putting the onus of a very dangerous medication on our patient.” Ingestible biosensors could tell physicians how patients interpret “as needed”: if they’re taking fewer pills than expected, doctors can prescribe less; “if they’re taking more, we should be careful not to get people hooked,” he says.

Boyer has been working with biosensors for nearly a decade, when he began developing wearables with the MIT Media Lab. As a drug abuse researcher, he wants to find ways to “be there” for his patients at all times. “You would not necessarily want to rely upon a face-to-face clinical relationship if you have a condition or a medical problem that can raise its head at any time,” such as drug cravings or relapse, he says. After years
of tinkering his wearable biosensors have evolved into unobtrusive wristbands, which Stephanie Carreiro, MD RES’13, a toxicologist and assistant professor at UMass, is using to identify relapse in cocaine- and opioid-addicted patients.

The wristband measures skin temperature and conductance, motion, and heart rate with small electrodes, Carreiro says, and streams the data wirelessly to a clinician. A drop in skin temperature, increase in skin conductance, and “hyperkinetic” activity suggest cocaine use, she says: “that constellation of findings is pretty dramatic.” Studies with cocaine users have been fairly successful so far, she says, and she’s completed a small pilot with opioid users, who exhibit nearly opposite symptoms.

“The appeal of using something more advanced is we can monitor [patients] continuously in real time,” Carreiro says. “There’s no way a urine or blood test can do that.” Furthermore, in these days of activity trackers and smart watches, wearing a wristband to monitor health trends is familiar. Patients can even download an app to see their data. “Patients have been incredibly engaged,” Carreiro says. “It takes away
some of the foreignness and the hesitancy some patients have to normal medical interventions and brings it back to their level.”

She adds that patients are free to remove the bracelet at any time, “but a lot of our participants, especially the ones who are motivated, have left it on even when they relapse.” Ultimately Carreiro hopes to collect enough data to predict relapse, so the clinician can contact the patient via text message or through a sponsor to head it off.

The wristband may help clinicians not only as monitors but as users themselves. For example, because some studies have found a correlation between stress and empathetic decision making, “you can trick out residents to see who is feeling stressed in a medical encounter, to teach empathetic skills,” Boyer says. “The application of these things is very broad.”

New ways of seeing

Chai, who began working in biotech development as a grad student at Brown, was dismayed to realize how much medicine lagged behind everyday tech trends. “Someone was critically ill, we needed to urgently communicate, but we were using pagers—technology from the ’80s—sitting by the phone, waiting for a call back. It caused delays in care,” he says.

When Google introduced Glass, a hands-free, head-mounted display, in 2012, Chai saw immediate applications in the Rhode Island Hospital emergency department. His 2014 study, with Ranney and several other MDs at Alpert Medical School, was the first in the nation to use the device in the ED, to conduct remote dermatology consultations by securely streaming live video and images to a specialist, who would diagnose the condition and recommend treatment. “It takes six months to see a dermatologist, but if a patient was in the emergency room with a skin complaint, we could get an immediate consult,” Chai says.

At UMass, Chai, with Boyer, demonstrated that Google Glass also could work for live toxicology consults. He says they use it a few times a month, for difficult cases. Consultants typically log in at the office or from home, but “we can send a live video feed anywhere. They could be in Asia or Europe,” Chai says. He adds that though patients reported they’d rather see a physician in person, they preferred Glass to the typical phone consult.

Back in Providence, the dermatology study changed hospital culture, according to Susan Duffy, MPH ’81 MD’88, the medical director of the Hasbro Children’s Hospital ED. “Now [with patients’ permission]we all take pictures on our iPhones,” she says, and save them directly to their electronic medical records; the photos help to track physical changes, like the progress of a rash. EMRs can store video, too. “We tell families to take videos of abnormal movement or seizures at home and bring it with them,” Duffy says.

Smartphones are becoming as indispensable inside the hospital as they are outside. Many physicians already use them to quickly search for information about drugs, diseases, and the latest research. But they can do much more. Geoffrey Capraro, MD, MPH, assistant professor of emergency medicine, is trying out inexpensive apps and attachable devices to take vital signs and examine children’s ears. “It’s an example of iPhone-based technology that will change what we do, change patient expectations of what we do, maybe increase patient understanding of what’s going on, and allow better teaching,” he says.

Capraro, who studies pediatric sepsis, is collaborating with Leo Kobayashi to assess apps that detect vital signs remotely. “Vital signs are the bane of my existence because they are so challenging to capture in kids,” Capraro says. Children squirm, they cry, they’re afraid of cords. With the FLIR One, an infrared camera attachment, and an app that encodes each pixel with a temperature, a clinician may be able to simply scan a patient’s face to measure body surface temperature; with another app, he can see each heartbeat by using the phone’s own camera to detect subtle changes in facial coloration. “Eventually we imagine a patient in triage and with a camera system we look at the patient and get real-time vital signs,” Kobayashi says. “We may find out they need to be in critical care now.”

The accessibility of these tools means patients—or their parents—could be more directly involved in care. “A parent could assess vital signs with her child in the comfort of her arms,” Capraro says. In the hectic pediatric ED, where Capraro says vital signs aren’t taken as frequently as they should be, “it allows for more frequent monitoring.”

Capraro also is trying out Cellscope, an iPhone camera attachment and app, for otoscopies. “In pediatrics looking at ears is a basic bread-and-butter thing,” he says. But the standard otoscope is challenging for trainees. “We can’t agree on what we see or we’re not looking at the same thing,” he says. The Cellscope takes videos that can be shared with other clinicians as well as patients. “People are coming together through technology,” Capraro says. “A parent sees a video of an infected ear and says, ‘Now I know why she didn’t sleep.’”

I SEE YOU: The author’s fundus is a large, clear image on the screen of a digital retinal camera.

I SEE YOU: The author’s fundus is a large, clear image on the screen of a digital retinal camera.

Elizabeth Prabhu, MD F’17, a pediatric emergency medicine fellow, has discovered that same utility with a digital retinal camera that she’s been testing. “Clinicians have varying funduscopic exam skills,” she says. Like the traditional otoscope, the ophthalmoscope found in every exam room can be tricky to use: the image is tiny, and sometimes clinicians don’t see the same things. The Horus Scope, which Prabhu got for her feasibility study in the Hasbro ED, records images that can be viewed on a screen, similar to that of a compact digital camera, and shared and saved in a medical record. “Families like to see the photos and it’s quick for attendings to use,” she says.

Duffy, who is overseeing Prabhu’s study, says her department quickly incorporated the new device into daily practice. “[Physicians] will identify a patient to take a picture for teaching purposes, or put it in the medical record, or get an image for another use,” Duffy says. “Twenty years ago, when I trained, there was very little tech. You had to rely on your clinical exam skills, your knowledge base, and your intuition.” Prabhu laughs, and Duffy continues: “We all have to be open to new techniques. … [But] it’s a tool that, as you become facile with the technology, it supplements your exam skills, it doesn’t replace them.”

Put it to the test

At up to $15,000 a pop, the Horus Scope won’t be in every exam room anytime soon. Money is only one of many factors that researchers consider when studying digital health tools. “We need to know when we are introducing new technology, is it valid? Is it feasible? What’s it cost? What’s the cost benefit? And does it lead to overtreatment?” Duffy says.

Roger Wu, MD, MBA RES’16, chief resident in emergency medicine, was a co-investigator on the Google Glass study at Rhode Island Hospital. “There’s often a lot of media hype around these new technologies … but you really need to let the dust settle and give it time to see what the real value is,” Wu says. His department stopped using Glass after the study ended, he says. “In order to successfully launch new technologies in health care, you need to keep in mind organizational culture and workflow.” Health care administrators should invest in new tech, he says, “but it’s a kind of cautious optimism. It’s important to invest with the understanding that there will be many challenges and obstacles.”

Capraro agrees. “We need to test if the performance matches the excitement factor,” he says. “We need skeptics. Does [the infrared camera]translate to clinical medicine? … It’s good we’re in a critical academic place to put this technology to task to find their limitations. There’s a lot to be learned. A lot of things fall apart as they get translated.”

Nearly everyone interviewed for this article had a story about flawed research and unethical claims: a device to help the elderly when they fall that was tested on college students; an app that supposedly could diagnose melanoma from a photo of a mole, but wasn’t tested clinically; another that scanned Twitter for signs of distress and, without users’ permission, emailed their contacts.

“Developers will develop an app for one illness only, or a fixed number of symptoms because it’s based on a book they read, instead of talking to patients,” Cyrena Gawuga ’03 AM’15 PhD’16 says. “They don’t have a concept of the user experience. They develop things the way they think things might go.”

A doctoral student in the molecular pharmacology, physiology, and biotechnology department, Gawuga came to Brown as a PLME but left the Medical School in her second year after struggling with chronic illness. She’s an avid digital health consumer, willing to try apps still in development to track her symptoms and moods, and an active participant in Twitter chats related to medical issues. “Physicians are not developers by and large, and patients are not developers by and large,” she says. “So by having groups of people work together on a project with different knowledge sets, we’ll get better apps and better tech.”

Rochelle Rosen has worked on several digital health studies to understand why and how participants use devices, texting programs, and other tools. “IT people aren’t necessarily users of tech developed for diabetes and heart disease,” she says. “Those patients are older; they’re not technology natives. The apps, the devices, the data must be relevant to their lives.”

And they have to work for the other end users: physicians. “Physician needs might include some consideration of what data are relevant, and what data are not,” Rosen says. “We want to make sure users have a voice not only in the development of apps but even the development of theories.”

“The people on the front lines, the physicians working with patients, they’re going to have the best understanding of what the problem is and what the obstacles to implementation are,” Wu says. He and Boyer say patients and clinicians must see an immediate benefit to any digital health tool for it to work. So, Boyer says, he often skips the usual research rigmarole and goes straight to real-world trials.

“If the interaction is off-putting in any way, they will never come back a second time to interact with your device. So I don’t do clinical trials,” Boyer says. “I’m interested in finding those features that make mobile health interventions deliverable for the rest of their lives.” He says he gauges a device’s effectiveness not by whether someone likes it, but whether they’ll use it again. “The best measure is leaving the technology with the patient [when a trial is over]and see if they continue to use it.”

Leveling the field

On social media and at conferences, Gawuga speaks passionately about the patient experience but seeks common ground with other constituencies. Doctors, patients, and developers can collaborate effectively only with mutual respect, which means breaking down traditional hierarchies. Social media is helping to do that, she says. “On Twitter everyone’s reaching out. Doctors are sharing information, patients are saying to doctors, ‘This is what’s important to me,’” she says.

Ranney, who is active on Twitter and has organized Twitter focus groups, arranged to meet Gawuga after a TweetChat to talk more in person about the patient perspective. She believes it’s up to patients, not physicians, to decide how much privacy they want. “It’s scary for a lot of doctors,” Ranney says. “It will level the playing field and make patients better consumers of their health care.”

Physician involvement in the development of digital health tools will better ensure that they adhere to ethical standards. Just because the technology is new doesn’t mean that time-honored commitments of doctoring, from confidentiality to the oath to “do no harm,” go out the window. Indeed, given the very real concerns about data security, it’s more important than ever that clinicians obtain patients’ consent, take steps to protect their health information, and honestly discuss privacy concerns.

This may be a greater worry for health care systems than for patients, however; in surveys, large majorities have said they want to link their medical records to non-HIPAA-compliant sites, including the data-sharing platform PatientsLikeMe and even their social media accounts. Patients who text or email with their physicians know their messages aren’t secure. “We need to be honest about the risks,” Ranney says. But we take risks every time we use a credit card, she adds. “It’s obnoxious of us to say, ‘No, you can’t have that.’”

“The reason [digital health]is coming is patients are driving it,” Boyer says. “I recognize that it might not work necessarily for my mom, but as people in my generation and yours and my son’s all get older, this will have increasing relevance for them, and that’s why we need it.”

See one, do one, teach one

That’s also why medical schools need to start incorporating digital health into the curriculum. Many devices have the potential to improve not only patient care but clinical training. “The medical education component of this is vast,” Duffy says. Large, clear, shareable images of the inner ear or the back of the eye benefit learners and teachers alike. Remote consults give residents instant access to specialized knowledge. Hardware and software that gather and analyze patient data help trainees see patterns and make medical decisions.

But most digital tools are so new that teachers are learning to use them alongside their students. And in a busy practice, who has time for that? “It’s going to be 15 to 20 years before digital health is ubiquitous in medicine,” Ranney says. She’s launching a preclinical elective in the fall, with the assistance of Margie Thorsen ’15 MD’19, that will include workshops where students can explore how tech can be used in medical settings, and develop their own ideas for a final project. The medical students who learn now how to use and develop digital health tools and, most importantly, how to adapt when something new comes along, will be leaders in the future.

Duffy isn’t ready to put her older colleagues out to pasture just yet. In every age group there are quick adapters and slow adapters, she says. The quick adapters will try out the latest tools, push buttons and play around and figure out how they work. The slow adapters wait and see. But if the technology works, she says, they come around. “When you realize the benefits to patients, you’ll keep up.”

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Bone collector

In the Winter 2015 edition of Brown Medicine, there is an article by Kris Cambra (“The Past Is Present”) about the wonders to be found in the basement of the Biomed Center.

As a freshman at Brown in 1968-1969, I was employed by Dr. George Erikson to measure the bones for research that he was doing on primates. While he was at Harvard prior to coming to Brown, he was famous (or infamous in today’s parlance) for taking trips to the Amazon rainforest. His express purpose in doing this was to “collect” specimens of various primates so that he could compare their bone structure. In the vernacular, this involved shooting the monkeys and preserving them long enough to get them back to the lab in Cambridge. I will leave to your imagination how the bones were cleaned and dissected, and to be fair I was not involved with that part of the process. I do remember sitting in a windowless room in the anatomy area, measuring monkey bones for about $2.50 an hour. I also remember him talking frequently about “the fire,” which occurred sometime while he was at Harvard and which apparently destroyed numerous specimens. He did salvage some of them, which is why they may look a bit fried…

Pardon R. Kenney ’72
MMS’75 MD’75 RES’80,P’03

Ghost in the Machine

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Doctors can help design better electronic records.

“And, we’re down.”

Amid the Halloween costumes, there was an eerie silence. No typing, no clicking, no mouse-shuffling. Just a bunch of medical professionals, ironically dressed as the Minions, staring at each other. The electronic medical record system had crashed, and we had to run the emergency room on paper.

I shuffled around the secretary’s desk looking for a makeshift chart. I selected a manila folder, and pulled out the papers. The layout was foreign. There were no links, no graphs, no interface. Just me, the Minions, and these pieces of paper. I looked up, and found one of the attending physicians smiling at me.

The lens through which I learned medicine was inherently digital. To me, charts are not folders or papers; the term “chart” represents an ecosystem of dynamic vitals, laboratory results, notes, and orders. Hundreds of lab results are displayed, shuffled, filtered at will; years of data are condensed into graphs. A patient no longer simply has a physical presence—she has a cyber-physical one.

Are trainees becoming a bunch of Minions following numbers instead of patients?

At its core, the medical interaction relies on human pattern recognition, and recent advances in medical technology enhance this capability. Using the electronic medical record (EMR), providers can rapidly synthesize information without having to first aggregate the data. As a result, physicians can spend their time using the EMR’s output—graphs, patterns, etc.—to inform medical management. In this scenario, a well-designed EMR enables the doctor to spend more of her time physically with the patient. As such, the EMR should seamlessly integrate into the background of medical care.

Yet the reality of EMRs is somewhere in between my description and the old world of manila folders. Current EMR platforms rely heavily on the end user to input the data. Due to the clerical burden, trainees spend 20 percent of their time at the keyboard and just 12 percent physically with their patients. I can personally attest to spending just as much time charting as I do counseling my patients.

At a system level, there are too many data standards for efficient back-office integration. Each EMR has its own user interface, data input requirements, and document writers; one system cannot freely communicate with the other. This data environment creates the illusion that a single EMR holds all the patient information when, in fact, there are several missing sources. The burden of verification is therefore shifted to the end user, who must learn multiple systems and personally integrate the information.

This is where the new generation of physicians should step in. As digital natives, we represent the intersection between technology and medicine. First, we need to focus on improving data integration. Some examples include automatic approval and integration of outside records upon patient transfer, streaming vital signs entry, and real-time diagnostic imaging upload. Together, these would greatly improve the information experience of the end user, which would, in turn, improve patient care.

Second, there is a booming medical technology industry. Many companies are developing third-party devices that integrate the newest sensor technology with medical platforms. We should insert ourselves into this design process to help create a product that improves the joint experience of the physician and the patient.

So, my fellow Minions, let us drive the change we need to see in our medical system.

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