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Goal Keeper

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The best defense is a good offense.

David Hernandez ’16 MD’20 has played defense for intramural soccer all four of his years at Brown. But in the classroom, he quickly learned that if he didn’t go on the offensive, he would fall behind, and fast.

A student in the Program in Liberal Medical Education (PLME), which admits high school seniors to Brown and Alpert Medical School, Hernandez enrolled in “Introduction to Neuroscience” in his first semester. The popular course attracts hundreds of students each year.

“I was one more student. It was hard to get individual attention,” says Hernandez, whose class at Central Falls High School numbered less than 200. “It was something new for me.”

Also new was his struggle to keep up with his coursework. The valedictorian at Central Falls, a tiny city just north of Providence, he says he was “not prepared” for the transition to college-level studies. “In high school there were so many ways to get graded and assessed. Here there were only three exams,” he says. “It was a huge shock for me. … So I almost failed neuroscience.”

But Hernandez went on offense. “It was a wakeup call,” he says. He attended office hours, worked with individual and group tutors, and studied with fellow students. He figured out what resources he needed and where to find them, and never hesitated to ask for help.

Over and over, Hernandez, who wears thin wire-framed glasses and his dark hair cropped close, expresses gratitude for the people in his life, from his parents and high school teachers to professors, tutors, and friends, insisting that without them, “none of this”—four successful years in the Ivy League, on the cusp of medical school—“would be possible.”

Joseph Browne ’10 respectfully disagrees. The former coordinator of the University’s New Scientist Program, Browne met Hernandez when he took part in the week-long Catalyst pre-orientation program, which prepares underrepresented students to major in the sciences. Right away, Browne says, Hernandez stood out from his peers.

“Some people are just going to get to where they’re going, and David is one of those,” Browne says. “Yes, people gave him a chance. They were supportive. But it’s more than the role they played in supporting him. He’s just a very determined kid. …

“Other paths could have been easier that excluded the sciences, and he didn’t choose to do that. He had a choice, and he chose to stick with it.”

First Gen

Since childhood, Hernandez has been familiar with big challenges. Not long after he was born, in Medellín, Colombia, an aunt who had moved to the United States and become a citizen began to petition the State Department to allow her family to join her. It took 15 years to get their visas; in 2008, just before his freshman year of high school, Hernandez, an only child, and his parents moved to Rhode Island.

Hernandez says his parents take education seriously, and they sent him to a Catholic school in Medellín through eighth grade, but private school tuition in the US was out of reach. Though Hernandez knew some English, he wasn’t prepared for full language immersion in an American high school—and ostensibly not one that perennially ranks among the lowest in the state, and garnered national headlines in 2010 when it fired all its teachers.

“But Central Falls opened their doors,” says Hernandez, whose fluent English still carries a Colombian accent. “They have a great ESL program. They encouraged me to work hard. It was a great school, in spite of what the media say, in spite of what everyone says. They always supported me.”

David Upegui became a biology teacher at Central Falls High School, his alma mater, during Hernandez’s junior year. They connected not only as fellow Colombian immigrants, but through their mutual affinity for science. “I remember meeting him very vividly,” Upegui says. “I gave my students a lab report to complete and I remember how his lab report was so impressive that I wrote on it, ‘This is college-level material.’ … He was not just completing an assignment. He actually explored ideas.”

Though Hernandez had been attending Rhode Island College’s Upward Bound Program, which prepares first-generation college students for higher education, since his freshman year of high school, Upegui’s comment excited him. “He wanted to make that happen,” his former teacher says.

That year Upegui formed Central Falls’ first Science Olympiad team, in which state high schools compete in science-themed events, from bridge building to meteorology to robotics. Upegui invited Hernandez to join the team, assigning him to the anatomy and physiology event with one other student, also a recent immigrant. With help from Alpert medical student volunteers, they prepared for two months for the competition, expecting to gain nothing more than new knowledge and the experience of a statewide academic competition. Instead, Hernandez and his teammate brought home the gold medal.

“I can’t even begin to tell you, the eruption from everyone there in that room because they understood what had happened: two immigrant kids, from the inner city, competing against all the schools in Rhode Island,” Upegui says, the memory still fresh. “And that sort of set the scenario for what would happen in the next few months. After that, David came back for his senior year and said, ‘I want to go to medical school, if that is feasible.’ I said, ‘Of course it is.’”

Savvy Student

Hernandez began shadowing local physicians in high school. At Roger Williams Hospital he watched 15 surgeries, including gastric bypass and hernia repair, and talked to patients. He decided to apply to Brown as a PLME, and wrote and rewrote his application and essays, seeking help from anyone who would give it. “He said, ‘I want to go to the PLME program but it will never happen,’” Upegui says. “And then I got the call from him. He was opening the email [from Brown] and crying, he was so happy.”

Julianne Ip ’75 MD’78 RES’81, P’18, the associate dean of medicine for the PLME, says the program—which had a 5-percent admittance rate for the Class of 2016—doesn’t interview prospective students, so her office didn’t meet Hernandez in person until he arrived on campus. But “we ‘met’ him through the newspaper after he was admitted,” Ip says. The local media, hungry for good news out of Central Falls after so much controversy, were all over the story of the Colombian immigrant who rose to the top of his class and got into not only Brown but its medical school. (The high school got another shot in the arm two years later when Upegui, who before becoming a teacher was a data manager at Brown, won the Evolution Education Award from the National Association of Biology Teachers.)

The Providence Journal’s coverage of Hernandez caught the eye of Joan Wernig Sorensen ’72, P’06, ’06, a trustee of the Brown Corporation. “I read his story and said, ‘This is unbelievable,’” she says. She further connected with the future Brunonian because her husband, Paul (Pablo) Sorensen ’71 ScM’75 PhD’77, P’06, ’06, was raised in Ecuador. The Journal reporter helped Sorensen get in touch with Hernandez, and she and her husband took him to lunch.

“In the very beginning it was very difficult for him,” Sorensen says. “I told him that when I came here in 1968, from an all-girls Catholic school, I had taken two AP courses while most of my classmates had taken many more. I also told David that many of his classmates were up against the same thing when they came to Brown. The freshman year is the hardest.”

Hernandez tried to get ahead of the game by enrolling in two pre-orientation programs: Catalyst, the science program, and Excellence at Brown, a week-long, writing-intensive seminar that introduces students to the academic and campus culture. “I wanted to hit the ground running,” he says. “But I didn’t have the study skills. I didn’t have the prior knowledge. …

“After neuroscience, getting a tutor and working with all the students has become a routine. I turned what was a weakness into a strength,” he says.

Ip says she had worried about how Hernandez would transition to Brown. “He was coming from a small, supportive school, where he was a big fish in a small pond, and here he’d be a smaller fish in a big pond. I didn’t want him to feel intimidated,” Ip says. “But he asks for help. … And he’s always very willing to listen to advice, which has made him successful.”

Plus, she adds, “He really utilizes his resources.” Hernandez discovered a love for French during his first year, and wanted to get a tutor to improve his skills. So he traded Spanish tutoring with a student who was fluent in French. “I thought that was a creative use of his abilities,” Ip says.

Though Hernandez receives scholarships, there are always extra expenses. “During David’s freshman year, before he was in the swing of things, he needed money for books,” Sorensen says. “I gave him some money, and he found the cheapest editions he could online and tried to give the rest [of the money]back. I told him to keep it; he’d have other expenses. But he’s most resourceful—he has applied for and received many grants.” He also holds campus jobs, including as a supervisor for intramural soccer and a teaching assistant for Advanced Spanish.

Because he’d fallen behind in his coursework, Hernandez wasn’t able to fulfill his dream of studying abroad, but in the summer after his sophomore year he spent seven weeks taking intensive French at Middlebury College, and got to go to Montreal. It was nice, he says, to have “a break from science.”

The trip was possible because, during his sophomore year, Hernandez got his US citizenship. “A Colombian passport doesn’t get you very far in the world, but an American one does,” he says. “It was a very special moment. It opens the door. You can now travel anywhere you want.”

That includes his home country, which he hadn’t visited since he’d left five years earlier. Because it’s so hard to get a visa, it can be difficult to return to the US, even for someone who’s established residency and enrolled in college. “Getting my citizenship is just as important as gaining acceptance to Brown,” he says. “It’s a dream come true that millions of people wish they have and millions of people are denied each year. It’s definitely a privilege.” Now he goes to Medellín every winter break to see his family.

Finishing Strong

Hernandez, a biological sciences major, got involved with research early. As a freshman he took the “Phage Hunters” course, in which students find, name, and analyze the DNA of undiscovered viruses; then, during his first summer, he studied amyotrophic lateral sclerosis in Drosophila with the Brown Scholars Program. He’s also shadowed neurosurgeons, cardiologists, and infectious disease doctors. “Every single experience has strengthened my wish to be a doctor,” he says. “To see a patient walk out of the hospital feeling better thanks to the work a doctor did—it’s something priceless. It’s something I hope to one day be able to do for other people.”

But more importantly, Hernandez wants patients to be comfortable and knowledgeable when they walk out of his office. That’s what he says his unique position—bridging the gap between immigrant and citizen, able to navigate the Hispanic community—will bring to his practice. “I want to be a doctor that my parents can go to—the doctor they haven’t had. … I want to give back to my community, to people who have gone through the things my parents have gone through.” Hispanic patients, he adds, “need someone who can speak the language, who can tell patients their options, their resources, who can explain insurance and different treatments.”

“He’s the kind of person I would want to have as my physician,” says Upegui, who has kept in touch with Hernandez. “I want someone who is a human, who makes their patients human again—someone who understands the complexity of the human experience. I don’t know if he sees that in himself.”

Sorensen has seen hints of what may one day be Hernandez’s bedside manner. In addition to the “touching emails” that he sends regularly, updating her on his coursework and grades, she says, “When my husband had knee surgery, David wrote to ask for his phone number so he could call him and wish him well.”

Ip, who taught Hernandez in her PLME senior seminar last semester, says he wrote thoughtful reflections for her class. “I think [as a physician]he’s going to bring a phenomenal amount of insight,” she says. She adds, “As an immigrant and a first-generation college student, he’s very proud of that. He knew he didn’t start at the same place as everyone else. I don’t think I’ve met many kids who have had to work as hard to get where he is.”

Medicine, Hernandez says, is “a field that’s very hard to get into, even more for a minority student, even more for a recent immigrant.” Though he makes time to ride his bike and play soccer, which help him get his mind off school, he rarely has time for chess anymore—he was a state champion all four years in high school, and his team won the Ivy League Chess Championship during his freshman year—or other extracurriculars. “I gave all my life to academics,” he says. “I went from getting 60s to getting 80s. It feels good to be in this position, because medical school is right around the corner.”

His pre-med requirements complete, he says he’s been able to enjoy his senior year, taking courses in exercise physiology and French photography as well as infectious diseases and biochemistry. “I’m finishing strong,” he says. He was thrilled to learn he’d met the requirements to earn a Bachelor of Science: “a nice reward,” he says. As for the rigors of med school, Hernandez says he feels prepared. “I’ve learned how to study. I’ve fallen in love with it,” he says, describing a strategy of reviewing every lecture within a few hours of class “to memorize concepts, clarify doubts, and identify questions.”

Browne, who now works at the MIT Sloan School of Management, says Hernandez draws satisfaction not just from his achievements, but from his struggles. “He’s aware of the frustration he felt, and how real and valid and important it was in that moment,” Browne says. “And now, in the grander arc of things, he’s past that. It could have been easier, it could have been better—and it was always going to be fine.”


Patrick S. Conklin, MD F ’10

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Patrick S. Conklin, 44, died in a motorcycle accident on Nov. 4, 2015, in Chicago.

He attended high school in Mukwonago, WI, and graduated from Semmelweis University Medical School in Budapest, Hungary, in 2004. He completed his medical residency in radiology at St. Vincent Memorial Hospital in Bridgeport, CT, and the interventional radiology fellowship at Alpert Medical School in 2010.

Patrick lived in Chicago, where he worked as a radiologist at West Suburban Hospital, Weiss Memorial Hospital, and Westlake. During his residency, he met Sandra Rao, who was his chief resident; they enjoyed 10 years of companionship together.

He will be remembered for his love of the Green Bay Packers, riding his motorcycle, traveling the world, and enjoying a good bottle of wine with his guests. He is survived by his partner, Sandra Rao, MD; his father; five sisters; and one brother.

The Golden Age

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An MD-PhD is part of a new era of cancer breakthroughs.

Alpert Medical School can brag of many remarkable students and alumni in its short history, but Raghu Kalluri, PhD MD’09 was certainly the first to be a full professor at Harvard Medical School while simultaneously studying medicine at Brown.

Born in St. Louis, Kalluri grew up in India and received his undergraduate degree there. After earning his PhD in biochemistry and molecular biology at the University of Kansas Medical Center and completing a postdoctoral fellowship at the University of Pennsylvania School of Medicine, where he did research on immunology and organ fibrosis, he became an assistant professor of medicine at Harvard Medical School and Beth Israel Deaconess Medical Center in 1997.

He had long considered the idea of going for a medical degree, but Kalluri continued his teaching and research at Harvard, building a lab focused on matrix biology and cancer biology. “The idea of pursuing the unknown was more important to me,” he says. At that point, he had already given hundreds of lectures around the world.

But a few years later, Kalluri, at 35, felt it was time to tackle the MD: “There was a knowledge gap I knew I should close. I had a personal desire to learn more.” He felt the degree would make him more useful as a researcher; besides, “I was never afraid to be a student.”

Kalluri confronted unusual challenges in finding a medical school. At Harvard he already was teaching its medical students, and so it was not an option. He needed to stay close to Boston because he planned to keep running his lab of more than 30 people. But some other Boston schools weren’t the right fit. Then a colleague suggested his alma mater, Alpert Medical School. Kalluri found the deans and the School receptive to him. He went through the exact same admissions process as everyone else, and was admitted to the MD Class of 2009.

“It was a humbling experience,” Kalluri says. He went from being “a master of my universe” in his lab to being one of a class full of remarkably smart students. “I learned to say ‘I don’t know’ with great pride and respect,” he says.

After graduating Kalluri continued his work at Harvard. But then came along an “amazing opportunity”: he was recruited to the MD Anderson Cancer Center as professor and chairman of the Department of Cancer Biology. In 2012, he joined the highly regarded hospital that is a key part of Texas’s aggressive, multibillion-dollar effort to fight cancer.

Kalluri, who continues to speak internationally, is full of enthusiasm and optimism. “This is the golden age of understanding cancer,” he says. “This is an extremely exciting time.” His research involves studying the environment of cancer cells, where he says great advances are being made. Recently he and his colleagues reported in Nature their findings that describe how pancreatic cancer could be diagnosed earlier. “We think in this decade we will have a lot more advances” as the cancer field reaps the benefits of many years of basic research, he says.

While he has moved farther from Providence geographically, Alpert Medical School remains close to Kalluri. “I am extremely grateful for the opportunity Brown gave me,” he says. “It made me a better human being.”

Understanding Value-Based Healthcare

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By Christopher Moriates, MD; Vineet Arora, MD, MPP; and Neel Shah, MPP ’04 MD’09
McGraw Hill Education, 2015, $55

“Some physicians and ethicists may warn that the separation of medical care and costs is an important, necessary aspect of the medical profession, ensuring a firewall between clinicians’ medical decisions and their financial incentives. However, this separation is actually relatively new to the profession of medicine. … Even as late as the 1960s, about 50% of healthcare costs in the United States were paid out-of-pocket.”

—from Understanding Value-Based Healthcare

AlAL-shahbook-reszMany of us are quick to blame politicians and insurance executives for the wasteful, inefficient morass that is the US health care system. But Shah and his coauthors argue that true reform can happen only on the front lines—when clinicians offer patients less wasteful, more affordable care that’s delivered fairly, equitably, and safely. Shah is the founder and a leader, with Moriates and Arora, of the nonprofit Costs of Care, which strives to improve the value of health care. They weave succinct, accessible presentations of research and data with case studies and personal essays to provide an overview of the many challenges of the existing system, and they dedicate more than a third of the book to solutions, from medical education to better screening practices to reimbursement reform. “[C]linicians can take the responsibility for helping alleviate this problem,” they write.

The First 15

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How are our young alumni faring in their careers?

At Alpert Medical School, the annual Ceremony of Commitment to Medicine, where students receive their first white coat, concludes with a class photo. The students smile up at the camera, all clad in their pristine, short coats. Though each has a different reason for being there, though each might wonder if she or he really belongs there, for that one moment in time they are united in their excitement, and in the promise and uncertainty of what the future holds.

Speaking to a diverse group of alumni who graduated 15 years ago or less, a new picture takes shape, one that is more heterogenic, less shiny. No longer are all of these MDs wearing white coats. Now they are united by their commitment to push the boundaries of medicine—against the scope of traditional care, the constraints of the health care system, and even the expectations of their profession. But the lessons learned as medical students have stayed with them and shaped them, not just as doctors but as people.

A Hero Profession

“I didn’t think I could step into a hospital again,” Jyothi Marbin ’96 MD’06 says. It was 1995, her senior year at Brown, and she was 21 years old. Her father had amyotrophic lateral sclerosis, or Lou Gehrig’s disease, and he had just told her that he wanted to be taken off his ventilator.

ALS, a neurodegenerative disorder, slowly wears down a person’s ability to live a normal life—to eat and move and breathe and sleep—and Marbin grew up taking care of her father. “We fed him, helped him get dressed, gave him a shave, and turned the pages of his newspaper,” she says. Her high school years had many nights in, and she spent weekends during college at home. Giving her father a normal life meant giving up a normal adolescence. “I think I expected to feel happy that his suffering was over, but instead I realized I needed to grieve,” she says of his death. It would be another five years before she returned to Brown to begin her medical education.

Marbin grew up in Brookline, MA, and her father was an incredible force and presence during her childhood. “He ran our household from his wheelchair,” she says. Her parents were originally from India, and her mother became a physician before she left for the US; doing so was uncommon in a culture where women were expected to focus on raising a family. And for that, she was an inspiration to her daughter. “My mom was a doctor, and I wanted to be just like her,” Marbin says.

“If you were proud of your parents, then the natural choice was to do what they did,” says Amit Joshi ’97 MD’01, a general surgeon at Einstein Healthcare Network in Philadelphia. “And I was always proud of my parents.” Both his mother and father were physicians, and medicine was infused in his childhood. “As early as I can remember, I wanted to become a doctor,” he says. Joshi felt no pressure from his parents to pursue medicine, but he never changed his mind about his path, applying early to Brown and the Program in Liberal Medical Education.

Joshi’s wife, Nikki Ariaratnam ’00 MD’04, was shaped by her parents’ experiences in much the same way. Ariaratnam, a radiologist, is the only child of two physicians—her mother a psychiatrist, and her father a radiation oncologist. “You saw what you loved in your parents,” she says. “They cared for people and that was their job. I couldn’t think of anything better than that.”

As Joshi put it, “Our parents were in hero professions.”

Early Lessons

Marbin’s father’s death left her an orphan; her mother had died eight years earlier. On a cold, snowy day in Boston on March 4, 1988, her mother was walking home after dropping her car off at the gas station. “When she arrived at the front door, she was gasping for breath,” Marbin says, and she collapsed in the doorway. “She never woke up after that.” Her mother had suffered a fatal asthma attack. “After losing her, I was so sure I wanted to be a doctor,” Marbin says, and her father pushed her along that path. “I understand now why he wanted this for me,” she says. “He wasn’t sure how long he would be there.”

Ariaratnam, too, grappled with a parent’s illness from an early age. When she was 13, her mother was diagnosed with ovarian cancer.

That year, clinicians were piloting a new radiological test for cancer, the PET scan. The uncontrolled growth of tumor cells leaves behind trails in the body where there is excessive glucose intake, and the PET scan flags the trails with a radioactive marker. When clinicians combine the PET scan findings with a traditional anatomic CT scan, they can easily follow the trails to the sources of cancer in the body.

Ariaratnam’s father came across the then-experimental treatment by chance while reading a radiology journal, and without hesitation he flew his wife to Kentucky to receive the treatment. It proved to be a pivotal decision—one that gave her seven more years of health despite a diagnosis with a five-year survival window.

“That was the first time I realized how radiology can save lives,” Ariaratnam says. As part of her day-to-day life now, she consults the same PET scans that saved her mother, along with lifesaving breast imaging techniques that can detect cancers in the body long before they become fatal.

In 2007, Ariaratnam’s mother died at Memorial Sloan Kettering Cancer Center in New York, blocks away from where Ariaratnam and Joshi were completing their residencies at Weill-Cornell NewYork-Presbyterian Hospital. After her mother’s death, it was important to Ariaratnam to remember her experience on the other side of patient care. “A physician needs to understand fear and doubt,” she says. “When I give my patients bad news, I feel connected to them because I’ve been through it with my own mother.”

Small Good

Elizabeth Niemiec MD ’10 didn’t always know she would be a doctor. Medicine came into her life later, as a way to turn scientific rigor and service into meaningful good with patients. Niemiec, a psychiatrist, lives and practices in Newport, RI, and originally pursued ophthalmology. She poured her energy into the field as a student, and even published research in the journal Ophthalmology. But when Match Day arrived, Niemiec did not match with any of her preferred programs. “It was a huge blow,” she says, and it forced her to reconsider what she truly wanted to do as a physician.

“I wanted to see someone now, and see someone later, and see how I have helped them or not,” she says. And that, she later realized, was a luxury psychiatry afforded. “The primary way we figure out what’s wrong with a patient is by talking,” she says. Psychiatry is a slow science, and it may take weeks for a patient to begin responding to treatment. But even though it can take time, Niemiec derives satisfaction from the process of helping patients recover.

Dermatologist Antonio Cruz MD’06, meanwhile, loves the immediacy of his work. Cruz has his own private practice, SKINPros, in Providence and specializes in performing Mohs micrographic surgery, which is widely accepted as the most effective technique for removing the most common skin cancers. “We’re lucky in our field,” Cruz says. “People can come in with cancer and leave without it.”

Cruz grew up in Cumberland, RI, and as a boy fixed boilers with his father. Many of his patients knew him back then, and Cruz relishes being close to his roots as a physician. His patients are also his neighbors. “My patients know of me and my family,” he says. “We drive the same roads.”

For Niemiec, medicine doesn’t need to be anything grandiose. “My mission is pretty small,” she says. “I want to be a good psychiatrist, and I know I can make a difference in lives one at a time.”

A Culture of Health

Growing up in San Francisco, Kara Chew ’01 MD’05 saw the forgotten faces of her community volunteering in soup kitchens and with the homeless. As a physician, she cherishes what she learned from their experiences. “Medicine is much more than treating a condition; it’s about advocating for patients in the face of immense barriers,” she says.

Chew, a physician-scientist at the David Geffen School of Medicine, UCLA, researches the ways hepatitis C affects cardiovascular risk in HIV-positive patients. But she still spends considerable time on patient care, seeing patients at a community HIV clinic and educating fellows in the infectious disease track at UCLA.

Early in her training she knew she would not be confined by the walls of a laboratory or a hospital, and as a student Chew began working with the prison populations of Rhode Island. At the time, very few prisons were treating or screening for hepatitis C in inmates despite the serious need; in Rhode Island alone around 17 percent of inmates are infected, according to a 2014 study in the Journal of Urban Health. Chew’s work in Rhode Island’s prisons rekindled a passion for primary care that solidified the kind of physician she wanted to be. “When I was younger I didn’t feel like I had much time to make a real difference,” Chew says. But now her work brings her into the same spaces as the shelters she grew up serving.

Primary care physicians often find themselves at a confounding intersection of medicine, where long-standing social inequalities and lack of access to care create barriers for both patients and physicians. But specialists are no strangers to the challenges of serving patients at the margins. Often patients will come to them in the late stages of disease, when earlier intervention would have led to better outcome.

The Grind

Akita Evans

Akita Evans

Akita Evans, MPH MD ’07, who came to Brown via the Early Identification Program with Tougaloo College, a historically black college in Mississippi, is a family practitioner. She began her career in community health centers right around the time that funding for such centers was beginning to dwindle. “We provided great care with minimal resources,” she says. Evans continued her work in community health centers at Oakhurst Medical Center in Stone Mountain, GA, and no matter where she went money was an issue for her patients. One visit could be the first and last chance she had to make an impact. “I would send my patients off with a hope and prayer because I didn’t know if they could afford to come back,” she says.

There can be an inevitable grind that defines specialties like family medicine. “As a primary care physician, you can do it all,” John Luo ’09 MD’13 says. The opportunity to use knowledge that spans specialties drew him to the field, but the same breadth of care eventually took its toll. “The toughest moments were feeling like I couldn’t make a difference,” Luo says. “Seeing physicians and patients suffer was awful, and to not have a solution for somebody was very difficult for me.”

Physicians in primary care suffer some of the highest rates of burnout in medicine, a problem that spans the profession. “It doesn’t take much to tip over,” Evans says, and last year, she decided to take a position at a practice focused on functional medicine. “You can’t meet every need in one day,” she says. “I could have stayed, but at my own cost.” Evans is now hoping to address the root causes of disease at ANWAN Wellness Medical Center, near Atlanta, an integrative medicine clinic that focuses on lifestyle changes and preventive care. Even in the face of daunting social problems, she says, “people can still be better stewards of their health.”

Faced with the same grind of primary care, Luo decided that he didn’t want to continue on to residency. Instead he launched his own company, Doctor’s Choice, which focuses on creating transparency and patient education around health insurance. The perspective he got while training in medicine was invaluable for learning how to spearhead change, he says: “I was always able to see inefficiencies when I was a student, and I always asked myself, how could I make it better?”

Root Causes

For Giridhar Mallya ’99 MD ’03, the answer to that same question lies in transforming social policies. “I want communities to demand more of their decision-makers,” he says. Mallya is a senior policy officer at the Robert Wood Johnson Foundation, and before that honed his expertise at the Philadelphia Department of Public Health. Dedicated to finding ways to mend invisible tears in a patient’s social web that create poor health and disease, he has tackled issues from tobacco control to childhood obesity.

Giridhar Mallya

Giridhar Mallya

And like Evans and Luo, Mallya’s first encounters with these issues came from his training in family medicine. Witnessing patients suffer from preventable problems was a watershed moment in his career. “It was really eye opening,” he says. “Without their health, people have much less ability to serve their families and communities.”

Jyothi Marbin’s approach takes something of a middle ground. “I want people to realize their potential to give,” she says. Marbin hopes to empower young physicians to engage with their communities and provide innovative care as director of the Pediatrics Leadership for the Underserved (PLUS) residency program at the University of California, San Francisco School of Medicine. The 11-year-old program, of which she is an alum, trains pediatricians to lead the transformation of health systems for underserved children.

“You can’t practice medicine in a silo,” Marbin says. She spent the five years after her college graduation at City Year, an AmeriCorps program dedicated to transforming education in poor communities. And at Brown she aimed to foster the same kind of change. As a medical student she helped to create the Rhode Island Medical Legal Partnership, which connects patients with the legal help they need to resolve issues beyond the scope of a doctor’s care: the presence of mold in a rental unit that causes asthma flare-ups, or an electricity shutoff in the household of a young mother. To instill the same innovative thinking in pediatrics residents, Marbin is working on plans to scale the PLUS program across other hospitals.

“Our problem is bigger than the solution we have,” she says, but she remains hopeful. “The power of medicine relies on whether physicians actually try to change things.”

Search for Meaning

In a sharp gray suit and Chelsea boots, Jason Slosberg MD’01 has the easy manner of success. Slosberg, 44, is the CEO of Linkbee, a technology startup, but he comes from humble roots. He grew up in a blue-collar town in Suffolk County, Long Island, where most kids pursued vocational studies. He became the first in his family to go to college, and by the time he arrived at Brandeis University, he was hungry for something different. After graduation his mother and father moved to opposite ends of the country. He knew he couldn’t go home again, and did not have a clear plan for his career. “I was quite lost,” he says. “I had drive, but no direction.”

Jason Slosberg

Jason Slosberg is CEO of Linkbee, a startup that creates smart-home technology.

After a chance encounter in Boston, Slosberg joined and eventually led the development of a small computer business, beginning work that would become his life’s calling: turning around failing businesses. Slosberg went on to lead a company focused on architectural skylights. But as much as he loved the work, he began to feel unsatisfied. Slosberg craved a career that could have a meaningful impact on others. A friend suggested that he check out the postbaccalaureate program at Columbia University, and the next day, on a whim, he was submitting an application.

He had never taken a science class during college. “When I stepped foot in Columbia, I knew that this was the right path,” he says. After finishing his postbac, Slosberg was among the few students admitted to Brown Medical School through its linkage with Columbia.

The Crystal Ball

There is a tradition in the second year of medical school at Brown called the crystal ball, where students predict the specialties their classmates will end up in. When it came time for his classmates to write their guesses for him, Brad Weinberg ’03 MD’11 was overwhelmingly a fill-in-the-blank for business. “I am medically trained but not a practicing physician—that’s my complicated relationship with clinical medicine,” he says.

After founding and leading his first venture-backed company while still a medical student, Weinberg went on to start Blueprint Health in 2011, and he is still the managing partner. The New York-based startup accelerator offers mentorship and funding for entrepreneurs in the early stages of launching health care-focused businesses. Even though Weinberg is now fully dedicated to his career path, he says he wouldn’t be where he is if he hadn’t gone through medical school.

Weinberg loved his clinical rotations, and still remembers patients from years ago. “It’s those moments when you really touched someone that were special,” he says. But he envisioned creating something bigger than what he alone could accomplish with patient care. In his third year of medical school, Weinberg launched his first company, ShapeUp, with his classmate Rajiv Kumar ’05 MD’11.

“There is so much about medicine that I love,” Weinberg says. “But there is something so amazing to see the impact we can have on thousands of people a year.” In his fourth year of medical school, he decided to go all in with ShapeUp. “And in that moment, I was saying goodbye to medicine.”

Taking the Leap

During the early years of medical school, Slosberg longed for more patient contact, and the clinical years more than made up for it. He fell in love with surgery, as did one of his best friends, Amit Joshi, and for a while he was intent on doing plastic surgery. “He has an inquisitive mind and an eye for imperfections,” Joshi says. “And Jason knew how to perfect them.”

When it came time to choose a residency, Slosberg felt a familiar unease. “I had to come to terms with picking something I would do for the rest of my life,” he says. “It was scarier for me to feel locked in than to take a leap into the darkness.” So he leaped.

That year, Slosberg got a call from his brother. He had just taken over a distribution company specializing in disposable goods, and wanted Jason to join him in running it. Slosberg said yes, and after graduating in 2001, he, too, said goodbye to medicine. For years, he was torn about the decision, and when he explained his medical background to his new coworkers, many of them were incredulous. “They would ask me what I was doing here and my heart would sink,” he says.

But it was ultimately the right decision. Since graduating from the Medical School, Slosberg has seen the turnaround of the company he joined with his brother, and cofounded another company, Legacy Converting, that was recognized by the state of New Jersey for its outstanding work culture. But with Linkbee, Slosberg is pivoting back toward his roots in medicine. Linkbee, he says, will connect household devices to an “Internet of things,” where common objects can absorb and learn from a web of data detailing how people live: a light bulb automatically lights a path when you are up in the middle of the night, for example.

“Being a doctor is still a part of my DNA,” Slosberg says, and for him the Internet of things is like the human body. “It’s a way of bringing together disconnected parts like a biological system.” Linkbee is in its infancy, but Slosberg has broad ambitions. “We are on the precipice of an era where technology will allow inanimate systems to act like biological entities,” he says. “I have a vision and belief that it can be done.”

Helping and Healing

Wherever their paths have taken them, these young doctors live by values solidified by their education at Brown’s Medical School. From transforming policy to launching businesses to caring for patients, alumni are serving their communities and changing the way people live. “It’s simple. Physicians heal—whether that’s a person, a system, or a problem,” John Luo says. “Being a physician is a frame of mind. It is never going to change.”

Brad Weinberg adds, “I see so much of what I do now to help founders in the same way as when I would help my patients.”

When the workday is done, alums change lives at home, too. This February marks two years since Jyothi Marbin took in her foster son. “We had the opportunity to help a wonderful young man who didn’t have a home,” she says. “We talk all the time about how important it is to serve our community, and this is how we brought that difference into our family.”

For these MDs, medicine is all about making positive changes—large or small—a reality for everyone. “People ask me if I miss being a physician,” Giridhar Mallya says, “and I tell them I can now be a physician to a community.”

That Was Then, This Is Now

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Where are these women surgeons today?

In 1992, the predecessor of this magazine, Signs & Symptoms, published a cover story about women medical students and residents going into surgery. Three of the women, pictured below, represented three-fourths of the chief surgical residents at Brown that year; Naji Baddoura, MD RES’92 was the lone male. At the time, about 8 percent of general surgeons nationally were women.

From left, Marlene Cutitar, Karen Vaniver, and Jean Marie Daley, in 2015.

From left, Marlene Cutitar, Karen Vaniver, and Jean Marie Daley, in 2015.

Last summer, three of the self-named “girl surgeons”—Marlene Cutitar ’83 MD’86 RES’92, Karen Vaniver, MD, FACS RES’92, and Jean Daley, MD RES’92—posed again for the camera. Cutitar is a breast surgeon at Randall Surgical Group in Providence and clinical assistant professor of surgery at Alpert Medical School. Vaniver is a plastic surgeon and principal physician at Lourdes Plastic & Reconstructive Surgery in Pasco, WA. Daley is an assistant professor of medicine (research) in the Division of Cardiology at Brown, studying tissue injury. Tara Sweeney MD’93, a medical student at the time of the story who wasn’t at the reunion, is an ophthalmologist in private practice at White Plains Eye Surgery in New York, where she specializes in cataract surgery.

Tara Sweeney in 2015.

Tara Sweeney in 2015.

The number of women entering general surgery has climbed steadily since those days; they now account for more than 35 percent of trainees in the United States.

“I think that Brown basically made me think beyond gender or race,” Sweeney says. “I never thought about being a woman as so many mentors, including the three incredible women who are in the photo, supported us equally. We were taught to pursue our interests and to develop our talents and skills irrespective of age, gender, or race. That experience was and remains a real education.”

Anthony J. Migliaccio, MD RES ’64

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Anthony J. Migliaccio, 83, died March 13, 2016, in Tiverton, RI.

Tony graduated from Dartmouth College in 1954, and from New York Medical College, with distinction, in 1959. He completed his internship and surgical residency at Rhode Island Hospital, and was elected in 1968 as a fellow of the American College of Surgeons. His commitment to ensuring better outcomes led him to write and publish a book focused on better health, Fitness and Expectations.

Tony was a clinical assistant professor of surgery at the Brown University School of Medicine. He was a partner with Northeast Health Care helping to pioneer a cost-effective alternative to emergency room services. In addition to being a coastal and offshore sailor and woodworker, he was an accomplished photographer whose work was featured in many art shows. A staunch environmentalist, he was a past president of Save the Bay.

He is survived by his wife of 60 years, Paula, four children, 13 grandchildren, and one great-grandchild.

Roots Down

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A young doctor finds his way.

A few months after finishing his residency, Stanley Voigt ’06 MD’10 moved to Fairfax, VA, and spent his first few weeks on the road, driving to meet the physicians in the community he would call home. Voigt, 31, is an ear, nose, and throat specialist who joined his first practice, Associates in Otolaryngology, outside of Washington, DC, in August 2015. Now he’s balancing his ambitions to grow as a young physician with building a new life for
his family.

In his early years of medical school, Voigt could not tell you what otolaryngology was. The oldest medical specialty in the US, physicians in this field specialize in the medical and surgical management of diseases affecting the head and neck—a broad palette of conditions ranging from hearing loss and tonsillitis to mouth and neck cancer. In the course of a day, ENTs can peer into a voice box or remove malignant tumors from a jugular vein. For Voigt, it was the perfect blend of surgery and internal medicine.

Voigt comes from a family of physicians: his father is a psychiatrist; his brother, Clifford Voigt ’05 MD’09, is an orthopedic surgeon; and his sister, Niesha Voigt ’14 MD’18, will soon join their ranks. Medicine was infused in his household, and he still remembers beaming at his father when he was growing up. “I was enthralled by what he could do,” Voigt says. “He’d come home with a stethoscope and that would drive my imagination.”

After residency at Tufts Medical Center, Voigt has seen the gamut of conditions ENTs encounter and has even brought novel techniques, like video-stroboscopy, to his practice. Video-stroboscopy turns the movement of a patient’s vocal cords into a slow-motion movie. Doctors place the strobe on the neck and pulse light at the vocal cords in steady intervals, slightly behind the speed of the vocalization. When projected on-screen, these pulses of light form a detailed picture of the voice box, and allow ENTs to see subtle pathologies that would otherwise be blurred by the movement of the vocal cords. Although the technique has been in use for many years, it is scarce in private practices. Voigt sees many patients with voice disorders, and offering this technique saves them a trip to another specialist.

His patients reflect the breadth and challenges of the field. “In ENT, you can feel like a primary care provider,” Voigt says. But he is careful not to take this routine care for granted: “We can lose sight of the impact we have. Something as simple as earwax removal gives people back their hearing, and can be a lifesaving measure against diseases like meningitis,” he says.

Voigt also faces issues that span beyond the walls of his clinic. When he cares for patients with cancer he is often fighting an uphill battle against smoking. Despite the challenges, he cherishes the road to recovery with his patients. “As a surgeon, you can be forced into quick encounters,” he says, “but even a bit of rapport is important.”

Elizabeth Davis, DVM ’06, Voigt’s wife, says: “Stan always calls his patients the night after performing surgery. He is always available for them.” The two met as freshmen in Perkins Hall, and were married a few days after Voigt finished medical school and Davis finished veterinary school. Their daughter, Clara Marie, was born five days after Voigt finished his residency.

“Before, I was so devoted to residency, but things are slowing down,” Voigt says. He plans to give that devotion back to his community. “The senior partner in my practice has cared for generations of patients,” he says. “I want people to say that about Dr. Voigt.”


Ideas into Action

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An alumna is changing the world, one mother at a time.

You might call Tara Shirazian ’99 MD’03’s office in midtown Manhattan a little cluttered. From wall to ceiling are boxes of birth kits, prenatal vitamins, and medical supplies donated to Saving Mothers, the nonprofit
she cofounded in 2009 to help prevent women in the developing world from dying in pregnancy and childbirth.

As the organization’s president and medical director, Shirazian travels about six weeks a year to the three countries where Saving Mothers operates: Guatemala, the Dominican Republic, and Kenya. When she’s stateside, she’s soliciting donors for funding, medical supplies, and equipment; persuading colleagues to join short-term medical missions; and handling staffing, budget issues, and other day-to-day concerns.

She’s also an assistant professor of obstetrics and gynecology and director of Global Women’s Health at NYU Langone Medical Center.

“As you might imagine, my hobbies are sleeping and taking care of my kids,” says Shirazian, the mother of two young children. She met her husband, Michael Schwartz ’99 MD’03, at Brown. (Her brother, Shayan Shirazian ’01 MD’05, followed her into the Program in Liberal Medical Education.)

Born in Baltimore to parents who emigrated from Iran to work as immunologists at Johns Hopkins Medical Center, Shirazian discovered her passion for service as a 19-year-old in the PLME. For her Emergency Medical Systems course, she observed daily operations in Rhode Island Hospital’s emergency department. She realized that medical care was compromised by language barriers between providers and patients from local immigrant communities, where as many as 50 different languages were spoken.

For a class paper, she proposed using Brown students to launch an Interpreter’s Aide Program at the hospital. She brought the idea to the dean of the Medical School; the program continues to this day, and interpretation for hospital patients is now required by Rhode Island law.

“I know it sounds cliché, but that taught me that you really can change the world,” she says. “It also propelled me into medicine and made me feel passionately about health care for those without access. Saving Mothers is essentially born out of those principles.”

During residency Shirazian traveled to Honduras for a medical mission, but was “troubled by the idea that there were no systems in place to continue to care for these women after we were gone, and that we were just putting a Band-Aid on the problem,” she says.

Believing that health care in developing countries needs to be long term and sustainable, she and a colleague, Nichole Young-Lin, MD, MBA, founded Saving Mothers. They first worked in Guatemala when a mudslide destroyed a hospital. “The idea was to focus on what we knew best: birth and the after-care period,” Shirazian says. “A large part of the challenge is that many of the caregivers we train and pay have either limited or no language and literacy skills.”

Since it began, Saving Mothers has trained more than 300 birth attendants and performed nearly 2,000 gynecological surgical procedures free of charge. They are providing ob/gyn subspecialty training for a physician at a rural hospital in Kenya. This hospital—which serves more than 300,000 women—does not have an ob/gyn on staff, so the training could vastly improve the quality of care for women in the region.

With 350,000 women dying in childbirth every year worldwide and 99 percent of maternal deaths occurring in developing countries, Shirazian wants Saving Mothers to become the global maternal experts for everyone. “We don’t need to be in 100 countries, but we’d like to say to nongovernmental organizations in other countries that we can help you set up low-cost, high-impact interventions,” she says.

Shirazian says she’s often asked if she thinks that her time and effort on behalf of Saving Mothers is making a difference. “My answer is that I know it makes a difference,” she says, “because I’ve seen it.”

It’s Humanly Possible

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A health center cares for its at-risk community by linking health and human services.

Myechia Minter-Jordan, MBA ’94 MD’98 was practicing at The Dimock Center in Roxbury, MA, when one of her long-time patients admitted that she had begun drinking heavily. She felt she couldn’t leave her dangerously abusive relationship for fear of ending up on the streets. With a phone call, Minter-Jordan got her patient admitted to Dimock’s inpatient detox program, which was next door.

Minter-Jordan joined Dimock in 2007 as chief medical officer, and took the helm as CEO in 2013. She says her mother, a nurse for 30 years, inspired her to want to help vulnerable populations in her career, one patient at a time. Today, she says, that patient who entered Dimock’s detox program—and went on to receive job training at one of the center’s residential programs—is employed and has her own home. Whenever she sees Minter-Jordan, she tells her, “Dimock saved my life.”

Minter-Jordan enjoys seeing patients, but in her role as CEO, she says, she is “making a larger impact on the system and helping many more patients and clients.” After completing the Sinai Hospital Program in Internal Medicine at the Johns Hopkins University School of Medicine, Minter-Jordan was an attending physician and instructor of medicine at Johns Hopkins Medical Center. She then completed an MBA at the Johns Hopkins School of Professional Studies in Business and Education, an experience that taught her “to look at quality improvement and processes in order to improve care,” she says.

The Dimock Center has 400 employees serving more than 17,000 clients in four economically disadvantaged suburbs of Boston. Dimock defines health care more broadly than many institutions; for example, it considers education a key component of successful long-term outcomes. Its Early Head Start and Head Start programs serve almost 400 children, and each year some 200 adults earn GED diplomas.

All patients seen by a pediatrician or internal medicine physician are screened for substance or mental health issues. Dimock offers “the full continuum of substance abuse services,” both inpatient and outpatient, Minter-Jordan says. Because behavioral health services are fully integrated and colocated, “we have better outcomes and better patient and provider satisfaction,” she says. “We can take care of your diabetes better, because we are taking care of your depression.”

Dimock runs on a combination of federal funds, reimbursable health care transactions, and donations; one of Minter-Jordan’s near-term goals is to gather the data to demonstrate its value to stakeholders. She says Dimock’s outcomes exceed those of state and national institutions on prenatal care, childhood immunizations, asthma management, cancer screening, HIV linkage to care, and a number of other important indicators.

Attracting and retaining dedicated physicians is another ongoing challenge, especially in light of the salary requirements of those with large medical school loans to pay. As a federally funded institution, Dimock offers a physician loan repayment program, and there are other rewards, Minter-Jordan says. “What drives many of our physicians is the ability to practice in a team-based environment,” she says.

Minter-Jordan lives not far from Dimock, in West Roxbury, with her husband, Lawrence, a high school special educator, and their two daughters, ages 8 and 10. She credits Lawrence with making it possible for her to balance work and family life. “I would not be successful in my career without having a husband who is an excellent father and whose schedule is more flexible and consistent than mine,” she says.

Be Our Guest

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How can we provide a good home for our microbiomes, so they’ll keep us healthy?

Fecal transplants may be one of the more surprising health news sensations in recent years. The process of transferring small amounts of one person’s stool to another’s gastrointestinal tract to treat a dangerous bacterial disease just seems too icky to make it out of the pages of obscure medical journals.

The media’s fondness for potty humor aside, it’s the astonishingly high success rate of the procedure in curing severe Clostridium difficile infections—as high as 90 percent in some studies—that has the public, and many physicians, excited about its potential. But fecal transplants also happen to dovetail nicely with that other media darling, the microbiome.

“I have patients who come to see me all the time who don’t have C. diff.—they have fatigue, bloating—and they’re insisting their microbiome is disrupted and a fecal transplant would help,” says Colleen Kelly, MD F’06, assistant professor of medicine and one of the nation’s, if not the world’s, foremost researchers and practitioners of the procedure.

Kelly’s patients can be forgiven for believing the microbiome holds the answers to life’s most vexing medical questions. Whatever the malady, from allergies and obesity to stress and low IQ, someone has declared the microbiome plays a role, some news outlet has breathlessly reported it, and most of the public ends up hopelessly confused.

But the field of microbiome research is so new that not everyone even agrees what “microbiome” means. So anyone who states definitively what our microbial fellow travelers can and can’t do for our health is probably peddling snake oil.

“We know it’s important. We know there’s a lot of research that needs to be done,” Jason Shapiro, MD RES’08 F’11, assistant professor of pediatrics and of medicine (clinical), says. “But how it affects the day-to-day treatment of our patients? We’re not there yet.”

That’s also what makes the microbiome so exciting to study. “It’s uncharted waters,” Kelly says. “It’s kind of fun to do things that haven’t been done a zillion times before.”

Path of Resistance

“This isn’t in your textbook,” Peter A. Belenky, PhD, assistant professor of molecular microbiology and immunology, told his Introductory Microbiology class one afternoon in late March. He was about to deliver a lecture on the microbiome, but, he cautioned the hundred-plus undergraduates before him, “the science is being done now, so anything I say could change.”

Here’s what (most) scientists agree on: the human microbiome is the trillions of microbial cells—bacteria as well as fungi, viruses, and archaea—and their individual genomes that have co-evolved with us over millions of years. Most of our microbiome’s members are benign or beneficial: they help with digestion and vitamin production, prevent pathogens from establishing themselves and doing harm, and play roles in metabolism and immune function.

About 1,000 species of microbes call Homo sapiens home, and have adapted to many different communities, including the gut, mouth, skin, lungs, and virtually every other bodily surface, inside and out. The microbiome gets its start when we’re born—though whether we come into the world vaginally or by C-section changes its initial makeup—and it grows and diversifies until we’re toddlers, then stays remarkably stable for the rest of our lives. Estimates of how many microbes there are in an adult body vary wildly, from 10 times the number of human cells to a 1-to-1 ratio that tips in our favor with each bowel movement. Regardless, it’s a lot, making it all the more remarkable that the study of the microbiome is only a few decades old.

So now that they know it’s there, scientists are asking: how do all those cells function in concert with our own? What happens when the microbiome’s delicate balance is upset, a condition known as dysbiosis? How much does that affect our health, and which afflictions does it cause? How can we hone our treatments to protect ourselves, as well as our microbiomes?

Belenky is trying to understand, at a genetic level, microbial response to external stressors, like antibiotics, and the role that plays in antibiotic resistance and disease. The problem, he says, often begins when we use broad-spectrum antibiotics to target one, specific pathogen. “But with the microbiome, you actually target 1,000 organisms,” he says. “We mostly know how [an antibiotic] affects the target bacteria, but not the other 999.”

Bacteria are able to share genes by taking up DNA directly from their environment. While they most commonly swap genes with fellow microbes, any genetic material that can aid a bacterium’s survival is fair game for uptake. “They can take up DNA from a mammoth bone,” Belenky says.

Gene transfer has a community benefit much of the time—in response to environmental changes, our microbes’ genomes can adapt much more quickly than ours can. But that ability also aids antibiotic resistance: if a microbe has a gene that can protect it from a drug, other members of the microbiome will take it up, including those that cause disease. That’s why “the toxicity [of antibiotics] to nonpathogenic organisms is just as important as the toxicity to pathogenic organisms,” Belenky says.

“In the impending antibiotic crisis—or it’s already here, depending on who you talk to—our current antibiotics will no longer be functional,” he says. Nor is there much likelihood of new antibiotics being developed, given the exorbitant costs and the bleak reality that they, too, would quickly lose effectiveness. So why not work with what we have? “I want to identify ways to use our current arsenal better,” he says—perhaps by combining different drugs, playing with duration of treatment and dosage, or other variables.

At Rhode Island Hospital, Belenky is recruiting inpatients to spit into vials so he can study how narrow- and broad-spectrum antibiotics affect the oral microbiome. It’s tricky because he needs a no-treatment baseline, yet most patients receive a dose of antibiotics soon after arrival in the emergency department, he says; “so we have infectious disease docs sitting in the ER for us and following patients.” After three days they collect another saliva sample, to see how the microbial community has changed.

“We’re using the oral microbiome to look at transcriptional profiles because while most research is done on the gut, on fecal samples, transcriptional changes happen in minutes or seconds,” Belenky says. “It takes food six or seven hours at a minimum to move through the gut, so [fecal]samples are too old. Oral samples show exactly what happens at the second we collect the sample. It’s essentially a freeze frame.”

His research is possible thanks to the latest technological advances that allow him to sequence an entire genome in hours, for relatively little cost, and gather data on transcriptional, metabolic changes. “We weren’t able to do that before,” Belenky says. But scientists still can’t culture most of the microbiome’s members because they seem to depend on each other, as a community, to grow, he adds.

For the past decade the revolution in sequencing technology, coupled with the realization that our bodies housed many more microbes than we could grow in a petri dish, meant that most microbiome research was descriptive and correlational, Belenky says. Papers described what species were present, and how microbial communities differed in people with disease. But the bar for publication has been raised. “Articles now are much less descriptive,” he says. “Now you need to do real science. You need to figure out, why are changes occurring, related to health outcomes?”

Few, if any, of those “whys” have been answered definitively. Even the premise of much of Belenky’s research—that overuse of antibiotics is harming us—is a strong but as yet unproven theory. “Statements that say, we should maintain microbiome diversity, reduce antibiotic use, use probiotics, are most likely true on a total population level,” he says. “But when it comes to making this decision for a specific patient, it becomes a lot harder. We simply don’t have the studies to provide concrete guidance to physicians about risk-benefit assessment of withholding therapy.

“This puts physicians in a difficult situation,” Belenky adds. “They know that overuse of antibiotics is a problem, but they don’t have all the tools at their disposal to address it.”

Mice in a Bubble

Deep in the bowels of the BioMed Center, research assistant Irina Maglysh dons a full complement of personal protective equipment—gown, shoe and hair covers, gloves, face mask—and swipes into a large, white room. In the middle, on waist-high tables, are several large, rectangular bubbles, inflated with sterilized air, each with a half-dozen clear plastic boxes inside them.

These are the sterile living quarters of about 50 germ-free mice, so called because, since birth, not a single microorganism has inhabited their bodies. Everything in their isolated enclosures—food, water, bedding—has been autoclaved; and every two weeks, Maglysh collects and tests some of the cleanest feces on the planet to confirm their aseptic state.

This is one of only about a dozen germ-free mouse colonies in the US, a technological development that, along with affordable, rapid genome sequencing, has accelerated microbiome research in recent years. “In my lab, [these advances] let us ask how a single bacterial species interacts with a host, to really delineate the role of keystone species in the gut environment,” says Shipra Vaishnava, PhD, assistant professor of molecular microbiology and immunology. This allows her to zero in on genetic changes and larger health impacts when microbes are added or eliminated.

“Bacteria can influence many aspects of host physiology,” Vaishnava says. “But how do we go from changes in the bacteria in the gut to having [a disease]? What are the key molecular pathways?” Vaishnava has a particular interest in the cells that line our intestines, and the role they play in host-microbe interaction. She wants to figure out what bacteria live where within our guts, to understand how that might influence our health.

“Scientists haven’t really thought about bacteria in the gut as, ‘Where are they with respect to host tissue?’” she says. “Maybe some diseases [occur]because bacteria are in the wrong place. But these differences wouldn’t come out if you look at the feces for who’s there.”

To tease out this biogeography, Vaishnava tailors the microbiomes of her germ-free mice by introducing into their guts the bacteria she wants to study, a science known as gnotobiotics. Her team then dissects sections of mouse intestines and, under microscopes and with lasers, isolates cells for sequencing to determine each species’ location. Armed with that knowledge, they can then tag the bacteria with fluorescent probes and see what effect antibiotic treatment or infection have on the location and abundance of these bacteria.

The research could someday answer many questions about our microbes and our health, Vaishnava says: “how the epithelial lining is regulating our gut microbiome, how it’s negotiating these [host-microbe] interactions, what are the mechanisms that help us maintain a peaceful relationship—and if you don’t have the mechanism, what is the physiological outcome?”

Defects and other disruptions in the gut epithelial lining have been observed in many diseases, from Crohn’s to liver cirrhosis, but it’s too early to say whether the cause is genetic, environmental, or lifestyle factors, or some combination of the three. “The diseases we are studying are so complex,” Vaishnava says. “It hasn’t been figured out, but I think it’s just a matter of time.”

Every Breath You Take

Though most research and knowledge of the microbiome is related to the gut, our bodies house billions of microbes specialized to other locations, including our hair, nostrils, and urogenital tract; our skin is home to many distinct communities, from our hands to our eyelids to our navels. Dependent on pH, moisture, and other factors, our microbial populations are as different, and as specialized, as the ecosystems of a reef and a desert.

Just a few years ago, Amanda Jamieson, PhD, assistant professor of molecular microbiology and immunology, became one of the first people to focus her research on the lung microbiome. “The first Human Microbiome Project left out the lung because it was thought to be sterile,” she says, referring to a five-year NIH push to identify and map our bodies’ microbial residents and find relationships between the microbiome and disease.

Jamieson was at the University of Vienna at the time, studying bacterial pneumonia, which can arise when a small amount of pathogenic bacteria infects someone recovering from influenza. “I thought, there has to be bacteria [in the lung]because we breathe it in all the time,” she says. “So I asked if bacteria in the lung could be causing it. … I did a PubMed search and got nothing.”

It’s well known that flu suppresses the immune response, and Jamieson wants to know if our lung microbiome influences that response, how it changes with infection, and whether it can be manipulated to improve outcomes. In September she won a Defense Advanced Research Project Agency (DARPA) Young Faculty Award to further that work.

Because lung microbiome research is many years behind that of the gut microbiome, it’s still in the descriptive phase, Jamieson says—collecting samples, sequencing genomes, and identifying what’s there. She also has to tease out the permanent residents from the visitors: which bacteria are there because they were inhaled, and which are part of an established community?

She is conducting some of that descriptive work on nasopharyngeal swabs collected from flu patients, to see if there’s a correlation between illness and bacteria. But getting samples from a living human’s lung is difficult, and uncomfortable, requiring insertion of a bronchoscope and then scraping or washing cells from the airway.

Jamieson’s lab uses mouse models, though that has its own challenges. “Culturing bacteria straight out of the lung is very difficult,” she says. “The intestine has a stratified, much more organized structure than the lung, which has a lot more nooks and crannies.” So after they painstakingly identify what bacteria are present, they culture strains ordered from a scientific supplier to test immune response to influenza and whether changing the amount of bacteria makes the flu worse or better.

In vitro research is unlikely to paint a full picture of the lung microbiome, however. “In human patients, there is no evidence of bacterial pneumonia in culture—but is there something there, and we just can’t culture it?” Jamieson says. “A lot of people with symptoms don’t have diagnosable bacteria.” The lung microbiome is smaller and less diverse than that of the gut; there is evidence in mice that low levels of harmful bacteria in the lung will cause problems.

Ultimately Jamieson hopes her lab’s focus on the role of bacteria in co-infections will lead to better patient outcomes. But she’s wary of the lessons learned from broad-spectrum antibiotics; treatments must be mindful of all systems in the body, she says. “We’re trying to develop ways to affect the lung microbiome without affecting the intestinal microbiome,” she says.

Cause and Effect

C. difficile infection is one of the most clear-cut examples of the importance of our microbiome to our health. The disease nearly always arises from a course of antibiotics that wipes out much of the gut’s biodiversity, allowing C. difficile, a normally benign resident of the intestine, to flourish. It can cause severe diarrhea, colitis, dehydration, and worse; according to the CDC, of the nearly half a million people sickened by C. diff. in 2011, about 15,000 died.

In the most serious, recurrent cases that don’t respond to standard treatment, fecal microbiota transplants have been remarkably successful at restoring patients’ gut microbiomes, and their health. Kelly, a gastroenterologist at the Women’s Medicine Collaborative in Providence, has led several studies in which about 9 in 10 patients were cured, with few side effects. But she cautions that more research is needed; only a few small randomized controlled trials have been done to date, and there’s little long-term safety data.

Also, though donors are rigorously screened before their stool is accepted for transplant into a C. diff. patient, there’s still a risk of other, unforeseen complications. Kelly says the FDA has shown interest in establishing a fecal transplant registry, like that for bone marrow. It would be funded by the NIH and follow 5 ,000 patients for up to 10 years after a fecal transplant. “It would be really helpful to the field, to get that safety data,” she says.

Patients suffering from other disorders of the GI tract could be helped, too. “Our next hope is moving into these other diseases associated with alterations in gut bacteria,” such as irritable bowel disease (IBD), Kelly says. She’s cautiously optimistic about small studies done so far. But she adds: “Nothing is all good. Are there people who would become worse after a fecal transplant, or would it trigger another problem?”

A more standardized approach, in the form of a pill, could prove safer than fecal transplants in the long term. Kelly is taking part in a phase II trial of a capsule containing just a few bacteria, derived from human stool, to treat C. difficile infection. Other companies are trying to design fully synthetic formulations; if successful, Kelly says they may be able to apply that knowledge to the treatment of other diseases associated with dysbiosis. “I’m a believer this is going to happen,” she says.

So is Shapiro, a pediatric gastroenterologist at Hasbro Children’s Hospital, though he thinks such therapies are “years away.” Many of his young patients suffer from IBD, the rate of which is increasing across the US and the world, he says. “This is proof of concept of how important the study of the microbiome is,” he says. “The diversity of [gut]flora in the US is really low relative to those in developing countries. While we don’t have to deal with parasites or poor sanitation, we are seeing an overall increase in chronic diseases such as IBD. … Is it causative?”

Shapiro may have the data to figure that out. Since he was a resident in pediatrics at Hasbro, he’s been involved with the Ocean State Crohn’s & Colitis Area Registry (OSCCAR); he took over as PI last year. The group annually collects blood, urine, and stool samples from more than 400 patients in Rhode Island and is examining the longitudinal data for specific microbiome signatures and how they change over time. “Are these biomarkers of disease or potential therapeutic targets?” Shapiro says. “How does the microbiome change with treatment? Analyzing the samples from OSCCAR represents a great opportunity to complete a variety of meaningful microbiome studies.”

OSCCAR began data collection in 2008, and already has a massive amount of it. In addition to sequencing patient and bacterial genomes in blood and fecal samples (they haven’t started examining the urine samples yet), they’re looking at protein signatures, and layering that with patient metadata, such as age, sex, and type of disease. “You need a mathematician now to do this,” Shapiro says. “To integrate and analyze these huge datasets while making it clinically relevant is exceptionally challenging.”

But he believes that down the line all of that data will help them refine treatments. “Now the way we treat IBD is such a shotgun approach from an immunologic standpoint. While our current medications work, they are not without risk, including the rare chance of developing a secondary malignancy,” he says. “You’re treating a disease by wiping out an entire neighborhood, but it would be nice to find the exact house.”

The future of personalized medicine, in which therapies are tailored to individual patients, will likely depend on better understanding of the microbiome, which appears to be more individual than even our genome; humans are more than 99 percent similar to each other genetically, while our microbiomes show considerably more variability. Even identical twins can have significantly different microbiomes, due to everyday differences in diet and other environmental and lifestyle factors. But Shapiro cautions that the potential to develop individualized treatments for conditions such as IBD by manipulating the microbiome has “yet to be determined.”

“The more we understand, the more we can treat [patients]with a targeted approach,” Shapiro says. “Hopefully, 10 to 20 years from now, that’s where we’re going.”

Dirty Living

Understanding the microbiome has big implications beyond treatment of individual patients: it is critical for the health of the population. Antibiotic resistance has brought us not just C. difficile infections but an ever-growing list of terrifying pathogens, including methicillin-resistant Staphylococcus aureus (MRSA), New Delhi metallobeta-lactamase-1 (NDM-1), and multidrug-resistant tuberculosis (MDR-TB). Many gain a foothold among already weakened patients in health care facilities, but others are infecting healthy people: MRSA, for example, is known to spread among athletes who play contact sports.

“As a society we have a responsibility to limit antibiotics in conditions where they are not absolutely indicated,” Shapiro says. Antibiotics play an important role in medicine, to be sure, and in some patients they offer the only hope for recovery. But the CDC reports that up to half of antibiotics prescribed are unnecessary or aren’t taken as directed.

Alexander Fleming, the discoverer of penicillin, saw this coming. In his acceptance speech for the 1945 Nobel Prize in Physiology or Medicine, he warned, “there is the danger that the ignorant man may easily underdose himself and by exposing his microbes to nonlethal quantities of the drug make them resistant.”

This is precisely what is occurring in US agriculture today: farmers give cattle, pigs, chickens, and other animals low doses of antibiotics preventively and to promote growth; statistics suggest that up to 80 percent of the antibiotics sold in the US is used for livestock, and despite FDA rules stipulating otherwise, investigators have found that many are sold over the counter. Pigs carry MRSA and spread it to farmworkers; it even has been found in pork for sale in supermarkets. In 2013 the CDC estimated that of the more than 2 million annual cases of antibiotic-resistant infections, one in five originated in food and animals.

Antibiotics given to the youngest patients have potential to cause long-term harm. Because the microbiome is still developing until we are between 2 and 3 years old, antibiotics may permanently alter its diversity; though, again, nothing is certain, long-term problems possibly related to a stunted microbiome range from allergies to IBD to celiac disease. This theory is of a piece with the “missing microbe hypothesis,” advanced by Martin Blaser, MD, a microbiologist at the NYU School of Medicine, who suggests that the overuse of antibiotics has ushered in modern-day Western “plagues” like obesity, asthma, and type 1 diabetes.

And then there’s the “hygiene hypothesis,” which states that a lack of exposure to infectious agents early in life—like the germs passed around in day cares, on playgrounds, and by animals—suppresses the immune system, in which the microbiome plays some as-yet unclear role. We are, essentially, too clean. “Keeping your kids dirty might be good,” Belenky says. Pulling up data plots of microbiome diversity in infants, he notes, “If you have pets, your early microbiome looks like your pet’s.”

Is that a good thing? Does it make those kids healthier adults? No one knows; at this point, it’s merely an observation, just as any implied connection between antibiotics and diabetes is correlative at best. To state otherwise is to give desperate patients false hope. But even though we don’t yet understand the mechanisms of the microbiome, we are certain it needs protecting, and many of the ways we think we can do that are harmless at worst, and who knows—they may help.

Since she began studying the microbiome, Shipra Vaishnava, whose kids are 4 and 7, says she’s made some lifestyle changes to nurture her and their inner microbes: she lets them dig in the dirt, avoids antibiotics and processed foods, schedules their vaccinations, and once in awhile she eats without washing her hands.

Eating better, playing outside, getting preventive care—sounds like a prescription for good health for all of our cells, human and microbial.

Cultural Shifts

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Have duty hour restrictions improved the resident experience?

Click. I hit my alarm and roll out of bed. It’s dark, very dark. What day is it? Doesn’t matter.

Throw my clothes on, grab my lunch from the fridge, and make my way to the car. As I drive to work, a pink sky bleeds into gray clouds. Is it rising or setting?

Again, frivolous question. What matters is that work starts in T-30 minutes. If you’re on time, you’re late—a modus operandi I acquired from my military spouse.

Swipe. Park. Lock car. Walk. A gush of sterile wind blows back my hair as I trot through the sliding doors.

Go.

Lights, sounds, smells, and clinical information hammer at the doorway to my senses.

Move faster.

Watching my brain at this moment reminds me of staring at the AOL icon as the internet tries to load. Frustrating, to say the least.

The key is focus. Identify the task at hand and execute. Check your work, and execute again. Now the real test: patient interaction. You know your emotions are down there somewhere, like that thought that sits at the tip of your tongue but just won’t come. You mold your face into a resting smile, double-check the name, inhale, and knock.

Resident work hour restrictions were formally put into place in 2003, and further revised in 2011 by the Accreditation Council for Graduate Medical Education (ACGME). Twenty-eight-, 30-, or 36-hour shifts? Experts agreed that peak function—or even adequate function—cannot reasonably be maintained. Hence the birth of the 80-hour week, the 16-hour shift limit for first-year trainees, and the eight-hour minimum between shifts. Yet many clinicians expressed concern about continuity of care. Who will have ultimate ownership over these patients? Patient care hand-offs are ripe for error. Will these changes really prevent medical errors?

The medical community responded with the FIRST trial, a randomized “non-inferiority” comparison of standard ACGME work hours versus flexible work hours that was published in the New England Journal of Medicine in February. Participants included general surgical residencies and their affiliated hospitals. They measured outcomes including: the 30-day rate of postoperative death or serious complications (primary outcome); other post-op complications; and resident perceptions and satisfaction regarding their well-being, education, and patient care. The study found that the residents working flexible hours were more likely than the standard policy group to report improved experiences on several measures, including continuity of patient care, acquiring of operative skills, and professionalism.

According to principal investigator Karl Bilimoria, MD, of Northwestern University’s Feinberg School of Medicine, “Residents in the flexible duty hour group did not work more hours; rather, they worked more effectively by rearranging their hours.” At the very least, the authors concluded that “less-restrictive duty-hour policies for surgical residents were associated with non-inferior patient outcomes and no significant difference in residents’ satisfaction with overall well-being and education quality.”

The sample size was good, the survey was carefully crafted. And yet, these results do not sit well with me.

KNOW THYSELF

Individuals who go into medicine are all, to some degree, perfectionists. We thrive on performance, we push limits, and we have high expectations. The very lens through which we understand reality is inherently biased toward these goals. In many ways, we come to understand our own dissatisfaction as a personal failure—we can’t balance our lives, we can’t appropriately handle the stress, we can’t keep up during long shifts. As such, I begrudgingly admit that we may not be the best judges of our own well-being. Thus mental illness and suicide continue to rise among residents and physicians.

So now what? The debate over work hours and hand-offs, while well-intentioned, somewhat misses the point. I am a trainee in a pediatric medical residency, and would argue that each specialty has its own, unique ecosystem within the medical biome. We need to think larger, and more about process. Helen Darling, CEO of the National Business Group on Health, put it succinctly: “Hospitals and medical schools should use business process reengineering to change the wasted tasks on which residents currently spend their time.”

How can we make residents more productive? How can we remove the systemic barriers to rapid and effective communication, order verification, patient information, and documentation? How can burgeoning IoT (Internet of Things) technologies enable these tasks?

Answering these questions will violate duty hours, indeed.

What would MD’16 do?

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We asked members of the (recently graduated) MD Class of 2016: What advice would you give to yourself on your first day of medical school?


Rachel Blake MD’16
Specialty: Obstetrics & Gynecology
Residency: Beth Israel Deaconess Medical Center / Harvard Medical School
“Dive into every opportunity, even if you’re not sure whether this will end up being your specialty choice or your career path. Make sure to try to enjoy every moment of this journey.”

Natasha Coleman MD’16
Specialty: General Surgery
Residency: NewYork Presbyterian-Columbia / Columbia University Medical Center
“This will be really hard and that’s OK. Don’t waste your time on doubt because you’re supposed to be here and you can do this!”

Minoo D’Cruz ’11 MD’16
Specialty: Family Medicine
Residency: Memorial Hospital of Rhode Island / Alpert Medical School
“Be kind to yourself. Celebrate the small victories, and brush off the bad days. Everyone has them. And remember, at the end of the day, this is not about your grades or your accolades. This is about those extra moments you spent by a patient’s side, whispering words of comfort, when no one else is watching.”

Patrick Lec ’12 MD’16
Specialty: Urology
Residency: UCLA Medical Center / David Geffen School of Medicine at UCLA
“Every year gets busier, so enjoy the days off!”

Theresa Lii ’12 MD’16
Specialty: Anesthesiology
Residency: Stanford University School of Medicine
“Trust yourself and trust others. I frequently struggled with reconciling my desire to learn with my fear of accidentally harming patients. I was good at putting on a confident face whenever I tried something new, but internally I would be fretting about messing up and hurting someone. It took me until fourth year to develop enough confidence to comfortably go after new tasks and trust my seniors to supervise me appropriately. The system had enough checks and balances to let me safely stumble through my ‘firsts,’ and with each successful first, I grew more confident in my ability to try the next new thing. I just wish I had known earlier that trusting myself and others is key.”

Olivia Linden ’12 MD’16
Specialty: Radiology
Residency: Cambridge Health Alliance / Harvard Medical School (transitional); UC San Francisco / UCSF School of Medicine
“Be open to everything, don’t be afraid to try anything, and you’re going to make some really amazing mentors and friends!”

Will Mangham MD’16
Specialty: Neurological Surgery
Residency: University of Tennessee College of Medicine
“Take time during your first two years to learn about all of the different medical specialties. Spend time with doctors from different specialties to get a sense of where you can see yourself. Your grades during the first two years of medical school are not important, so invest time now into making career decisions. It works to your advantage to know early on what specialty you want to go into so that you can begin strengthening your résumé.”

Caitlin Naureckas ’12 MD’16
Specialty: Pediatrics
Residency: Massachusetts General Hospital / Harvard Medical School
“Bring a sweater because the lecture hall will be freezing! And keep an open mind—there’s a lot you don’t know yet, and even though you think you have it all figured out, med school will always find a way to surprise you.”

Liz Rubin MD’16
Specialty: Obstetrics & Gynecology
Residency: Hospital of the University of Pennsylvania / Perelman School of Medicine at the University of Pennsylvania
“Wake up early, and when that inevitably fails, stay up late. Do the things you want to do, not the things you think you should want to do. Find mentors who think you are more awesome than you think you are. Shoes that give you blisters don’t get second chances. Eat more kale. Everything is going to be OK.”

Ravi Sarpatwari MD’16
Specialty: Emergency Medicine
Residency: Rhode Island Hospital / Alpert Medical School
“Gain exposure to as many medical specialities as possible from day one, whether through shadowing, research, or longitudinal exposure. You may be surprised by what fields you find interesting, and the only way to appreciate that is to see how the field is practiced on a daily basis. There are so many medical fields out there, and unfortunately there is not enough time during the clinical years to gain full exposure.”

Jovian Yu ’12 MD’16
Specialty: Internal Medicine
Residency: Yale-New Haven Hospital / Yale School of Medicine
“Look out for the opportunities to learn more about myself. I think that the most valuable thing I have gained from medical school beyond the knowledge, experience, and privilege of working with patients is a better understanding of my personal identity both as an individual and as a future physician.”

Mega Milestone

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There was lots to celebrate at the first-ever emergency medicine reunion.

Feeling lost, anxious, clueless—just utterly, glaringly, brand new—every physician has been there on the first day of residency. But what’s it like if it’s the residency program’s first day too?

“It certainly was an experience like no other,” says Selim Suner ’86 ScM’87 MD’92 RES’96 F’04, one of seven members of Brown University’s first emergency medicine (EM) residency class. “On my first day as an intern, there were no senior residents to guide me. We took care of the sickest patients from day one. We did a lot of learning on our own.”

From those shaky first steps, the Alpert Medical School emergency medicine residency program—the first in the Ivy League and in New England—now stands firmly as one of the top programs in the nation. The group boasts more than 100 physicians, who train 48 residents and serve 270,000 patients each year.

“It’s been a very interesting journey to see what those seeds that we sowed turned into,” says Suner, who has turned into a professor of emergency medicine and director of one of the department’s many subspecialties, the Disaster Medicine and Emergency Preparedness Fellowship Program.

Suner was also a member of the planning committee for a reunion like no other: the Department of Emergency Medicine Mega-Anniversary Celebration, an over-the-top name to mark three significant milestones: the 25th year of the residency program; the 20th year of the University Emergency Medicine Foundation, the physician practice plan; and the 12th year of the academic department.

Peter Chai ’06 MMS’07 MD’10 RES’14, an assistant professor of emergency medicine at the University of Massachusetts Medical School, was also on the planning committee, and Brian Clyne MD’97, an associate professor of emergency medicine and of medical science at Alpert Medical School, was chair. More than 120 faculty, alumni, and residents attended the two-day celebration, in September, including more than a dozen who spoke about their careers and how the EM residency helped shape them.

“They talked about how Brown was the catalyst for our ability to become effective physicians and to find all of our interests outside of Brown and leverage that stuff to become who we are today,” Chai says. “People who go to Brown are a little bit different than everybody else, in a good way.”

Plus, he adds, “It’s cool, we all went to Brown! We all had that singular experience.”

The Mega-Anniversary marked one other department milestone: its 10th year with Brian Zink, MD, the Frances Weeden Gibson–Edward A. Iannuccilli, MD, Professor of Emergency Medicine, at the helm. “He really did take us to the next level and expanded the department,” Suner says of Zink, who came to Providence from the University of Michigan in 2006 to be the inaugural chair. “He opened the program to the rest of the country. It was not a homegrown program anymore; now it had a nationally well-known leader. That legitimized us to some extent.”

In gratitude, the reunion organizers gave Zink the 2016 Outstanding Leadership in Emergency Medicine Award, and promptly renamed it the Brian J. Zink, MD, Outstanding Leadership in Emergency Medicine Award, which will be given annually.

“EM’s not the best at reflecting on the past—we’re always moving forward,” Zink said at the celebration. He asked attendees to reflect on the hard work, the vision, and especially the people who built “one of the premier departments of EM and, I think, the best EM residency in the world.”

In a toast at the final banquet, Zink added: “What we are celebrating today is on the backs of people who had it much harder than we do today. It’s not enough to say thanks. We are so indebted to you.”

Baby Steps

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As more and more infants are born dependent on opioids, hospitals and researchers are working together to chart the best path to recovery.

Caitlyn O’Brien has been here before. That doesn’t make it any easier.

It’s mid-August, and the slim 29-year-old is eight months pregnant with her third child, and first son. She shifts uncomfortably in a floral-patterned chair at Women & Infants Hospital, her partner, Perry Fedorak, 26, by her side. They’re preparing, for the second time, to bring a baby into the world dependent on opioids.

“I’m scared,” O’Brien says. “It sucks that he has to go through this for the decisions I made.”

The medical director of the Newborn Nursery, Adam Czynski, DO, has a different take.

“It would be worse if you weren’t taking medication,” he says, referring to the methadone O’Brien needs to recover from an addiction to Percocet. If she’d detoxed, he says, she could have gone into withdrawal. “You’d be at risk of delivering preterm. Any parental stress can be bad,” Czynski says. “You’re making sure that his home is perfect.”

But when he’s born on August 25, after 38 weeks of daily methadone, Bentley Fedorak will go cold turkey. Then they’ll wait for signs of withdrawal, such as fever, diarrhea, or tremors. The constellation of symptoms indicates neonatal abstinence syndrome (NAS), and it extends an infant’s hospital stay by days or weeks as clinicians assess the severity of the withdrawal and administer an opioid—usually morphine or methadone—to ease the symptoms and wean the newborn off the drug.

“His body is making changes based on hormones and chemicals he’s seen,” Czynski tells the anxious couple. “Then when he’s born, we’ll tweak it. We’ll slowly let him readapt back.”

O’Brien and Fedorak saw this firsthand in January 2015, when their daughter, Hailie, was born. She stayed at Women & Infants for two weeks as doctors helped her taper off the opioids in her bloodstream.

“That was the hardest thing when I had Hailie, when my dad asked, why are you still here?” O’Brien says. “It felt like forever.”

But she says it helped that Hailie is participating in a longitudinal study at Brown and Women & Infants, which O’Brien and Fedorak are doing again with their son. Though children have been born dependent on opioids for years, no one agrees on the best way to wean them off, so every hospital that treats NAS babies has its own standard of care. The trial now underway is assessing treatment strategies and long-term effects, an attempt to define a no man’s land of personal experience, observational studies, and anecdotal evidence.

“If we can be of assistance to other people, if I could save someone else from going through the unknown, help find the best way to make sure the baby’s comfortable, the mother’s comfortable…” O’Brien trails off.

“Nobody wants their child to have to go through this.”

Old Problem, New Face

The escalating opioid epidemic has claimed millions of victims. In 2014, the Substance Abuse and Mental Health Services Administration reports, there were 1.9 million people in the US with a substance use disorder involving prescription pain relievers, and nearly another 600,000 involving heroin. Hundreds of thousands more use an opioid replacement therapy, such as methadone or buprenorphine, to treat their dependence.

The sheer scale of the tragedy has done much to raise awareness about the disease of addiction, and that it can happen to anyone. That includes pregnant women. The rate of babies born in the US with neonatal abstinence syndrome has skyrocketed along with opioid use: from 2000 to 2012 it nearly quintupled, to 5.8 per 1,000 hospital births. According to a 2015 analysis in the Journal of Perinatology, that’s 21,732 infants diagnosed with opioid withdrawal every year.

It’s a distinctly regional issue: in New England, the NAS birth rate is 13.7 per 1,000, while in the Pacific states it’s 3.0. “This is the only place I’ve encountered with a specific NAS unit in the nursery,” instead of in the NICU, says Czynski, an assistant professor of pediatrics at Alpert Medical School who moved to Rhode Island from southern California in March. “In California, it’s all methamphetamines,” he says. “Here, everything’s opioids, opioids, opioids.”

Thirty years ago, it was cocaine. Barry Lester, PhD, professor of psychiatry and human behavior and of pediatrics at Alpert Medical School, has been studying the effects of drug use during pregnancy for decades. Babies exposed to cocaine in utero are born with the drug in their system, and right away they may have a high-pitched cry, tremors, and other symptoms that look like mild opioid withdrawal; as the newborn metabolizes the cocaine, the symptoms go away.

But how did cocaine affect these children long term? Many people—doctors, lawmakers, the general public—were sure they suffered developmentally for it. “People didn’t understand the consequences of prenatal cocaine exposure,” Lester says. “There was a knee-jerk reaction: cocaine equals inadequate mother equals take the infant away and put it in foster care.”

From 1993 to 2011 Lester ran the NIH Maternal Lifestyle Study, which followed almost 1,400 kids nationwide to document the long-term effects of prenatal cocaine exposure. Their findings suggested that poverty and other chronic stresses, not just prenatal drug exposure, adversely affected those children’s behavior, educational achievement, and other factors.

“There was so much hatred and anger in this country against these women using drugs, which has improved, I have to say,” Lester says. “Research has shown that addiction is a disease of the brain. … This is not about women willfully doing harm to their babies. It has helped dispel myths and deep-seated prejudices and shift policy from punitive to treatment approaches.”

What is Best?

Around the time Lester began recruiting for the Maternal Lifestyle Study, neonatologist Mara Coyle MD’86, P’15ScM’16 became the director of the level II nursery at St. Luke’s Hospital in New Bedford, MA. Right away Coyle was caring for patients with NAS, whose mothers had taken heroin or methadone. “Prescription opiates were not an issue yet,” she says. Twenty years later, “the face of opioid dependence has changed”—and so has treatment.

NAS is related to exposure in the latter stages of pregnancy; what opioid a woman is taking at that time—street drugs, replacement therapy like methadone or buprenorphine, or a prescription—will impact the degree to which the newborn will experience withdrawal.

But there’s no recognized standard of care for NAS treatment, leaving hospitals to figure it out on their own. Most use morphine or methadone; diluted tincture of opium (DTO) has fallen out of favor. Some administer sedatives like phenobarbital or clonidine to reduce opioid dosage. How much medication infants receive, and for how long, depends on the results of a scoring system that attempts to quantify NAS symptoms to standardize treatment, yet which every hospital interprets differently.

“It’s not because there’s been an absence of research,” Coyle says of the varied approaches. “There have been dozens of studies attempting to define which is the best treatment strategy for a standard of care. But what is ‘best’? Cut the length of stay? You can quantify that. Or is it long-term outcome? We don’t have the information, we don’t have good follow-up data, which ultimately is the more important issue.”

Coyle, a professor of pediatrics (clinical) at Alpert Medical School, who considers Lester a mentor, has published numerous papers since the early 2000s on treatment strategies for moms and babies and their effect on the newborns’ symptoms and length of hospital stay. For the double-blind, multisite MOTHER study, published in the New England Journal of Medicine in 2010, Coyle e valuated neonatal outcomes for exposure to buprenorphine and methadone, the more widely recommended treatment. In an earlier trial, in Pediatrics, she investigated whether phenobarbital alleviated NAS symptoms.

“I don’t think newborn treatment should be one-stop shopping,” Coyle says. “It’s not the exact same dosing strategy for each patient, because they have different levels of dependence.” She found that giving babies phenobarbital helped wean them off opioids, and go home, sooner. Meanwhile the MOTHER trial showed that infants who had been exposed to buprenorphine needed less morphine and the duration of treatment was shorter than those exposed to methadone.

“That’s important information [for mothers]to have,” says Coyle, who now sees patients at Women & Infants. “But they’re not the same drugs. … Buprenorphine has a ceiling of effect, meaning more drug doesn’t mean more opioid effect, so if you’re seriously addicted you may not be a candidate for buprenorphine because you could go into immediate withdrawal. So it’s not a replacement for methadone.”

A key part of Coyle’s work is prenatal consultation, to counter misinformation about replacement therapy and NAS. Most women don’t want to be on any drug when they find out they’re pregnant, she says; they want to quit then and there. “They don’t want their baby to go through withdrawal,” Coyle says. While some recreational users may be able to quit, she says the majority will relapse, which is why she recommends replacement therapy; piling the agony of detox onto the normal discomforts of pregnancy is simply unrealistic for most women.

“The first thing I tell a patient is congratulations for being in treatment. It’s far better to be in treatment than to be using,” Coyle says. As for NAS, she tells moms, “It’s a medical condition, it’s short lived, and we’re going to help your baby get through that.”

Coyle focuses on the certainties of NAS during prenatal consults: withdrawal symptoms, how they’re assessed and treated, how long treatment might take, the benefits of breastfeeding. While opiate-exposed newborns have a greater incidence of complications, like low birth weight and respiratory problems, she says she doesn’t discuss these because not all babies will experience every problem.

A 2015 retrospective study in the Journal of Perinatology that Coyle co-authored with developmental pediatrician Jo-Ann Bier, MD RES’88 F’90, an assistant professor of pediatrics at Harvard Medical School, noted smaller head circumferences and lower motor skill development among infants exposed to high doses of maternal methadone. “This shouldn’t be interpreted as causal, but merely an observation of a select group of opiate-exposed newborns,” Coyle wrote in an email. “A prospective blinded study to specifically look at these outcomes would better confirm these findings.”

The need for such research is critical, Lester says. “There are no studies in the literature of the long-term developmental outcome of babies who went through NAS. Period,” he says. “One of my PowerPoint slides says, ‘Summary of outcome studies for NAS kids,’ and there’s nothing on the slide.”


Think Big

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In elephants’ cancer-resistant genes, an oncologist sees new hope for people.

A few years ago pediatric oncologist Joshua Schiffman ’96 MD’00 learned an astonishing fact. Elephants have an extraordinarily low rate of cancer, despite their enormous size and long lifespan.

An investigator at Huntsman Cancer Institute at the University of Utah, and a childhood cancer survivor himself, he’d dedicated his career to understanding why people get cancer and to caring for sick and dying kids, like the doctors who’d once cared for him.

He’d been studying human hereditary cancer syndromes, focusing on a tumor-suppressing gene that, when absent, heralds a nearly 100-percent cancer risk. Elephants, Schiffman learned, have 40 copies of the gene. “I almost fell out of my seat when I heard that,” he says. Over its lifetime, an elephant’s chance of dying from cancer is less than 5 percent.

The finding turned his research on its head. “What if we focus on who’s getting less cancer, not who’s getting more?” he asked himself.

Still, he didn’t see how this quirk of elephant genetics could translate into anything useful for humans. “People always would say, how will you actually use this discovery to help people?” Schiffman says. “I would say there’s not really a way to do that. Maybe one day we’ll find a drug that mimics the effects, but there’s no way of actually putting an elephant gene into people.”

That was before he met Avi Schroeder, PhD, a nanotechnologist in Israel. Their labs have since joined forces, and their goals are not small. “I want a world where no one has to go through what I went through, or what my patients go through,” Schiffman says. “Maybe one day, we can prevent cancer.”

Personal Touch

Many physicians are spurred into the field of medicine by a personal encounter with disease; many others because they have a doctor in the family. Schiffman first was inspired by his dad, Fred Schiffman, MD, a hematologist/oncologist and the Sigal Family Professor of Humanistic Medicine at Alpert Medical School. “He’s always there for his patients and his colleagues,” Josh Schiffman says. “When he goes kayaking, he puts his phone in a pouch so patients can reach him, or another physician can call him up.”

When Josh was diagnosed with Hodgkin’s lymphoma, at age 15, Fred initially sought help from his colleague Edwin Forman, MD ’56, P’92, who practiced pediatric hematology/oncology at Rhode Island Hospital, and then Hasbro Children’s Hospital, for more than 40 years. Josh, who ultimately was treated at Dana-Farber Cancer Institute, in Boston, survived his illness “very determined to be like Ed Forman,” he says. “I wanted to learn to be a good doctor humanistically and spiritually—to sit on the bed, hold a patient’s hand, and look them in the eyes.”

Schiffman enrolled at Brown in the Program for Liberal Medical Education, studying biology, psychology, and animal behavior as an undergraduate and spending his summers as a camp counselor, including working with seriously ill kids at the Hole in the Wall Gang Camp. In medical school he took an elective with Forman. “[Josh] was just wonderful with patients. Obviously he could identify with the patients and the families,” says Forman, now a professor emeritus of pediatrics at Alpert Medical School who still sees hematology patients at Mount Sinai and Elmhurst hospitals in New York City.

But Forman says he also witnessed Schiffman’s “terrific curiosity and independent creative thinking.” He recalled a 5-year-old patient who appeared to have a bone marrow disease, yet Schiffman insisted that because the boy had recently been bitten by a tick, they should order a blood test for ehrlichiosis instead of a marrow biopsy. “So we did both. The marrow came back normal, and the ehrlichiosis was positive,” Forman says. “A paper came out of it,” in the Journal of Pediatric Hematology/Oncology, in 2001.

“His aggression is not the kind that would ever turn anyone off,” Forman says, chuckling as he remembered Schiffman’s persistence. “It’s, hey, can we think about this in a different way?” He adds, “He’s always giving credit to others. … He credits me with more than I deserve.”

Schiffman says, “Ed Forman and my dad taught me your patients guide your career. You’ll learn more from your patients than from any medical textbook.” After graduating, Schiffman moved across the country for a residency and pediatric oncology fellowship at Stanford. During his first year as a fellow he saw a 4-year-old girl who had acute lymphoblastic leukemia and Li-Fraumeni syndrome, an inherited disorder that dramatically increases the risk of developing cancer, often at a young age. “I’d never heard of it,” he says.

As long as Schiffman could remember, he’d wanted to become a pediatric palliative care physician. But in that young patient, and her rare genotype, he found a new calling—at the start of life, instead of the end. “I wanted to know who is at risk for cancer,” he says, “and could there be a way to intervene?”

No Apologies

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To succeed in a male-dominated field, be yourself.

I carry a pink briefcase. Not a subtle pink, but a vivid, intense, practically bubble-gum pink. I set it down each morning among the ubiquitous black backpacks, drab brown briefcases, and camouflage baseball hats. I finish rounds and attend morning lecture, where the speaker invariably scans the room and identifies me as the only female in a sea of male orthopedic residents.

When I first arrived at Brown, in 2011, I was the fifth woman in the program, and at 16 percent female, our program matched the national average for orthopedics. However, as each successive Match Day yielded six men and no women, that number fell. And finally, as a fourth-year resident, I was the lone woman in the annual orthopedic residency photo, standing proudly in fuchsia high heels.

In medical school, senior attendings in multiple specialties tried to convince me that orthopedic surgery was for male jocks and athletic has-beens, and a female orthopedic resident told me that the only way to fit in was to chest bump my way through residency and “act like a man.” I questioned my choice. During residency interviews I was frequently asked what sort of things I did with my hands. Could I play the ukulele? Could I build a shed? Did I whittle wooden animal figurines? After I stared back blankly for a few seconds, I quickly endorsed my ability to shop for shoes online and my penchant for baking. Did participating in stereotypically female gender role activities make me unable to do orthopedic surgery? Despite my hesitance, I matched into orthopedics, believing in my passion for the patients, the surgeries, and their outcomes.

In the last five years, I have been called into my program director’s office because I have been easily identified as “the lady doctor,” for both the good and the bad (thankfully more frequently for the good). I have been told I’m too young or too pretty to be a surgeon, and that’s when I’m not mistaken for the nurse, physical therapist, or dietary aide. Yet I would choose it all again. The satisfaction of fixing fractures, restoring quality of life, and improving a patient’s pain and disability has far outweighed any of the perceived, or actual, negatives. I embrace being a woman in a department that has embraced me. I learned how to succeed while contributing a much-needed female perspective in a male-dominated field.

According to AAMC data, orthopedic surgery residencies and fellowships across the nation rank behind only interventional radiology and interventional cardiology for the lowest percentage of women. I have two female mentors among more than 30 attending surgeons in our department, both of whom are strong advocates for women in orthopedic surgery. Together we have spoken at interest groups, held workshops, and invited medical students to spend time with us, all in an effort to prove that orthopedic surgery is an amazing, fulfilling career for anyone.

Until these efforts translate into an increase in female orthopedic residents, there is significant work left to do. For now, I will continue to answer questions about what it’s like to spend my days surrounded by male colleagues (a little smellier and messier) and gently remind patients that my junior resident is not their surgeon despite his Y chromosome. I will then take my sparkly lead to the operating room, use a collection of power tools, and fix one more patient. When that patient walks into my office at follow-up, I will have a smile of satisfaction on my face. And maybe some delicious baked goods.

Open Mind

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Neurologist Karen Furie has devoted her career to understanding and preventing stroke.

Karen Furie has always been a reader. As the daughter of a nurse and a dentist growing up in Queens, NY, she would marvel at the medical textbooks she pulled off her parents’ shelves, particularly the parts about tropical diseases and brain parasites.

And it was her love of literature that drew her to apply to the Program in Liberal Medical Education at Brown while attending Stuyvesant High School, a science- and math-focused magnet school.

“I always had a passion for literature and English, and coming to Brown enabled me to be an English major while fulfilling all the premedical requirements,” says Furie, MPH ’87 MD’90 RES’94 F’95, P’19MD’23, now the Samuel I. Kennison, MD, and Bertha S. Kennison Professor of Clinical Neuroscience and chair of the Department of Neurology at Alpert Medical School.

Today if you sit next to Furie on a train or a plane, you might catch her in one of her guilty literary pleasures: reading mystery novels (her current favorites are by Deborah Crombie and Louise Penny). “I read them like popcorn,” she says. “That’s the way I relax and unwind.” But even her favorite pastime is intimately connected to her true passion: neurology.

“When I think of neurology, I see all the patients and the problems as mysteries to be worked through,” she says. As a neurologist and researcher, Furie has spent her career unwinding the mysteries of one of the most common and debilitating neurological afflictions: stroke.

Stoked by Stroke

Furie’s fascination with stroke was ignited by the first person to hold her current position, J. Donald Easton, MD, Brown’s inaugural chair of neurology. “He was a stroke neurologist before there even was such a thing,” Furie says. She was especially inspired by Easton’s ability to balance seeing patients with research into how best to prevent and treat stroke. “It was so exciting,” she says, “trying to answer all of the many questions that were still unresolved.”

She left a similarly strong impression on Easton. “It was obvious that she was really smart, driven, and going to be a future success,” he says.

In medical school, Furie took an elective at Massachusetts General Hospital with J. Philip Kistler, MD, director of the MGH Stroke Service. “He was an amazing mentor,” she says. “He is an incredibly dedicated clinician and he had a roll-up-your-sleeves-and-do-the-work attitude toward things.”

During her elective, Furie and Kistler determined that the drug warfarin (Coumadin) can help prevent stroke in patients with atrial fibrillation. Their finding is now so fundamental that it’s taken for granted as the course of treatment. “He had recruited patients from hospitals all around Boston and he would get in his truck with a little portable centrifuge,” Furie says. “We’d go to people’s kitchens—quite literally—and draw their blood and spin it.”

When it was time for Furie to pursue her residency, Easton encouraged her to consider Brown’s program, which was then only four years old. “She was, of course, top of her class, and that was an attraction to having her join us, but it became pretty obvious that she was a risk taker and had great self-confidence,” says Easton, who’s now a professor emeritus of neurology. “She just jumped right in and decided she was going to thrive here. And she sure did.”

After completing her fellowship at Rhode Island Hospital and earning a Master of Public Health from Harvard, Furie joined the faculty at MGH’s Stroke Service. Besides treating stroke patients there and at Spaulding Rehabilitation Hospital, Furie joined Kistler on another clinical trial—this time looking at clotting propensity and blood markers for cryptogenic stroke (stroke of unknown cause).

Furie wrote a career development grant from this work, seeking to identify genes that put people at risk for developing thrombosis, or blood vessel clotting, which can lead to stroke. In addition to identifying potential risk genes, she created a unique database of well-characterized stroke patients that included a blood biobank, genetics bank, and clinical database complete with imaging data. It’s a major part of Furie’s MGH legacy: “There are still papers being written on that database,” she says.

Stroke Around the World

Furie has had a hand in dozens of clinical studies related to preventing and treating stroke. “She’s really moving along in the field, nationally and internationally, because she’s recognized to be intelligent, knowledgeable, and very easy to work with,” Easton says.

In February, Furie and others published in the New England Journal of Medicine the results of a decade-long international study on the effects of the diabetes drug pioglitazone on stroke survivors with insulin resistance. “You can reduce the risk of heart attack and recurrent stroke by 24 percent,” she says. “That’s pretty dramatic.”

As the primary neurologist for the study, Furie traveled extensively, to the UK, Germany, Israel, and Australia. She also got to explore her childhood interest in tropical medicine when she went to Brazil to study Chagas disease, a parasitic infection that can cause inflammation of the heart and brain.

“Neurology, and stroke in particular, is a major problem globally,” she says. “We’re fortunate in the US to have so many resources at hand, but when you travel to other places in the world, you realize how much there is to be done.”

Homecoming

As the head of Alpert Medical School’s neurology department since 2012, Furie is traveling a lot less these days. But she couldn’t be happier.

“When the opportunity came up, I got emails from multiple people who knew me from my time at Brown saying, ‘Oh, this was the job you always wanted,’ and it’s true,” she says. “It felt so right—that desire to come back to this environment and the culture of Brown.”

“This community nurtured us for a dozen years,” adds Furie, who met her husband, neurosurgeon Marc Friedberg ’87 PhD’91 MD’93, P’19MD’23, as an undergraduate. “There was this sense of coming home.” Brown feels even more like home these days, since one of their two sons, Adam Friedberg ’19 MD’23, enrolled as a PLME.

In four short years at the helm, Furie has implemented some big changes in the department, including a required neurology clerkship for all medical students, an increase in the number of residency spots in neurology from 15 to 18, and the requirement of a clinical research project as part of resident training.

Furie marvels at just how different training for these residents is now, thanks to advances like the invention of the stent retriever, a mesh tube that can remove large clots from blood vessels in the brain. The device has changed clinical outcomes for some of the most poorly off stroke patients.

“They would often be left unable to move one side of their body, unable to speak, unable to swallow, unable to return home to any type of an independent lifestyle,” Furie says. Now these patients can go home “virtually normal” in a matter of days. “It’s really been a transformation of our whole field,” she says.

Looking Ahead

But there’s still much to be done. “We really still don’t understand completely how the brain recovers from injury and how we can augment that,” Furie says. “That’s the question that patients who are left with any deficits want to know: how can I improve my language function? How do I help get my weak arms strong again?” She has been working to get FDA approval to test a new drug that may preserve brain tissue that’s injured by the lack of blood flow during an acute stroke.

Developing treatments for brain recovery—whether pharmaceuticals, stem cell therapy, or brain stimulation—will require coordinated efforts between basic and clinical researchers. Furie says this is something that Brown is uniquely situated to foster, with collaborations between the Brown Institute for Brain Science, the VA Center of Excellence for Neurorestoration and Neurotechnology in Providence, and the Norman Prince Neurosciences Institute at Rhode Island Hospital, of which she is coclinical director. “That’s the real joy of Brown: thinking outside the box and forming unconventional partnerships to solve problems,” she says.

Meanwhile the already blossoming neurology department will continue to grow under her watch. “We’ve gained about six new positions and we’ll probably add that many again in the coming year. Lots of good things are happening in neurology,” she says.

Despite the administrative demands, Furie still makes time for her patients. “Karen Furie is everything you’d like your doctor to be like—smart, knowledgeable, nice, concerned about you,” Easton says. “As busy as she is and as involved in as many things as she is, she’s still able to stop when she’s at the bedside and talk to the patient and put those other things out of her mind. She’s a winner.”

Commencement/Reunion 2016

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Sights and scenes from Commencement/Reunion Weekend 2016.

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Catch Them If You Can

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Chinese medical education is rising, rapidly but unevenly, from Cultural Revolution rubble.

For scores of years after the first medical school opened in China in 1886, the country progressed in building a medical education system for its fast-growing population. Then 50 years ago, it not only came to a screeching halt, but to a full reversal with the Cultural Revolution.

“Indeed, throughout the decade in question (1966 to 1976), all extant medical schools were effectively shuttered and their faculty disbanded,” write the authors of a new paper describing the history and current status of China’s medical education system. “It was only in the aftermath of the Cultural Revolution and the passing of Chairman Mao Zedong in 1976 that the medical education enterprise embarked on a slow recovery process during which some of the schools affected were allowed to reopen.”

Since then, the pace has quickened considerably to the point where the country has more than 2.1 million practicing physicians and more than 167 civilian medical schools enrolling about 64,000 students. The restoration of a large national system for undergraduate medical education in just 40 years is remarkable, says study corresponding author Eli Adashi, MD, professor of medical science.

“They had to go from 0 to 60 in three seconds,” says Adashi, who has visited China many times since 2008, often to study and to advise colleagues within the system. “They had to cover a lot of ground, and since they are trying to catch up to the rest of the world, they had to go about it fairly quickly. For the hardships and difficulties and hugeness that characterizes China, they’ve done pretty well on the medical school part.”

In addition to Adashi, the authors of the paper in the American Journal of Clinical and Experimental Obstetrics and Gynecology are Nan Du MD’16, now a resident in the pediatrics program at Yale, and Huanling Zhang of Fudan University in Shanghai.

Read more about the study here.

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