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Battling Deadly Fungi

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Study reveals workings of immune response to deadly fungal infections.

Every year, fungal infections threaten thousands of patients—from those with depressed immune systems to others who have had surgeries or devices such as catheters implanted. Moreover, some anti-fungal medications are beginning to lose their power.

To help protect patients, researchers at Brown University and Rhode Island Hospital have focused on understanding the body’s natural immune response, revealing key details in a new study that could ultimately help to develop new therapies.

“To combat rising fungal infection rates and growing drug resistance, an increased focus on additional ways to enhance the innate immune and anti-fungal response may offer alternative treatments,” the authors of the study wrote in the Journal of Immunology.

The research reveals how three receptors, called integrins, on the surface of the white blood cells called neutrophils signal the cells to take action against the fungus as it spreads its tendrilous hyphae into infected tissue.

The research team in the Rhode Island Hospital lab of Jonathan Reichner, PhD, professor of surgery (research) at Alpert Medical School, not only observed these specific mechanisms, but also manipulated the integrins in the lab to change the behavior of the neutrophils. That sets the table for studies in which scientists can gauge the clinical effects of doing so to see if they can improve the body’s defenses.

“We are looking for ways to mobilize and activate our neutrophils to eliminate fungal infections, especially hyphal forms of fungal infections,” says Courtney Johnson PhD’15 MD’17, who co-led the study with the late Xian O’Brien PhD’10. “At the same time, by learning more about how neutrophils cluster and what happens in those aggregations, we can also learn when they may be causing damage to tissue.”

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SINCE YOU ASKED: Gretchen Green

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Gretchen E. GreenGretchen E. Green ’96 MMS’98 MD’00
Radiologist
Vice Chair, Board of Directors of the National Women’s History Museum
Greensboro, NC

How did you become interested in the history of medicine and women’s history?

In high school, I wrote a history paper on Dr. Bertha Van Hoosen, the founder of the American Medical Women’s Association. The paper placed second nationally at the National History Day competition, and I was hooked on history. Her life was such an inspiration that it has kept my fascination ever since.

I continued my history research through the Program in Liberal Medical Education, combining the history of the pharmacology of twilight sleep, the obstetrical anesthesia technique developed by Dr. Van Hoosen, with the history of women physicians’ actions during the Progressive Era, culminating in a master’s degree. I am eternally grateful to the PLME and especially Dean Edward Beiser for the support I needed to pursue that study.

There is a great need to educate everyone on the nuances of women’s history, so everyone can benefit from knowing women’s diverse accomplishments. That is what motivated me to join the board of directors of the National Women’s History Museum, where I serve as vice chair.

How does this inform your practice?

My interest influenced my decision to specialize in women’s imaging in radiology, primarily breast, obstetrical, and pelvic imaging. History isn’t just a look back in time, it’s how we look ahead to what we can do better in the future. In the field of childbirth anesthesia, equality in pain relief for women in 1915 became a rallying cry for basic human rights. Women argued that receiving medical care was a key indicator of their social standing, and played an active role as advocates for their own health care decisions. The desire to organize on behalf of medical causes was just as important for women 100 years ago as it is in 2017.

Your clinical expertise is in breast health/mammography, an area that can be very confusing for patients because of the evolving screening recommendations. How do you explain that to your patients?

Knowing the history of medicine has inspired me to pursue the difficult challenges of breast cancer diagnosis and treatment, because I see how far we’ve come despite daunting odds.

We continue to face challenges in breast cancer detection and treatment even as technology has progressed, but a culture of continuous improvement helps me create perspective for patients that in a specialty filled with uncertainty and anxiety. We constantly learn how to care for patients better than ever.

Organized medicine plays an important role in screening recommendations, for both physicians and our patients. Speaking with one voice is so important for patient understanding and confidence. The American College of Radiology and Society of Breast Imaging continue to recommend yearly screening mammography beginning at 40 (for average risk patients), to provide the greatest public health benefit.

What’s on your music playlist?

My favorite artist is Peter Gabriel, but my playlists contain everything from Gregorian chant to hip hop. Some songs are great for running, others are more meditative.

How do you manage work/life balance?

Cooking helps me keep things in perspective and to reframe “mistakes.” We spend our professional days as physicians so afraid of doing something wrong. Cooking is much more forgiving, and a way I show love for my family. If I burn something in the kitchen, I call it caramelized. If it’s not very pretty, it’s rustic. I love Julia Child’s quote: “Learn how to cook—try new recipes, learn from your mistakes, be fearless, and above all have fun!”

Helping to build the National Women’s History Museum has become a lifeline for me. Our goal is to build the first museum of its kind in any nation’s capital, to serve as a physical manifestation of the idea that women’s history is much more than most of us know, a diverse collection of stories begging to be told.

Who lives at home with you?

I am married to a physician and we have two children, ages 6 and 8. Being a two-MD family definitely has its challenges, and we have taken a creative approach to do enough of all the things we need and want to do. After 10 years as a full-time partner in private practice, I took a sabbatical last fall to carefully consider my next life chapter, and to work on the museum’s next phase of development.

Test Could Misdiagnose Diabetes in African-Americans

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Sickle cell trait may lower blood sugar readings, causing missed diagnoses and treatment.

A new study in JAMA provides evidence that hemoglobin A1c (HbA1c), a common blood biomarker used to measure blood sugar over time, may not perform as accurately among African-Americans with sickle cell trait and could be leading to a systemic underestimation of blood sugar control among that population.

Sickle cell trait (SCT) is a genetic hemoglobin variant found in 8 to 10 percent of African-Americans. It occurs in people with one copy of the mutation that, if they had two copies, would result in sickle cell disease.

The analysis of data from more than 4,600 people participating in two major studies found that HbA1c readings were significantly lower in individuals with SCT than in those without SCT, even after accounting for several possible confounding factors.

“We found that HbA1c was systematically lower in African-Americans with sickle cell trait than those without sickle cell trait despite similar blood sugar measurements using other tests,” says lead author Mary Lacy, a doctoral candidate at the Brown School of Public Health. “We might be missing an opportunity for diagnosis and treatment of a serious disease.”

Indeed, Lacy and her co-authors found that using standard clinical HbA1c cutoffs resulted in identifying 40 percent fewer potential cases of prediabetes and 48 percent fewer potential cases of diabetes in people with SCT than in people without SCT. Meanwhile, when the authors used other blood glucose measures as the diagnostic criteria, they found no significant difference in the likelihood of diabetes and prediabetes among patients with or without SCT.

The questions the study raises about using HbA1c among sickle cell trait carriers matter for treatment as well as diagnosis, adds study senior author Wen-Chih Wu, MD F’02 MPH’10, a cardiologist at the Providence Veterans Affairs Medical Center and associate professor of medicine (research) at the Warren Alpert Medical School.

“The clinical implications of these results are highly relevant,” Wu says. “For patients with diabetes, HbA1c is often used as a marker of how well they are managing their diabetes, so having an underestimation of their blood sugars is problematic because they might have a false sense of security, thinking they are doing OK when they are not.”

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The Genuine Article

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For 40 years, Ed Feller has been an inimitable teacher, mentor, and friend at Brown.

When Walter Klyce MD ’18 was trying to decide when to get married, he didn’t seek help from his parents or religious leader. Even his fiancée wasn’t sure what to do. So Klyce went to see Ed Feller.

“Dr. Feller’s known as a good person for giving life advice,” he says.

The two men had never met before. But Feller was ready with words of wisdom.

“When you’re in the medical profession, there is real pressure to put that before everything else. He does a good job of saying it doesn’t have to be your whole world,” Klyce says. “He said, ‘Medical school is fine, but getting married is a huge deal. You should plan your life around getting married, not around medical school.’ So we’re getting married in April, during a week off.”

Feller’s deprioritization of medicine and medical education may be unconventional, but it wouldn’t surprise any of the hundreds of students, alumni, colleagues, and others he’s befriended in his 40 years at Brown. “He’s one of a kind,” says Alex Morang, director of career development. “They broke the mold.”

On paper, Edward Feller, MD, PMD’03 sounds like a conventionally overachieving, ultra-accomplished Ivy League medical school faculty member. A gastroenterologist, he graduated from the University of Pennsylvania and New Jersey Medical School and trained at McGill and Harvard. His expertise in endoscopic techniques to visualize the pancreatic and bile ducts got the attention of a GI group in Providence, which recruited him; he went on to lead the GI division at The Miriam Hospital for 18 years. He’s a clinical professor of medical science at the Warren Alpert Medical School, and he codirected the Community Health Clerkship for a decade. Until last year he also was a clinical professor of health policy, services, and practice at the Brown School of Public Health.

But look closer at his CV. Feller left clinical practice in 2002 so he could devote himself to teaching at Brown. His 10-page list of scientific publications and presentations is liberally peppered with boldface and underlined type, to call out his hundreds of med student and resident coauthors. He’s earned dozens of awards and honors for teaching, mentoring, and humanism.

And then there’s that four-year stint at the University of Dijon Medical School, in France, with no degree earned. “I graduated the University of Pennsylvania with a 2.2 grade point average,” Feller says frankly. “I couldn’t get into any medical school in the United States.”

Then he flunked his second year at Dijon. And he couldn’t pass Step 1. “I was a horrible student,” he shrugs.

He’ll share these facts with anyone—especially medical students. “That kind of honesty about personal failures,” Klyce says, “you can’t believe how rare that is in medicine. People think confessing fault shows weakness.”

“The students walk away feeling, boy, if Dr. Feller had all of these stumbling blocks … that gives me hope,” Morang says. “Maybe I will get through this, and I will also be successful.”

Dogged Pursuit

If you know Woody Allen’s voice, you’ll recognize Ed Feller’s. He has a kind face, the trace of a smile dancing on his lips. His white coat days behind him, his work uniform now is neat but casual: a sweater over a collared shirt, dark jeans, and a red Brown University lanyard with his Miriam Hospital badge. When you bump into him at the Medical School, he has a friendly word or an inquiry about some tiny detail in your life that he recalls from your last encounter, even if it was weeks or months ago; friends, colleagues, and students marvel at his photographic memory.

RENAISSANCE MAN: Ed Feller left his gastroenterology practice 15 years ago to teach full time. “My job description is working with medical students,” he says, “which is great.” Photo by David DelPoio

RENAISSANCE MAN: Ed Feller left his gastroenterology practice 15 years ago to teach full time. “My job description is working with medical students,” he says, “which is great.” Photo by David DelPoio

He grew up in Brooklyn, in Williamsburg, when it was “really a slum.” The son of a housewife and a general practitioner, whose office was in their basement, Feller sometimes tagged along on his dad’s house calls. Tall and lanky, he played basketball in high school and as a freshman at Penn. There he studied English, “and I got Cs, Ds, and Fs in my science courses,” he says. “I didn’t have to worry about what to do in the summer. I was always at summer school.”

Feller started running in college. “The most interesting thing about me is my lifelong hobby is running nonstop, 100-mile trail races in mountains,” he says. (The second most interesting thing, he adds, is that 2.2 GPA from Penn.) He’s run some of the best known ultramarathons, including Leadville (“I think I saw God at about 80 miles”) and Vermont (the “easiest” of the 100s), and the Boston Marathon more times than he can count.

“It’s a simple measure of your own worth,” he says of running. “You just get out and do it. And I’ve always felt great about that. And I just don’t back off. … I know what it means when it’s the middle of the night, and you’re on top of a mountain, you’ve got a flashlight, and you’re just exhausted, and you just say, well, I’m just going to keep doing it.”

That same doggedness—not mental strength, he insists, just doggedness—kept him on the path to medicine, even when no US med school would take him, even after his failing year in Dijon. His wife, Wendy, an actor, supported them by singing in cafes. Feller took stock of himself, shaped up, and earned the grades to transfer to New Jersey Medical School for his third and fourth years. “France made me a man,” he likes to say.

Feller didn’t plan to pursue gastroenterology, but he fell in love with Montreal, and McGill, when he and Wendy went there to visit his brother, a surgical resident. The only elective available to Feller as a med student was in GI, so he took it, then stayed for residency. He liked the research, too; during his fellowship at Mass General, he published two papers in the New England Journal of Medicine, one as lead author. An expert in endoscopic retrograde cholangiopancreatography, or ERCP, Feller had joined the clinical faculty at Harvard, in 1977, when Herbert Rakatansky, MD ’56, a cofounder of a GI practice in Providence, came calling.

“We wanted to recruit people who were smarter than we were,” says Rakatansky, now a clinical professor emeritus of medicine. “We wanted to stay on the cutting edge. He had certain skills we didn’t have.” The new recruit also had to want to teach, supervise, and patiently explain himself to inquisitive students and residents. “[Feller] had a desire to be in an intellectually stimulating environment,” Rakatansky says. “He was a superb, multitalented gastroenterologist.”

But never intimidating. Anish Sheth ’97 MD’01 was interested in GI before he took an elective with Feller; the experience clinched his decision. “He sort of made it a no-brainer because he was such an inspirational guy,” says Sheth, a gastroenterologist with Princeton Medical Group in New Jersey. “His way to approach medicine in education is to take knowledge that’s encyclopedic and present in a way an individual could understand.”

Sheth has appeared on TV shows like the Rachael Ray Show and Good Morning America to answer common questions about GI problems, and he’s co-authored a few books for a lay audience, including What’s Your Poo Telling You? Feller, he says, “showed me you can be a great doctor and teacher and also be down to earth and have a sense of humor.”

Feller used the same approach with his patients. “In practice he was responsive, attentive, caring, and he has an encyclopedic knowledge of medical literature,” says longtime friend and colleague Fred Schiffman, MD, P’96MD’00, the Sigal Family Professor of Humanistic Medicine. “He always knew what the current information is and is able to put it in perspective” and into practice. “He would make creative, original connections and he was able to step back and see things from a different angle.”

He wanted future doctors to be able to do the same. For 30 years, Feller has supervised a weekly journal club at The Miriam for third-year students, teaching them how to read scientific articles, put them into context, and identify their merits and flaws. For each paper, he assigns a facilitator role to one student, and questions to everyone else. Then they discuss it over lunch; Feller provides the cookies. “The way he does it, everyone contributes because everyone has a role,” Klyce says. “He puts a lot of thought into it.”

“I don’t know of any other experience in my medical career that has been as fruitful in teaching me process to enable me to generate perspectives independently,” Aaron Kofman MD’14, an internal medicine resident at UC San Diego, writes in an email. “I carry Dr. Feller’s approach with me regularly and know it has made an enormous impact on my practice.”

The education portion of Feller’s job description was key to luring him to Providence from Boston. “I’ve always loved teaching,” he says. As much as he loved his clinical work, over time he realized that he loved his work with students even more. “I decided that if I died without teaching full time, I would have missed something,” he says. “I literally just left my day job.”

Second Act

Now ensconced in the Medical School, Feller is in his element. In addition to the journal club and periodic lectures, he teaches first-year Doctoring, and at any given time he’s working with a dozen or more students on projects for publication or presentation. This school year Alex Morang asked him to be one of five faculty advisers.

“I had always thought of him, how do we tap this reservoir that he has, of knowledge and interest and passion of working with the students?” Morang says. “I think that speaks to how highly I value him, that we only have five people who have been selected to do that, to work with all of our students in that capacity, in such a longitudinal way.”

This new title makes official what Feller’s been doing for years: mentoring and guidance, in life and career. “Dr. Feller truly wants students to figure out what makes them happy in medicine,” Kofman writes. “Dr. Feller’s mission is to really push you to investigate all aspects of what drives you and make decisions that help you hone your professional future.”

Kofman says it is thanks to Feller’s early and enthusiastic support that he will begin a two-year fellowship with the CDC’s Epidemic Intelligence Service this summer. Some may consider public health an “unconventional” career path for an MD, he says, but Feller affirmed his choice from the start.

That’s evidence, Kofman writes, of “how much he invests in getting to know his students and help them find the path that is the most rewarding for them.”

Many current and former students praise Feller for pushing them to challenge themselves. Michelle Diop ScM’19 MD’19, who’s in the Primary Care-Population Medicine Program and hopes to pursue a career in palliative care, had disappointing research experiences before coming to Brown. She told Feller she was concerned about finding a mentor who shared her goals for the program’s required thesis project.

“I was only interested in qualitative work, but he vouched for a mentor with quantitative work,” she says. Feller connected her with Associate Professor of Medicine James Rudolph, MD. Now she loves research; their meta-analysis on palliative care interventions for patients with heart failure—of which Diop was lead author—was published in the Journal of Palliative Medicine in January.

Diop says Feller regularly sends her articles about palliative care and tells her about events and opportunities in the field. “The fact he remembers what I’m interested in … when he has so many students and remembers me—he’s amazing,” she says.

“Dr. Feller has a real passion to help other people with their passion,” says Za Janopaul-Naylor ’10 MD’14, a psychiatry resident at Harvard. She met Feller just weeks before she graduated, but he tracked her down after she got to Boston with an offer to cowrite a chapter on cyberbullying for the medical textbook The 5-Minute Clinical Consult. They’ve collaborated on three editions.

“His openness to all areas of interest is really surprising. He’s a GI doc and here he is helping me with cyberbullying,” Janopaul-Naylor says. “Often people get siloed and feel they have expertise in only one area. He’s not scared to go outside his boundaries and to learn. He’s excited to learn about every topic.”

Anish Sheth says he and his wife, Shilpa Pai ’97 MD’01, a pediatrician, always visit Feller when they’re in Providence. “My wife has nothing to do with gastroenterology,” Sheth says, “but when we go out for dinner the two of them end up talking a lot more than he and I do. He can talk about anything. He’s passionate about a lot of stuff.”

In 2012 Sheth spearheaded the establishment of the Dr. Edward Feller Term Scholarship at the Medical School. “Everyone had a realization [Feller] was a special guy in medical school, but only when you leave Brown … you realize he’s very unique in what he does,” Sheth says. “This isn’t hyperbole: through medical school, residency, fellowship—to this day I don’t think I had a mentor as strong and influential as he was.”

Bon Vivant

“Medicine is the best,” Feller says. “I think that it’s the most extraordinary career and calling that you could have. … But I think life happiness is a great relationship, good friends, things which excite you and which you enjoy, and no nasty personal surprises.”

Feller always has enjoyed a full life outside of work, and constantly pushes med students to do the same. Thanks to his wife’s influence he’s an avid theater goer, and travels to theater festivals across the country. He loves jazz and classical music. He reads everything he can get his hands on. He hikes and he still runs (much shorter distances). He even tried playing the flute, after Wendy got him lessons as a gift. “I’ve always been good at finding stuff I love to do,” he says.

He and Wendy raised two children, both physicians: Alex MD’03, a psychiatrist in private practice who teaches at Weill Cornell Medical College; and Sophie, who is doing postdoctoral research at the UCLA Center for Health Services and Society. Both worked in other fields before deciding to go to medical school, which pleases their dad.

“I proselytize for taking time off and doing something great—especially for doctors, who start so early and just keep going through,” Feller says. “It’s that extra time that you spend doing something else that gives the depth and texture to living.”

Students who got to know Feller also knew his wife: Wendy was a regular presence on campus—she was a standardized patient in addition to her theater work—and at the dinners and social gatherings Feller hosted for his journal club groups and other classes. When Wendy was diagnosed with acute myelogenous leukemia, in 2004, the students rallied around them.

“Medical students would stay with her [at The Miriam]so I could go home and sleep for a couple of hours,” Feller says. “They would set up a system.”

“They took care of him,” Morang adds. “They were always checking in on him. And they were bringing meals. And they were taking care of him like you take care of family, because they see him as family.”

After Wendy received a bone marrow transplant, she went on TV and radio to encourage people to join marrow registries. That galvanized Feller to do the same on campus. In 2012 he received the Leadership Award from the National Marrow Donor Program, and he continues to advise registry drives at Brown. Since 2005, he says, his group has identified 27 donors—including Adam Vasconcellos ’07 MD’11, one of the students who coordinated the drives.

Wendy died in 2013. She and Feller had been married 45 years. “It will never be the same. My life is diminished,” he says. But he went back to work the next week. “It’s not what I do—it’s who I am.” Returning to work, he says, “was life enhancing.”

“Students are my safety valve,” he adds. “I feel close to a lot of students—like a generation of students.” He keeps in close contact with scores of current and former students, who treasure his funny emails, thoughtfulness, generosity, and unfailing support of their interests.

“Every time I see him, I walk away happy. He lifts you up,” Diop says. Kofman invited Feller to his wedding in California last fall. “All of the time, he’s flying somewhere to go to an alumni wedding, a baptism, a major life event,” Morang says. “I think that speaks volumes.”

Students and alumni also have spoken with honors and awards—many, many times over. Feller is a seven-time recipient of the Senior Citation, the highest honor a graduating class can confer on a faculty member. Thirteen graduating classes have given him the Faculty Award for outstanding teaching. He received the W.W. Keen Award from the Brown Medical Alumni Association in 2012. And the Association of American Medical Colleges has honored Feller four times with the Humanism in Medicine Award, which recognizes excellence in mentoring.

“Getting the awards is the gravy,” Morang says. “Making the connections and having these amazing experiences and these valuable relationships that, in many cases, have gone on for decades with the alumni, is the true reward.”

At 71, Feller says he never thinks about retiring. “I don’t consider what I do work. I feel as if I’m blessed,” he says. “I love writing, I love interacting with students, I’m learning every day new things. I have a lot of outside interests, but I love my work and I would do it forever.”

Expect the Worst

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Conference brings disaster planners to Brown.

On June 23, 2014, a patient walked into the emergency room of Phebe Hospital in Bong County, Liberia, suffering from vomiting, nausea, and diarrhea. Within a week, the patient and six of the nurses who cared for the patient were dead.

This was the first case of Ebola in Bong County, though the epidemic had begun in nearby Guinea several months before. The outbreak eventually killed nearly 30,000 people, including almost 10 percent of the health care workforce in West Africa.

But the virus did not spread throughout Nigeria, thanks to Ameyo Stella Adadevoh, MD. When a patient with Ebola symptoms arrived at First Consultant Hospital in Lagos, Adadevoh recognized the symptoms and immediately quarantined the patient. Adadevoh contracted Ebola from the patient and died, but she prevented the virus from spreading.

Adam C. Levine, MD, associate professor of emergency medicine, presented this “tale of two countries” at the third annual New England Society of Disaster Medicine conference at the Warren Alpert Medical School in December. “The foremost line of defense against an epidemic is having a well-trained health force able to recognize these diseases,” Levine says.

The New England Society of Disaster Medicine is a collaboration among the disaster medicine programs at Brown, Harvard, Beth Israel Deaconess Medical Center, and the University of Massachusetts Medical School. It expanded in 2016 to include Massachusetts General Hospital.

Selim Suner ’86 ScM’87 MD’92 RES’96, a professor of emergency medicine, surgery, and engineering, cofounded the society about three years ago. “Disaster medicine has been around for 20 or 30 years, but bringing disaster medicine into the academic fold is something new,” he says.

Doctors at the conference discussed how to prepare for all types of disasters: infectious disease outbreaks, mass casualty events, natural disasters, and even power outages. “You prepare your [hospital]system for anything that can happen,” Suner says. “It’s all-hazards preparedness.”

At Brown, residents and fellows in the emergency medicine program participate in trauma simulations at the Lifespan Medical Simulation Center every month and disaster simulations two to three times a year. “You want [physicians]to fail in a controlled environment because that’s the best way to learn,” Suner says.

Paul Biddinger, MD, is the director of the Center for Disaster Medicine at MGH and an assistant professor of emergency medicine at Harvard Medical School and the Harvard T.H. Chan School of Public Health. He’s also the chief of the hospital’s division of emergency preparedness.

Biddinger runs Ebola outbreak simulations at MGH and other disaster simulations at Harvard’s Center for Medical Simulation. The point of disaster medicine is “not to think about what a disaster should look like, but to learn what they really look like,” he says.

Because of the simulations, doctors at MGH were prepared to respond to the Boston Marathon bombing in 2013, Biddinger adds.

Nevertheless, emergency preparedness funding is not always available.

John Foggle, MD, MBA, a clinical associate professor of emergency medicine at the Warren Alpert Medical School, designs the curriculum at the Lifespan Medical Simulation Center. He says “disaster amnesia” is a big problem. “The minute nothing is happening, the money dries up,” Foggle says.

Suner’s goal is to make federal emergency preparedness funding available “at an even keel throughout time.”

“Preparedness doesn’t happen in a vacuum,” he says. “You have to continually exercise your plans.”

Peter Smith, MD F’77

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Peter Smith, 75, died December 9 after a 10-year struggle with Parkinson’s disease and Lewy body dementia. He attended medical school at the University of Basel in Switzerland and completed residency at T. C. Thompson Children’s Hospital in Chattanooga, TN, in 1975. After completing the fellowship in pediatric hematology and oncology at Rhode Island Hospital in 1977, he joined the faculty of Brown University, where he loved teaching, the intellectual challenge of medicine, and the emotional intensity of working with children and their families. He served as the pediatrics clerkship director from 1984 to 1991, and received the Senior Citation from the Brown MD Class of 1986.

In 1987, Dr. Smith received the Senior Class Award. He was recognized several times during his career with awards for his service to patients with hemophilia and served as the medical director of the Rhode Island Hemophilia Program for many years. He was appointed professor emeritus of pediatrics in 2001. He spoke French, German, and Spanish fluently and enjoyed traveling the world. He is survived by his wife, Heidi; two children; and two grandchildren.

Xian Marie O’Brien PhD’10

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Xian O’Brien (née Christian Shaver), 42, died unexpectedly November 15. She graduated from MIT with a bachelor’s degree in biology and cognitive studies in 1998, and earned a PhD in the Pathobiology Graduate Program at Brown in 2010. She completed her graduate and postdoctoral research in the Department of Surgery at the Warren Alpert Medical School and was appointed an instructor in surgery. Her research focused on the development of new drugs to improve the ability of the human immune system to fight disease. She published scientific papers and trained a number of young investigators.

She is survived by her partner, Michael Cross, and her mother. Gifts in her memory can be made to the East Greenwich Animal Protection League, PO Box 184, East Greenwich, RI 02818; or Hasbro Children’s Hospital, Hasbro Children’s Hospital/Rhode Island Hospital Foundation, PO Box H, Providence, RI 02901.

Vision: How It Works and What Can Go Wrong

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From the bookshelf

Vision: How It Works and What Can Go Wrong
By John E. Dowling, PhD, and Joseph L. Dowling Jr., MD ’47 GP’19
The MIT Press, 2016, $32

Vision is the dominant sense of the five we humans rely on to perceive the world; it’s no surprise that blindness is the disability people fear most. And in a structure as complex as the human eye, there’s a lot that can go wrong.

Joseph Dowling, a practicing ophthalmologist and clinical associate professor emeritus of surgery (ophthalmology) at Brown, and his brother John, a professor of ophthalmology (neuroscience) at Harvard, offer here a comprehensive, highly readable account of eye anatomy, function, dysfunction, and disease from their respective positions as clinician and researcher. Never stinting on the science, they keep the narrative humming with the history of eye research, a Milton sonnet, anecdotes from the late neurologist Oliver Sacks, MD, and even some optical illusions to demonstrate visual perception, like the famous vaseface picture. They close on a hopeful note, ticking off the many advances in research and patient care.

While acknowledging the challenges ahead, they write, “thousands of dedicated scientists worldwide are attacking these problems, and we have no doubt that amazing developments will soon appear for the cure of various causes of blindness and to the benefit of mankind.”


Married to Work

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For better or worse, boundaries blur when both spouses have MDs.

My grandmother in India is perpetually worried about me. Born in a generation when women seldom worked, especially after marriage, every Sunday phone call with her usually ends with a slew of concerns about how I am balancing running a household, staying healthy, and planning for a family while working a full-time job as a first-year resident. All of this coupled with being married to a first-year neonatology fellow. She’s right, it is hard. But life with a physician partner is a unique experience.

Female physicians in dual-physician relationships are not uncommon. Women constituted 47.6 percent of all US medical school graduates in 2014-2015, according to the Association of American Medical Colleges. And nearly 40 percent of physicians are likely to have a spouse who is a physician or health care professional, according to a 2014 report released by AMA Insurance. It seems that the plethora of “Life of a Doctor’s Wife” (and husband/partner) online forums and Facebook pages may need to rethink their catchy but outdated titles to keep pace with the shifting demographics of physician relationships.

Beyond the appeal of a good old office romance, sometimes mired in spicy affairs or even tragic death as in the world of Meredith Grey, there are discernible benefits to having a partner to relate to on a personal and professional level. My husband and I are constantly thankful for how little explaining we have to do about our erratic work schedules. When setting up our bedroom after moving in together we thought as much about the furniture as the light-blocking shades we needed to install. Melatonin and sleep masks are always within reach on both sides of the bed. Conversations over the kitchen island flow freely from descriptions of body fluids to upcoming local wine tastings and then to myriad acronyms about the “G1 with PEC who needed Mag stat” or “the 28 weeker with NEC on TPN.” The innocent bystander would be confused or, worse yet, appalled.

Processing challenging work situations or patients with a partner who experiences similar situations can be extremely therapeutic. Not to mention the free “curbside consults” they come with. On cross-cover during my adult medicine rotation, I was taking care of a frail 84-year-old woman with metastatic lesions to her spine. She had insisted on radiation treatment; however, she was now refusing the pretreatment MRI that she had agreed to earlier in the day. I paged the oncologist on call for advice on alternatives; he was on his way to dinner and unsure, but happened to be sitting next to his radiologist wife who could answer my question.

The blurring of work-life boundaries does come with its challenges. When two individuals are used to being decision makers at work, compromise can be a particularly hard pill to swallow at home. Sharing domestic responsibilities equally for us is sometimes as simple as willing yourself to fold the laundry at the end of an exhausting day if your partner put it in the dryer in the morning.

Before hanging up the other day, my grandmother struck a deal with me. She generously volunteered to come visit us and help out at home. In return, she asked only for a great-grandchild to dote on. I politely declined. For now, Grandma, we’re just trying to keep the plants alive.

Race in Medical Education

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The curriculum must challenge assumptions and unconscious bias.

In fall 2014, Professor of Medical Science and Africana Studies Lundy Braun, PhD, offered an elective on race, health, and structural inequality to medical students. We examined the faulty biological basis of race—the fact that genetic differences are far higher within than between racial groups—and how the biomedical framing of race contributes to physician bias, which in turn perpetuates racialized health disparities.

This exploration stood in stark contrast to what we were learning in our preclinical lectures. For example, we were taught that African-American patients have a significantly higher risk of developing childhood asthma, with several lecturers naming genetic factors as the cause of this disparity. Social factors that disproportionately affect African-American communities, including disparities in health care access or housing inequality, were rarely mentioned—even though these factors contribute more substantially to the higher prevalence and poorer health outcomes of African-American children with asthma.

Frustrated by this disconnect, students wrote a letter to the Medical School administration questioning the reliance on race as a biological construct. The letter urged a rethinking of preclinical education, specifically an integration between social and scientific portrayals of race. In the national context of fall 2014, with Ferguson in flames and the growing Black Lives Matter movement, the importance of translating what we were learning into action felt urgent. While the tradition of student activism at the Warren Alpert Medical School around health disparities is strong and precedes these efforts by decades, what was missing was an institutional commitment.

To further investigate our observations on the use of race in medical education, we sampled basic science lecture slides from the required preclinical curriculum and found that race was almost always presented as a biologically salient factor (96 percent), while only 4 percent of slides contextualized race by examining social differences. Furthermore, an informal survey of all Warren Alpert medical students demonstrated overwhelming peer support for reform of the current approach to race in medicine. After we presented our findings, the administration established a task force chaired by Associate Dean for Medical Education Allan R. Tunkel, MD, PhD; we began an ongoing collaboration with the faculty of the Office of Medical Education; and we continued organizing with other students (now formalized under the name Against Racism in Medicine). We also published our findings in Academic Medicine, joining the conversation around medical racism at institutions across the country.

The collaboration among faculty, administrators, and students in the Race in Medicine Task Force has begun to produce concrete and longitudinal curricular changes that are impacting the preclinical and clinical years. For example, a first-year lecture on radiation science introduced the idea that people with darker skin have evolved a pattern of melanin pigment distinct from those with lighter skin and that this difference was produced by differences in environments and geographies, not inherent genetic differences. These changes in content are not driven by an administrative mandate, but instead by ongoing conversations between the faculty lecturer, the Office of Medical Education, outside experts, and students.

The preclinical curriculum is further reinforced through systems-specific lectures and small group sessions in the Doctoring course. One especially effective session, “Race Correction of Pulmonary Function Tests: Why History Matters,” was led by Professor Braun during the pulmonary block. The lecture equipped students with background on spirometry and clinical lung function tests, illuminating the historical basis for race corrections, including its role in justifying the enslavement of blacks in the antebellum South. It provided rich material for discussion and continued dialogue even outside the lecture hall.

These advances come at an opportune time as medical institutions across the country rethink and reformulate how they teach about race in medical education. The Race in Medicine Task Force’s vision aligns neatly with national goals to incorporate health equity and advocacy training into physician training. It also coincides with Brown’s renewed commitment to diversity and inclusion, as articulated in Pathways to Diversity and Inclusion: An Action Plan for Brown University, and the Warren Alpert Medical School’s long-standing position as the nation’s trailblazer in education innovation. Educational reform around race and inequity fundamentally improves the quality of medical education for all students, and has the added potential to promote physician leaders with the skills to meaningfully reduce health disparities.

Just the Beginning

As the task force looks to the opportunities ahead, it is important to reflect on new and continued challenges. Task force members—especially the often heroic faculty of the Office of Medical Education—have proved to be dedicated and focused on implementable changes. While instruction around race and health inequities at the Medical School has been deliberate and well intentioned, curricular reforms thus far remain sporadic and moderately effective. The bulk of curricular changes have focused on first- and second-year medical education, despite abundant evidence that the clinical years have a greater impact on students and their future professional practice. Though further efforts on longitudinal coordination across all four years are underway, these small changes do not, on their own, add up to the rigorous, systemic curricular reform that is needed.

Significant controversy around the conversation on race in medicine persists. The proposed modifications to lecture content, while evidence based, sometimes run at odds with conventional medical wisdom and may not reflect the lecturer’s own beliefs around race, or clinical practice witnessed by students on the wards. This further underlines the need for robust faculty development that prioritizes critical thought around a controversial topic and developing skills around unconscious bias and structural competency—instead of a simple replacement of dogma.

A final limitation of the current reform efforts is the lack of assessment. While we are proud and grateful for the immediate impact these collaborative efforts have generated, we cannot predict the long-term effects and efficacy without data. A recent query to the Office of Alumni Affairs yielded no information on what proportion of Brown medical alumni go on to work in underserved communities, which could be one way to measure the success of our initiatives. Another measure is the Medical School’s commitment to faculty and student diversity. At institutions across the country, it is clear that attracting, recruiting, and retaining faculty, students, and administrators of color is key to addressing health disparities. Brown is far behind the curve on diversity, with one black male medical student in the current first-year class and 1.65 percent of the clinical faculty identifying as black or African-American.

These ambitious goals require real financial and administrative commitment. As we progress in our own professional development and imagine how to best care for all our patients, we remain cautiously hopeful about the current direction toward change and look forward to continued collaboration.

Alumni interested in these reform efforts or who have more information on their work in under-resourced communities may contact the authors at against-racism-in-medicine@googlegroups.com.

Social Justice League

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A cadre of medical and legal advocates cares deeply about the health of people behind bars.

In 2005, Bradley Brockmann, JD ’76 was working in Boston as a civil rights litigator for Prisoners’ Legal Services of Massachusetts. On December 20, Nelson Rodriguez, a 26-year-old man with a cognitive disability and mental illness, hanged himself in Cell 49 of the isolation unit known as 10 Block in the maximum security prison in Walpole, MA. Brockmann and colleagues went to the prison the next day to begin interviewing the other 25 men on the tier, who claimed that Rodriguez had spent the night screaming for help and received none.

Brockmann describes those interviews as “horrendous,” but the experience shaped the way he sees the problem of incarceration. “What I came to understand over time was that virtually all of my clients—dozens and then hundreds—had a substance use issue and/or a mental health disorder. And that is what’s driving recidivism in our prison system: individuals with co-occurring mental health and substance use disorders.”

He’s not wrong. According to the Bureau of Justice Statistics, more than half of inmates in US state prisons have a mental health problem, and three-quarters of those individuals also meet the criteria for substance dependence or abuse.

At Brown, physicians and public health and policy experts like Brockmann have joined ranks under the aegis of the Center for Prisoner Health and Human Rights. Based at The Miriam Hospital, the center and its affiliated physicians and advocates work to develop programs to enhance continuity of care for released prisoners, as well as diversion programs to keep individuals with behavioral health disorders out of the justice system in the first place.

The Other 1 Percent

The number of people behind bars with mental illness and addiction has been a disaster decades in the making, the result of two social policies that have arguably exacerbated the problems they purported to solve.

President Nixon’s 1971 declaration of a “war on drugs” opened the door to a host of harsh penal policies for relatively minor drug offenses. The contribution of such policies to America’s current epidemic of incarceration is widely acknowledged. Since 1981, when the “war” began in earnest, the number of people incarcerated for drug possession has swelled by 500 percent, from 41,000 to almost half a million. By 2012, 1 in 108 adults—nearly 1 percent of the American adult population—was behind bars.

Around the same time, many people with mental illness found themselves on the street, thanks to the well-intentioned deinstitutionalization movement. Starting in the 1950s and gaining momentum in the ’70s and ’80s, deinstitutionalization aimed to take psychiatric patients out of state hospitals, where conditions were often deplorable, and move them into group homes, where they could live with more autonomy and dignity. The idea took: in 1950, there was one psychiatric bed for every 300 Americans; by 2004, there remained one for every 3,000.

Radical cuts to federal mental-health funding, however, meant that the vast majority of planned facilities were never built. Patients were discharged with nowhere to go and no one to oversee their care. Many became homeless—and many ended up in jail or prison. By 2004, there were three times more individuals with serious mental illness in jails and prisons than in psychiatric hospitals. As the Boston Globe put it in a 2005 series on suicide in prison, the “inmate[s]now flooding the corrections system [are]the mentally ill for whom prison is increasingly the asylum of last resort.”

The last resort—and for many, the last place they should be. Some, such as Rodriguez, end up in solitary confinement (also known as segregation), which can be psychologically damaging to a healthy person, let alone someone with a major mental disorder like schizophrenia. In one federal case, a judge ruled that “putting mentally ill prisoners in segregation is the mental equivalent of putting an asthmatic in a place with little air.” And once they’re in the system, the exit is more of a revolving door. People with certain mental health issues, such as ADHD, can have difficulty in the highly regimented environment of prison, which only exacerbates their problems. “They can’t follow orders—they spiral,” Brockmann says. They rack up disciplinary infractions for noncompliance or simply “bizarre” behaviors. If they’re released, they go untreated and fall into the same problematic behaviors as before. One-quarter of state prisoners with mental health problems have been incarcerated at least three times.

The “collision” of her patients’ lives with the law intrigued Christine Montross MD’06 MMS’07 RES’10. A psychiatrist in the intensive treatment units at Butler Hospital and assistant professor of psychiatry and human behavior, she deals with the most severe cases of psychiatric illness. “I noticed over the years that many of the patients I treat come into contact with the criminal justice system,” she says. “The questions that began to arise for me were ‘Why?’ and ‘What happens when they do?’”

The answer, often, is that they get into trouble and they can’t get out. In a 2016 paper published in the New England Journal of Medicine, Montross described a man suffering from paranoia who was ordered to leave a convenience store, refused, and was taken to jail. There, still paranoid, he refused to take antipsychotic medication and had to be forcibly removed from his cell. The man fought back, further worsening his plight by being charged with assaulting an officer—a felony. Instead of being treated for his mental illness, he’s likely to spend years, probably without adequate psychiatric care, in a carceral setting that will only make his mental condition worse.

“If we recognize that prison or jail is not the appropriate first place for these people, then we need to have systems in place to offer support and treatment,” Montross says. “Any of us could [have a psychiatric illness]at any point in our lives. Rather than see these people as ‘other,’ we must see them as vulnerable, and work for their care and protection.”

In 2015, Montross received a Guggenheim fellowship to support research for a book about the intersection of mental illness and the criminal justice system, and has used it to study correctional facilities from Cook County Jail, in Chicago, to Norway’s maximum-security Halden Prison. “Our society at times takes a simplistic and comfortable view that anyone who ends up in [jail]belongs there. … We’ve adopted a position that is more punitive than rehabilitative,” Montross says. In contrast, the Norwegian approach is to use the time of incarceration productively, to equip prisoners with skills so that they emerge able to thrive in and contribute to society. “That,” she says, “is a very logical approach.”

One promising step in the right direction is the 21st Century Cures Act, which former President Barack Obama signed into law in December. The legislation includes initiatives to reduce mental illness and addiction in the criminal justice system, including community treatment, diversion, and reentry programs, as well training programs for police and first responders. Says Brockmann: “Here in Rhode Island, the center is working with law enforcement agencies, the public defender, the mental health advocate, and other state actors to create an effective pre-arrest diversion program for individuals who need treatment, not jail, when they have a behavioral issue. We are optimistic that federal funding will help us move this forward.”

Treating Addiction Like the Disease It Is

Prisoners are among the unhealthiest Americans, beset not only by mental and substance use disorders, but by chronic diseases such as asthma and diabetes and communicable diseases such as tuberculosis, HIV, and viral hepatitis—all of which are significantly more prevalent behind bars than in the community. Studies have found health care is uneven, with prisoners in short-stay settings such as jails getting the least amount of care.

Yet where most people would see a human health disaster, some see a chance to turn the tide.

“Make no mistake. Overincarceration is bad for families, for communities, for society. It would be far better to dramatically reduce incarceration rates with more appropriate interventions that can lead to better outcomes for everyone. But given that this high-risk population finds itself in an institution temporarily, it would be foolish not to capitalize on the health and public health opportunities that presents,” says Professor of Medicine Josiah “Jody” Rich, MD, MPH, who has been treating prisoners in the Rhode Island Department of Corrections (RIDOC) for almost a quarter-century.

AVENGERS UNITE: The staff of the Center for Prisoner Health and Human Rights, from left to right: Michelle McKenzie, senior project director; Jody Rich, cofounder and director; Milly Perez-Cioe, executive secretary; Alex Macmadu, senior research assistant; Heather Gaydos, reentry project manager; Sarah Martino, project director; Bradley Brockmann, executive director. Photo by Patricia D’Aiello

AVENGERS UNITE: The staff of the Center for Prisoner Health and Human Rights, from left to right: Michelle McKenzie, senior project director; Jody Rich, cofounder and director; Milly Perez-Cioe, executive secretary; Alex Macmadu, senior research assistant; Heather Gaydos, reentry project manager; Sarah Martino, project director; Bradley Brockmann, executive director. Photo by Patricia D’Aiello

Working with fellow Brown infectious disease docs Scott Allen MD’91 RES’94 (who is now at the University of California, Riverside), Timothy Flanigan, MD, Curt Beckwith MD’99 RES’02 F’05, Charles Carpenter, MD, and others, Rich has helped make Rhode Island a model for correctional health programs that address infectious diseases and substance abuse. Early on, he saw prison as an ideal place to make inroads into the HIV/AIDS epidemic as well as drug addiction, thanks to the, well, captive audience. (Rich is also known for helping change Rhode Island’s five-year felony sentence for possession of syringes—“the craziest law in the country”—after years of advocating for a needle exchange program. Once sterile needles became available, the rate of HIV transmission dropped significantly.)

Today Rich is tackling another scourge from inside the walls: opioid use disorder. According to the Centers for Disease Control and Prevention, over the past decade and a half, the rate of deaths in the United States from drug overdose has increased 137 percent—and the rate of deaths involving opioid overdose has risen 200 percent. Two pernicious trends underlie this new epidemic: the dramatic rise in prescribing opioid pain relievers, and the availability of heroin and its evil cousin, fentanyl, a prescription synthetic opioid 50 to 100 times more potent than morphine.

Rhode Island has not been spared. In 2013, the smallest state in the union earned the dubious double distinction of having the highest rate of illicit drug use in the country and the highest rate of drug overdose in New England. In August 2015, Governor Gina Raimondo took action, establishing the Overdose Prevention and Intervention Task Force, which includes both policymakers and medical experts—Jody Rich among them. The group released Rhode Island’s Strategic Plan on Addiction and Overdose last November. The goal of the plan is to reduce overdose deaths in the state by one-third within three years. Its strategy relies on intense collaboration among the Department of Health, RIDOC, insurers, and other agencies to, among other things, increase distribution of naloxone, widely known as Narcan and a key lifesaver in cases of opioid overdose, and expand treatment for people on opioid agonists such as methadone.

Medication-assisted treatment, or MAT, combines behavioral therapy and medications—methadone, buprenorphine (commonly known as Suboxone), or Vivitrol—to treat opioid use disorder. Although methadone has been FDA-approved since 1972 and is recommended by the World Health Organization, opponents object to what they perceive as rewarding offenders rather than punishing them, or as replacing one addiction with another. But forced withdrawal, which is still the rule in the vast majority of US prisons and jails, has dire consequences both for the individual—it’s notoriously painful—and for society.

Methadone maintenance is more effective at keeping people alive: because an individual taken off methadone develops a much lower tolerance, he is at a much higher risk of overdose—and death—if he uses again on the outside. In a study released last year, Rich and others showed that keeping prisoners on methadone makes them twice as likely to seek treatment after they get out—and therefore much less likely to engage in drug-seeking behaviors, such as stealing.

Then there’s the ethical dimension: in a paper that appeared in a special series of the Lancet in July 2016, Rich wrote that exacerbating imprisonment with “the physical and psychological burdens of opiate withdrawal … amounts to a double punishment.” Further, he spotlights society’s double standard when it comes to substance abuse. “We don’t take [prisoners]off their blood pressure medicine, we don’t take them off their diabetes medicine,” he says. “When you take someone off [opioids]you cause predictable pain and suffering. I thought we were medical professionals. I thought we were supposed to be alleviating pain and suffering.”

Epidemic Proportions

Late on a Monday night last July, Rich returned to Providence from the International AIDS Society meeting in Durban, South Africa, where he had presented a paper on HIV, viral hepatitis, and tuberculosis among prisoners. The next morning, jet-lagged, he rounded on patients at his AIDS clinic at RIDOC in Cranston. That’s when he got a call from colleague Jennifer Clarke, MD RES’96 F’98 MPH’04.

“Jennifer said, ‘There are a couple of women interested in starting medication-assisted treatment for opiate use disorder. Can you go over to the women’s division and get them started?’” Rich recalls. When he got there, the nurse told him there weren’t two, but a dozen women who wanted to begin the treatment. He didn’t leave the prison until after dark—as usual, on his bike.

“I’m riding home that night having just heard all these heart-wrenching stories about how people did not get connected to treatment … I just wanted to cry,” Rich says. “Why haven’t we been doing this all these years? But now we’re doing it. Every Tuesday since then we’ve been getting people started as quickly as possible. That’s what’s exciting me these days.”

Last year, Governor Raimondo secured $2 million for the 2017 fiscal year to expand the MAT program, which is now available to eligible inmates for six months to one year. Some 120 RIDOC inmates are on the program on a daily basis, with plans to accommodate 300 a day—not only individuals already on methadone when they enter prison, but also those who aren’t but could benefit from it.

The urgency of the Task Force’s work intensifies daily. On average four Rhode Islanders die of overdose every five days. Last year 80 percent of overdose deaths in the state involved illicit drugs, and half of those involved fentanyl. Notably, 21 percent of 2014 and 2015 victims had been incarcerated in the two years before death.

Clarke, an associate professor of medicine, agrees with Rich that prison is fertile ground for improving people’s health. Back in 1998, as she was completing a fellowship in women’s health at Brown, she knew she wanted to work with the underserved and heard there was a job at RIDOC’s women’s facility. “I was the only one who thought that sounded amazing,” she recalls. “So I got it.”

For the next 18 years, she provided primary care to the female (and eventually male) prison population, and authored studies on the reproductive health and perinatal care of incarcerated women and on the practice of shackling pregnant inmates during labor and delivery.

But in December 2015, Clarke traded her white coat for a gray suit and became RIDOC’s medical programs director. Now, instead of directly caring for individuals, she juggles the meetings, emails, and problem-solving that come with overseeing the health care of more than 3,100 inmates—not to mention the thousands of individuals who pass through on a short-term basis. Although she has been called a “drug pusher” by those who oppose MAT, she is quick to make the case for its merits, which include cost effectiveness.

“For every dollar we spend on substance use treatment, we save 7 to 12 dollars,” she says. “It’s a win-win.”

To Clarke, inaction is unacceptable. “We’ve all heard the definition of insanity: you keep doing the same thing over and over and expect different results. We’re there. We know we have to do something different. We have leadership here, with the governor and [RIDOC Director] A.T. Wall. They are really forward-thinking and want to do the right thing, even if it might not feel good in the moment,” she says.

Like Brockmann, Montross, and Rich, Clarke considers caring for prisoners a matter of social justice. For many inmates, the medical attention they receive from RIDOC is more than what they were getting on the outside. The irony that for some people prison is the best thing that ever happened to them, at least where health care is concerned, is not lost on Clarke.

“One of the saddest things I hear is when someone says, ‘Thank God I was incarcerated. Otherwise I’d be dead.’ That really speaks to how unstable some people’s lives are in the community: lack of housing, violent relationships, substance use, mental health problems where they can’t get treatment,” she says. “[This] can be a time out for someone who’s here for 30, 60, 90 days. We’re not primarily a social service organization. … But for people whose lives are chaotic, for whom this is a better place, I feel it’s really important to take that opportunity to provide health care.”

Hi, Neighbor

Even with the most caring and effective doctors on the inside, an inmate’s troubles may start all over again when he or she is released. Rich compares reentry to “walking out of a cabin into a blizzard. Where are you going to get money? Your next meal? What about the voices you hear? How do you keep from getting beaten up? You’ve also got a lot of people with a vested interest in your picking up drugs again.” Sixty percent of inmates with a substance use disorder relapse within two weeks after their release.

It helps to have a supporter in the community. If you’re lucky, it will be someone like Lynn E. Taylor, MD RES’00 F’05, a fiercely committed advocate for the marginalized and the stigmatized, with a special focus on people infected with hepatitis C virus (HCV). She is director of the HIV/Viral Hepatitis Coinfection Clinic at The Miriam Hospital and founder of Rhode Island Defeats Hep C, a project dedicated to the elimination of HCV in the
Ocean State. RID Hep C’s goals include ensuring all electronic medical record systems in the state include a prompt for one-time HCV screening of baby boomers, who, along with people who inject drugs, are most at risk of carrying the virus.

“I’m trying to help individuals while working on affecting system-level improvements,” Taylor says.

One such individual is Paul Kelly, a 50-something man whose life story reads like that of so many caught in the cycle of incarceration, drug use, and illness: arrested at 14 for stealing, he’s been in and out of prison for most of his life. He contracted HIV by injecting drugs while on the inside, where he contracted hepatitis C as well. Off and on for the past 18 years, he’s been treated by Rich in prison and by Taylor on the outside.

Taylor, who is an assistant professor of medicine (clinical), says: “How do you really effect change? You hang in over time. Jennifer Clarke and Jody Rich have been doing this for years and years. They met many of our patients in the DOC, diagnosed them with HIV and HCV, became their docs, and said, ‘I will stand by you through whatever for forever.’ A lot of patients have never had that—not with a family member or friend, not ever. The continuity of care and investment by physicians helps people endure and improve their health and lives.”

Kelly did endure, but not without a lot of effort—and some setbacks along the way, including a few relapses and stints in federal prison. Today, thanks to Rich and Taylor and his own resilience and determination, Kelly is sober and HCV free. He lives in AIDS Care Ocean State’s Sunrise House, a drug- and alcohol-free facility for people living with HIV, and works in construction.

“I’m not on probation, I’m not on parole,” he says, smiling. “I’m free. I haven’t had that since I was 14 years old.”

Kelly is among the 95 percent of incarcerated people who are ultimately released. That’s 12 million individuals a year returning to their communities. Put that way, it’s hard to keep seeing the health of prisoners as something that only matters behind bars. As Brockmann says, “Prisoner health is public health.” The question we should be asking ourselves is, Do we want healthy neighbors?

  • Educating the medical community, policymakers, and the general public is one thing, but the Center for Prisoner Health and Human Rights aims to educate prisoners as well. One way it does this is by harnessing Brown students’ strong interest in health, justice, and human rights.
    Read more here.

Mind the (Gender) Gap

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Mindfulness class helps women, but not men, overcome a downcast mood, study finds.

In a new study of a Brown University scholarly course on mindfulness that also included meditation labs, researchers found that the practice on average significantly helped women overcome “negative affect”—a downcast mood—but did not help men.

The finding, the authors said, should call more attention to considering gender as a potential factor in assessing mindfulness efficacy.

More women than men engage in mindfulness meditation, the practice of intentionally and non-judgmentally directing one’s attention to present sensations and feelings, says Willoughby Britton, PhD, assistant professor of psychiatry and human behavior and of behavioral and social sciences. There hasn’t been a prevailing notion in the research literature that the practice affects men and women differently. Yet the data Britton and her co-authors present in a new paper in Frontiers in Psychology shows a clear gender difference in outcomes for mood.

“That was the surprising part,” Britton says. Since this study, though, she has found the same pattern in two other studies under review for future publication. “I wouldn’t be surprised if this is a widespread phenomenon that researchers hadn’t bothered to investigate.”

On the other hand, she adds, it was encouraging to see a clear benefit for women, who are generally more vulnerable to negative affect and depression.

“Emotional disorders like depression in early adulthood are linked to a litany of negative trajectories that further disadvantage women, such as poor academic performance, school drop-out, early pregnancy, and substance abuse,” Britton says. “The fact that a college course could teach women skills to better manage negative affect at this early age could have potentially far-reaching effects on women’s lives.”

Co-lead author Rahil Rojiani ’13, a medical student at Yale, says he hopes the study will narrow disparities in mental health care.

“The gender gap in mental health has been inadequately targeted and often only within the standard medical arsenal of pharmacological treatment,” Rojiani says. “Our study is one of the first to explore the effects of mindfulness across gender.”

Read more here.

The Other Side of Match Day

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For residency program directors, there’s less drama, but still plenty of excitement.

As the Medical School erupted in cheers and screams at noon on Match Day, it was business as usual at the residency program offices where students will begin their medical careers in July.

“Match Day is like any other day,” says Craig P. Eberson, MD RES’00 F’01, director of the Brown University Orthopaedic Surgery Residency Program. “There’s less drinking involved on our end.”

That’s partly due to timing. Residency program directors got the news, via email, the day before. They just couldn’t tell anyone. “It’s cool to have a secret, but then you can’t say it. So what’s the fun in that?” says John Kawaoka ’00 MD’04 RES’08, director of Brown’s dermatology residency program.

Program directors admit it’s a slightly less pivotal day for them than it is for fourth-year medical students. Though of course programs have favorites, and rank them accordingly on the list they submit to the National Resident Matching Program (NRMP), they like and want to work with every candidate they’ve listed. “I don’t put them on the list if I don’t want them in my program,” Emergency Medicine Residency Program Director Jessica Smith, MD, says.

But the match is still a thrill for program directors, no matter where they are. “Last year I was in Miami at a conference, and I was on my phone constantly checking [email],” Eberson says. “No one else could care less, and I’m in the back of the room—‘Yes! We got that guy!’”

Playing the Numbers

For residency program applicants and directors alike, the match is the culmination of an intense, months-long slog that essentially places the futures of tens of thousands of aspiring physicians at the mercy of a computer program.

In an oversimplified nutshell, the NRMP fills available hospital intern slots each year by taking graduating medical students’ ranked lists of programs and programs’ ranked lists of candidates and feeding them into an algorithm that attempts to match each applicant with their highest-possible choice. The results are binding for both parties—so stakes are high.

It’s a remarkably effective system: this year, according to the NRMP, 94.3 percent of fourth-year MD students matched to PGY-1 (first postgraduate year, or intern) programs. More than three-quarters of all applicants matched to one of their top three choices.

That success rate, however, belies the angst and uncertainty of an undertaking that residency program directors call “heartbreaking,” “out of control,” and “Game-of-Thrones-like.” “Not matching is horrendously traumatic,” says Eberson, an associate professor of orthopaedic surgery.

While the number of people seeking US residencies continues to rise, residency positions have not kept pace. This year, 35,969 candidates competed for 31,757 spots—both record highs, the NRMP reports. Though fourth-year allopathic students have consistently matched at rates between 92 percent and 95 percent over the decades, they’re applying to 50 percent more programs now than they were 10 years ago, according to research by Warren Alpert Medical School professors Phil Gruppuso, MD, and Eli Y. Adashi, MD, that was published in Academic Medicine last year. Though no data support it, they wrote, “The notion that ‘more is better’ appears to have taken hold.”

And perception is everything. “It’s just known that, really, if you want to increase your chances, you just have to apply as many places as you can,” says Kawaoka, an assistant professor of dermatology.

His field is a case in point: nationwide this year, there were 651 dermatology applicants; more than 550 of them applied to Brown. “So they’re applying to pretty much every [program],” says Karen Medici, the program coordinator. And they were vying for only 423 available PGY-2 dermatology slots nationally (four of them at Brown). In other words, about a third of aspiring dermatologists failed to match. “The joke that the people who are in derm now say is that if we had to apply now, we would never get in,” Kawaoka says.

The avalanche of applications that programs receive each fall means that, by necessity, most candidates begin as little more than words and digits on paper. Most programs have a minimum threshold for board scores, grades, and other criteria, including the Internal Medicine Residency Program at Morristown Medical Center in New Jersey, associate program director David Kuo ’89 MD’93 F’98 says. His program gets well over 5,000 applications each year, for 50 categorical and prelim slots; the cutoff “helps us separate the wheat from the chaff,” he says.

That concerns program directors and educators. Not only can reliance on quantitative metrics “further erode emphasis on students’ backgrounds and qualitative indicators of performance,” Gruppuso and Adashi wrote, it may penalize “students from disadvantaged educational backgrounds who may be at risk for underperformance on standardized examinations.”

With that in mind, even program directors who have thresholds read every application. “One of the things we like to do is recognize potential,” says Smith, a clinical associate professor of emergency medicine. “If your board scores are not at the top of the charts but you’ve done really well clinically, you’ve had great scholarly productivity, you’ve rebounded [from Step 1 to Step 2]… that is a sign that academic potential is there.”

For some candidates, cost can be a further disadvantage. “It’s a huge financial strain on students to have to travel to 30 programs to interview, when the reality is they probably don’t even need to interview at 30 programs,” Smith says.

Students are “taking nearly two months off from medical school to engage in what is a nonstop, travel-across-the-country process,” says Simone Thavaseelan, MD RES’10 F’11, director of Brown’s Urology Residency Training Program and a clinical assistant professor. The average urology candidate does 14 interviews, she says, and “that cost is many thousands of dollars to them to travel, to visit, to lodge, to crisscross the country.”

That doesn’t even include several month-long away rotations during fourth year, which increasingly have become the norm for competitive residencies. Also called audition rotations, they’re opportunities for both sides to make a good impression and see if they’ll be a good fit. According to a study Eberson coauthored in January in the Journal of the American Academy of Orthopaedic Surgeons, the average orthopedics aspirant completes 2.4 away rotations and spends $2,799 to do them. Furthermore, he and his coauthors wrote, the rotations may not align “with the mission of undergraduate medical education.”

Yet again, Gruppuso and Adashi found no data to support the belief that away rotations improve the odds of a match. But they’re part of the culture in certain specialties, including urology, Thavaseelan says: “I’m convinced that my away rotation at Brown was critical to my successful match.”

If the Program Fits

Fit is a top concern of program directors as they sift through mountains of applications. Kuo says as he reads them, “I try to ferret out if they’re a good fit for this program, which for me, it’s finding out if they have good team spirit, a strong work ethic, if they’ll fit in with our culture here.”

But the electronic application lets students effortlessly play the odds, and apply to dozens of programs they may know little about—which worries program directors. “It’s just click, click, click,” Thavaseelan says. “It’s very difficult to discern who might actually be interested in Brown Urology.”

Program directors “agonize” over interviewee selection, Smith says, because they know, inevitably, they will give some of their precious few interview slots to candidates who really have no interest in their program—and pass over others who would thrive there. “It’s really heartbreaking to say, oh, god, we have to reject someone because they’re average,” she says. “That person could come here and do amazing things.”

“You’re reading through [the applications]and you’re saying, yes, no, yes, no,” Kawaoka says. But “every single one of them is amazing. … It’s a skewed viewpoint of the world.” He adds: “These are real people. This is not Monopoly money. This is real. Real chances, real opportunities.”

Interview days are as long and exhausting for program staff and faculty as they are for candidates, with everyone trying to impress. They conduct dozens of interviews each day; depending on the size of the program, directors meet with most or all of the interviewees. Kuo says it’s one of his favorite things. “It gives us an opportunity to meet these fresh and enthusiastic faces. We only meet for 30 minutes at a time, but it’s a lot of fun to interview them,” he says. “We’re interviewing them as much as they’re interviewing us.”

“We hope it’s not a lot of pressure,” Smith says. “We really want to get to know the students. The hard part is getting the interview.” She tells candidates, “By virtue of the fact that you are in these seats, we like you. We want you.”

With their focus on fit, many interviewers don’t ask candidates about medicine. “We take into account interesting stories about their childhood, their background,” Eberson says. “Those intangibles are important; otherwise why invite them to interview?” Thavaseelan says her go-to questions include “what do you think makes a good resident? … What are those qualities that you want to emulate?”

Naturally, programs want—and need—team players. “Some [orthopedics]programs don’t have an ER. Here the ER is slamming,” Eberson says. “It’s an enormous team atmosphere.” But directors want their residents to gain from the programs they join, too: fit is as important for their well-being as for the team’s.

“You’ve got to be in a place where you’re going to feel as supported as you can with a network of friends that’s going to carry you through the tough years of residency,” Smith says. “They might be a great applicant, but who are their friends going to be here? And that is a legitimate question that we ask ourselves because we don’t want someone to feel isolated or alone.”

It’s a lot to assess in only a few minutes, and Kawaoka finds it stressful. “They try to figure out what we’re like, we try to figure out what they’re like,” he says. “That’s just bound to not work out sometimes.”

Leap of Faith

To finalize the rank order lists for the match, most departments hold several meetings, attended by program directors, faculty, senior residents, and others, where they compare notes about interviewees and arrange and tweak (and rearrange and retweak) the list in order of favorites.

“We have a number of people who interview, and then a lot of opinions,” Kawaoka says. “There’s definitely some heated discussions at times, but no one’s thrown a punch yet.”

Most programs discuss and rank every interviewee, save one or two who may have taken themselves out of the running voluntarily—or behaved unprofessionally on interview day. “If on the one day you need to put your best face forward, if you cannot get through an interview without profanity, that’s a red flag,” Smith says.

“Anyone who goes on the list, we want to be very, very sure that we want to have them in the program,” Thavaseelan says. Disagreements are inevitable, and reputations may be on the line. “Everyone remembers when you really advocate for someone, so when they match, god forbid they’re not perfect,” Eberson says.

Despite the hours upon hours of application review and interviews and deliberations and debates, there’s simply no way to know what a candidate will be like until they report for duty, as a resident. “It’s like if the NBA draft got numbers from the weight room and a speed test but they have never seen [the player]shoot a basketball,” Eberson says.

“We’re doing our best to make the list full of people who we think are going to work well together and contribute. And it’s hard,” Kawaoka says. “It’s hard.”

There probably is no way to make the ultimate task of residency program directors—annually creating the best possible class of new physicians for their departments—any easier. But some reforms, if widely adopted, could ease the stress and burden for everyone involved.

In their Academic Medicine article, Gruppuso and Adashi suggest that “capping the number of interviews per student would go a long way towards stemming the time and resource drain on both applicants and GME [graduate medical education]programs.”

Thavaseelan would go even further. “If you consider application caps, perhaps it limits free choice, but it would increase, on the program side, the percentage of people that we review who are truly interested in our program,” she says. Her program received 270 applications this year for just two positions. “We’re flying by the seat of our pants trying to get all our work done and all these applications reviewed in a meaningful way.”

But, she acknowledges, the intense competition for urology’s limited spots—it has only a 75 percent acceptance rate nationwide—prevents “wholesale change.” “It’s hard to counsel a candidate against them trying to increase their odds,” she says.

Advisers help, Smith says—as long as they’re “honest and realistic with [students]about their competitiveness as an applicant so that way they can target an appropriate number of programs to apply to.” This might mean counseling them to consider a different specialty. “Sometimes it feels like you’re crushing someone’s hope or dream,” Thavaseelan says.

There’s more that programs could do: for example, conducting a first round of interviews online via Skype or another platform is a potential money- and timesaver, Gruppuso and Adashi wrote. They also advocate coordinating the timing of interviews, across all disciplines. Thavaseelan says New England urology programs already do this, so interviewees can schedule one visit to the region. Brown’s dermatology program is one of only a handful nationwide that hold their interviews on Saturdays, instead of weekdays, which Medici says reduces conflicts for candidates.

But it’s unlikely any changes can ever alleviate the anxiety of the residency placement process. Because once the matches are finalized, everyone’s fates are sealed.

“What the match is, is it’s a contract,” Eberson says. “On the surface everyone knows the contract says: you agree to train, you agree to come. What it really means is, if you show up here and you have an issue—a personality problem, you’re stressed out, you don’t work well under pressure, you’re not a good surgeon—we have no test for dexterity—we agree we will do everything in our power to help you graduate a confident and competent surgeon.”

The Big Day

After the lists are submitted, it’s a waiting game until the third week of March—Match Week. The big day, for most program directors, is Thursday: at 2 p.m. Eastern, they receive, via email, their uber-confidential match list. And at 2:01, they start getting phone calls and texts and personal visits from colleagues: “How did we do? Who’s on the list? Who did we get?” Smith says. “It is a wild secret. I can’t even tell the chair who is on that list.” Only associate program directors and program coordinators can know; she avoids everyone else. “I do not have a very good poker face,” she says.

But on Friday, at 1 p.m., the list is public, and the celebrations can begin—muted though they may be. “Is there champagne? No, not usually. … I’ll be at the clinic,” Kuo says. But “generally there’s a lot of happiness.” Faculty are especially thrilled about the people they vouched for, he says: “If we know someone will be really good and we have them accepted to the program, it is a great accomplishment all around.”

Program directors and other interviewers usually call the new interns Friday afternoon to congratulate and welcome them. But that’s just a short break from an otherwise regular day. “We’re pretty much back to work 10 minutes after we find out,” Thavaseelan says.

But maybe with a smile on their face, or a little skip to their step. “These are people we spend a tremendous amount of time working with, and they’re really part of our family,” Eberson says. “It’s a big deal to us.”

Want more Match Day coverage? Read the feature.

Joanne Giuttari Mitchell MD’87

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Joanne Mitchell, 70, of Holliston, MA, died August 15, 2016. Born in Providence, she studied German and premed at Trinity College in Washington, DC, and earned her Master of Education in Child Studies at Tufts. In 1978, she decided to pursue her dream of a career in medicine; she completed her MD at age 41, and then her pediatrics residency at UMass Medical Center and a fellowship at Boston Children’s Hospital.

Dr. Mitchell’s career focused largely on the care of children and young adults with developmental and other disabilities. She was on staff at Boston Children’s for 20 years, receiving their Community Pediatrician Award in 2006. She taught and oversaw research for more than 15 years at Harvard, and also served at the Massachusetts Hospital School in Canton throughout her career.

Dr. Mitchell is survived by her husband, Jon; two sons; and three brothers. Donations in her memory may be made to United Cerebral Palsy of MetroBoston, 71 Arsenal St., Watertown, MA 02472, www.ucpboston.org.

Nathan S. Ross ’76 MD’79

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Nathan Ross, 61, of Tacoma, WA, died January 27, 2016. A native of Worcester, MA, he did his residency, including a year as chief resident, at Case Western. He began his career in medicine at the West Los Angeles VA Medical Center, where he was assistant chief of endocrinology. He went on to become the chief of medicine at the Huntington VAMC in West Virginia and then the chief of staff at the VA in Columbus, OH. He later worked in private practice in Amarillo, TX, and Tacoma, WA.

Dr. Ross was a generous supporter of the University Place School District that his sons attended near Tacoma. A devoted reader, he bought all the books at the annual book fair on each teacher’s wish list for their students. In the same generous spirit, he regularly treated patients without private insurance. Dr. Ross was well known among family and friends for his wit, dry sense of humor, and compassion toward others.

He is survived by his wife, Patricia; two sons; his father; two brothers; two sisters-in-law; and 14 nieces and nephews. Donations in his honor may be made to the National Multiple Sclerosis Society at www.nationalmssociety.org/donate or 800-344-4867.


Leading for Change

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An alum heads a university with a mission to combat health disparities.

When Charles R. Drew University of Medicine and Science in Los Angeles needed a new leader, taking on the role was a no-brainer for David M. Carlisle, PhD MD’81.

The historically black university, known as CDU, established its medical school to care for underserved populations following the 1965 Watts riots, when more than 30 people were killed in the South Los Angeles neighborhood while protesting allegations of police brutality against a black resident.

“We’re in the middle of a community where health disparities are incredibly important,” Carlisle says. “We train health professionals who intend to combat those disparities.”

Carlisle’s commitment to caring for underserved communities isn’t just professional—it’s personal. His family is from South Los Angeles, and he grew up in the View Park neighborhood, one of the dozens of predominantly African-American neighborhoods that make up the region.

“I’ve seen what happens to relatives or friends when they don’t have access to mainstream medical care, and it’s particularly frustrating when you know it’s available right around the corner,” Carlisle says.

CDU students perform a rotation at the Venice Family Clinic, the largest free clinic in the nation, which provides health care to more than 25,000 patients in Los Angeles County each year. Carlisle volunteered at the clinic for many years and now sits on its board.

“A resident of Watts deserves the same high-quality health care as a resident of Beverly Hills,” he says.

Carlisle became president of CDU in July 2011, a tumultuous time for the university. It was facing serious financial problems; two years earlier, it had nearly lost its accreditation.

He credits the intervention of community members and local agencies with helping to turn things around, and he says he was “humbled” to be chosen as the university’s president. After he took over, enrollment at CDU increased, as did federal funding for research. Recently, the university expanded its undergraduate program.

Prior to joining CDU, Carlisle was the director of California’s Office of Statewide Health Planning and Development, serving for 11 years under the administrations of three different governors. He has been an adjunct professor in the Department of Medicine at the David Geffen School of Medicine at UCLA since 1992. He is also a professor in the College of Medicine at CDU.

Reflecting on his time at Brown, Carlisle credits the Medical School’s “exceptional” clinical training environment and its proximity to major teaching hospitals for his ability to expertly care for critically ill patients.

He transferred from the Stanford University School of Medicine to Brown to join his wife, Sylvia Gates Carlisle, MBA MD’82, a senior medical director for Aetna Better Health who is also a board-certified internal medicine specialist and geriatrician. The couple has two grown children: David, a public defender in Oakland, CA, and Aimee, a public defender in the Bronx.

“The thing that makes me proudest is having conversations with our students and feeling motivated and inspired by the young people on campus who are dedicated to achieving the same mission as the university,” Carlisle says.

Ars Medica

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‘Return to play’ has broader meaning for artists.

Amity Rubeor, DO RES'05, the first physician in Rhode Island to receive certification in performance medicine.

Amity Rubeor, DO RES’05, the first physician in Rhode Island to receive certification in performance medicine.

Performing artists have much in common with athletes, Amity Rubeor, DO RES’05 says. Their activities result in specific types of injuries and strains—tennis elbow, in the case of the violinist who practices three hours a day, or Achilles tendonitis in the dancer—and they are just as eager to return to play as the football player who’s suffered a concussion.

“Their identity is wrapped up in it,” she says.

Rubeor is the first physician in Rhode Island to receive certification in performance medicine, an expertise centered on the specialized musculoskeletal issues of musicians and dancers. Performance medicine is a natural offshoot of her practice at Care New England’s Affinity Sports Medicine.

Rubeor treats many concussions, and says it’s important to consider the role that other activities play in “return to play” strategies. “I had a young hockey player who was also in the band,” she says. “I realized that he shouldn’t play the tuba while he was recovering from a concussion, because of high pressure required to play that instrument.”

That was one of her earliest insights into the medical needs of performers, and it was confirmed by observations of her daughter’s dance classes, and the particular types of injuries to which dance students are prone. She pursued her interest by taking a workshop on performance medicine with the American College of Sports Medicine, and followed that up in July 2016 by earning certification from the Performing Arts Medical Association.

For Rubeor, this focus on performance medicine isn’t just a desire to treat a specific type of patient using specialized skills; it’s a tool for understanding important dimensions of the patients she already has in her practice. For example, one patient who had been struggling with intractable back pain after a car accident is a music teacher who plays the saxophone. “I have to think about her posture and how she holds her sax. I have to balance what I want to see a musician do as far as posture and behavior, with what they have been taught to do and have been doing for years,” she says.

“Before I took the course, I might have told a violin student, ‘Just don’t play for two weeks,’” Rubeor adds. “But now I realize that they can’t. Performance matters so much in their lives.” Now she gives performing artists and athletes the same reassurances: “I’m going to get you back to doing what you love and need to do as quickly as possible, but I’m going to take into account what that is doing to your body. We are going to try to make that work.”

Word Play

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A resident learns the secret language of medicine.

For anyone who has been in the company of medical professionals, it is immediately apparent (and possibly nauseating) that we share a complex jargon that can be hard to switch off. Recently, a colleague and I were musing over the medical hijacking of familiar English words. Wandering through the hallways of a hospital during change of shift, it is not uncommon to hear descriptions of “heart murmurs appreciated,” “diet tolerated,” and “catheters colonized.” Are those with a “productive cough” to be proud of their contribution to society, while those with a radiologically “unremarkable liver” considered subordinate citizens, I wonder?

The impact of language in medicine extends far beyond vocabulary. Every medical trainee becomes well-versed in the “SOAP” format for presenting patients: “Subjective, Objective, Assessment, and Plan.” This widely used format evolved from the Problem-Oriented Medical Record first proposed by Lawrence Weed, MD, an academic physician and developer of one of the first electronic health records, in the New England Journal of Medicine in 1968. By dividing impressions of the patient into “Subjective” and “Objective” components, the presenter can substantiate the patient’s own experience of their symptoms such as “feeling feverish” with concrete information such as a recorded elevated temperature. He or she then moves on to the “Assessment” or conclusion statement—the grand finale. Here, the presenter skillfully synthesizes all of the data gathered and makes an argument for a particular diagnosis that will shape the treatment plan. A true connoisseur will list several possible diagnoses in order of likelihood and offer evidence for or against each one, in this way convincing the listener that he or she has cast a wide net and carefully considered multiple possibilities before reaching the conclusion. Finally, we arrive at the “Plan,” which is the first time that the presenter proposes a treatment plan based on the working diagnosis.

By holding the SOAP format sacred, and in communicating about patients in this disciplined way, physicians like Weed believed we could optimize the care provided to each individual patient and minimize “anchoring bias,” or the willingness to accept another’s initial diagnosis without further thought.

TALK THE TALK

As a generalist, I also have encountered the power of language in effectively liaising with specialists. On an emergency medicine elective as a medical student I was tasked with consulting the on-call cardiologist about a patient with persistent chest pain in the setting of a recent cardiac catheterization. Several minutes into our conversation the cardiologist asked a series of questions concerning the patient’s symptoms and medical history that I felt ill-prepared to answer. Sensing his mounting frustration, I apologized and sheepishly handed the phone to my attending to finish discussing the patient. “It’s all in the way you sell it to them,” I was told later. “You’ve got to know your audience and hook them with your opening line.” Mrs. Bowker, my fifth-grade English teacher, had been right all along. Yet as a physician-intraining you quickly learn to code switch between the methodical way of communicating with colleagues and more natural speech with patients and families.

When I began my pediatrics clerkship during medical school, one of the most terrifying parts of the six weeks that lay ahead of me had little to do with examining inconsolable infants or forging connections with jaded teens at risk. Instead, the challenge lay in deciphering the craft of presenting on “family-centered rounds.” A well-established model of care in the inpatient pediatrics world practiced by more than 44 percent of pediatric hospitalists in the US, it has given new life to the age-old, forgotten tradition of bedside rounds by discussing the patient in their room and incorporating patients and families in decision-making. While studies show that family-centered rounds improve parental satisfaction and coordination of care, as a student I found myself having to repress months of training how to “talk like a doctor” and relearn the art of everyday communication while involving parents in complex medical discussions in their own lexicon.

Reflexively, we emphasize the subjective when talking about patients by using terms such as “the patient denies drug use” or “he reports 10/10 pain.” For the recently sober patient, or those who consciously avoid illicit substances, or for patients with persistent pain of unknown etiology, these terms can be perceived hurtfully. As physicians, we also thrive on acronyms. Why waste time talking about the “77-year-old male with past medical history significant for systolic congestive heart failure with 30-percent ejection fraction who presents with shortness of breath” when I can just say “77yo M with PMH of HFrEF (EF 30%) p/w SOB?” Much to the patient’s (and physician’s) horror, commonly employed acronyms can be misconstrued as a reflection of the provider’s opinion of them or their family members. An unfortunate double entendre.

The practice of medicine undoubtedly relies equally on data and how they are expressed. Much like every clinical test we use, increased sensitivity (toward patients or colleagues) and specificity (of language utilized) results in far more effective care. And as I’ve learned repeatedly, good communication, like a whopping heart murmur, is always appreciated.

Health By the Numbers

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With a new biomedical informatics center, Brown is taking a deep dive into big health data.

On a chilly evening in downtown Providence, a gaunt man is rushed to the hospital, unconscious. He knows no one; no one knows him. Yet his doctor, whom he’s never met, already has an intimate knowledge of his health. His history of asthma. His heart problems. His struggle with opioid addiction.

This man is fictional, but his circumstances might well be real. New electronic health data systems are improving care for countless patients by sharing their data instantly—not just with physicians, but with pharmacists, public health researchers, academics, and scientists.

If harnessed correctly, circulating “big health data” among all these players may change the face of medical treatment. The information is useful not just in the clinic, but behind the scenes, helping to inform public health policy, to create new treatments or consumer products, and even to shed light on the mysteries of the human genome as they pertain to human health. In order to use it, though, you first need to build the right tools and safeguards to work with vast datasets.

Meeting that need is the driving force behind the new Brown Center for Biomedical Informatics (BCBI). Its founding director, Indra “Neil” Sarkar, PhD, MLIS, and associate director, Elizabeth Chen, PhD, who are also associate professors in both the Warren Alpert Medical School and the Brown School of Public Health, are creating ways to harness electronic health data securely from a wide range of sources—like electronic health records, gene sequences, or even wearable devices like a Fitbit.

“[The health care community] is collecting information that we can use to learn about our patients. We can use it to study populations, develop models, and predict if a patient is at risk for a particular illness,” Chen says. “We’re all about trying to improve health in general—using data, data science, information technology, or some combination of those.”

Through a unique blend of collaborative research, educational outreach, and community partnerships, she says, the work being done at BCBI could help create a new personalized standard of care in Rhode Island and beyond.

Statewide Experiments

Both Sarkar and Chen have celebrated careers working with biomedical and health data, and have been collaborating since graduate school—so much so, they’ve been called an “informatics power couple” by a close colleague. Before coming to Brown in 2015, the pair—both elected fellows of the American College of Medical Informatics—worked at the University of Vermont, where they developed projects that they’re now continuing at BCBI. Chen’s work has focused mainly on clinical informatics, finding ways to extract and analyze information in electronic health records; Sarkar has worked largely in translational bioinformatics, creating tools to sort through mountains of genetic and evolutionary data in the lab.

When the opportunity arose to start a new center at Brown, they say, it offered an ideal place to put their multifaceted research into practice. “Rhode Island is a perfect petri dish to do population studies and longitudinal studies with patients,” Sarkar says. “The state is the nation’s smallest geographically, but at least 60 or 70 percent of the people who are born here, stay here. And because we have only one medical school that partners with the largest civilian health care providers in the state—as well as the Department of Veterans Affairs—we can figure out a way to coordinate all those data into one spot, and can do very powerful population analysis.”

One of Sarkar and Chen’s first goals for the center is to improve access to health data across the state. “BCBI’s greatest advantage is our access to those data,” Chen says. “It can be challenging for researchers to get that, and there’s no systematic process for it.”

Right now, they are working to create partnerships to share data between health care systems like Lifespan, Care New England, and the Providence VA Medical Center, as well as with the Rhode Island Department of Health and Rhode Island Quality Institute (RIQI). The overall goal of this collaboration, Chen says, is to build a computing infrastructure at Brown that can intelligently comb through disparate systems and pull relevant data from patients’ health records—essentially creating an ultra-secure, “one-stop shop” for health information that reflects the state’s entire population.

Those new computing tools will build on work that the state is already doing, says Laura Adams, president of RIQI, a nonprofit that works to solve regional health issues. (The group also runs CurrentCare, Rhode Island’s health information exchange.) By spreading health information freely between all care providers, she says, the state is able to provide emergency departments with lifesaving information for unconscious patients, like our hypothetical stranger. Before CurrentCare, if the patient wasn’t in a particular hospital’s health records system, doctors had to guess at his medical history when his gurney was wheeled in the door—meaning they had no way of knowing in advance if the patient was deathly allergic to a certain drug, or taking medication that might interfere with treatment.

“[Doctors] had to make some clinical judgments on the basis of very limited data. In some cases, actual harm was done to the patient that could have been avoided if they had data from competing systems,” Adams says.

Letting both clinicians and researchers access this data will be essential for improving care, Chen adds. In addition to giving new insight in the clinic, she’s hopeful that CurrentCare will be able to inform new scientific studies.

“That’s one of our big initiatives,” she says. “We want researchers to be able to come to us if they’re designing a study and ask, ‘How many patients meet my inclusion/exclusion criteria? If I’m doing a study on asthma, how do we actually find those patients?’”

One of the challenges of doing this, she notes, will be creating software that can deal with many different formats of health records. Certain hospitals may use a records system that’s formatted in a different way than another’s. Even a clinician’s own note-taking habits come into play—some may record a patient’s care as a narrative paragraph, whereas others create something akin to an Excel spreadsheet—yet each version has the same valuable information scattered within it.

To make sense of these data, Chen says it’s necessary to develop computational tools that can analyze natural language and intelligently summarize data for researchers—not an easy task by any standard. According to Sarkar, though, it’s just part of the bargain when it comes to the work being done at BCBI.

“One thing that is essential in informatics is to avoid getting in the way of a doctor being a doctor,” he says. “We want the technology to work behind the scenes—so we spend a lot of time studying the process, studying what a care provider is doing, and teaching computers cues to follow through based on that. If we’re truly successful, clinicians and patients don’t even know we’re there.”

By looking deeply into data from multiple hospitals, the BCBI team is also hoping to uncover trends in patient outcomes that hint at how well specific interventions actually work. Ideally, Sarkar says, these tools may help fine-tune best practices that clinicians follow in emergency situations—not just by improving them for the field as a whole, but by customizing them to the needs of patients in specific geographic areas.

Decisions, Decisions

Orthopedic surgery offers one example. Given the icy winters of New England, slip-and-fall accidents happen at a much different rate here than in, say, Miami. Surgical treatments for broken bones and torn ligaments are costly not only in terms of dollars, but in quality of life: recovery, especially for elderly patients, can be long and painful after going under the knife. So, Sarkar asks, in each location, what factors lead a surgeon to choose either a full hip replacement or care that would simply make a patient more comfortable?

“Medicine is very well informed, but most of the guidelines and standards are based on measures that were developed at a single institution—and that place may be nothing like your institution,” Sarkar says. “We have the opportunity to look at all the data produced by patients in a single region, and build a quality registry to guide physicians working there. That’s our grand vision.”

In addition to shaping best practices, those data could also help clinicians decide when to use specific procedures or treatments in complex cases, especially ones where time is of the essence. Powerful computer algorithms may help them narrow down and diagnose ailments that aren’t immediately obvious, and automatically suggest the best course of action to support their own judgment.

“As a young intern or resident, there is a massive amount of information that you are expected to be the conduit for,” says Cedric Priebe, MD. “You’re taking information from the laboratory, from diagnostic imaging, from bedside monitoring, the pharmacy, pulling that all together, synthesizing it, and then sharing it with your team and your supervisors.”

Priebe is a practicing pediatrician and chief information officer at Lifespan. He’s working with BCBI to share electronic health data for research purposes, and plans to use those data to develop and improve existing decision support tools. Along with shaping best practices in the emergency department, he adds, these sorts of tools are helping to spot dangerous ailments that develop in patients over several days, catching them while they’re still easily treatable.

In cases like sepsis, a severe immune reaction that attacks all organs of the body, improved decision support would be potentially useful. At its onset, the condition can be difficult to spot, and if it advances, it can become deadly. By looking for a combination of early symptoms—like elevated heart rate, low blood pressure, high temperature, and high levels of lactate in the blood stream—new algorithms could automatically flag information that a single physician might otherwise miss.

“The ultimate secret sauce would be an algorithm that you can use in cases where you don’t know a problem is going to develop,” Priebe says. “That’s the essence of predictive analytics—it needs big data, sophisticated math, and electronic systems that can make those decisions actionable by caregivers.” In short, it needs areas of expertise that BCBI is helping to develop.

Data in the Genome

Although the center is focused mainly on improving care in health care settings, it’s also working to provide data for researchers outside of the clinic. The same analytic tools and techniques used to comb through a patient record, Sarkar says, can also be adapted to spot patterns in genetic information. Our genome, after all, is just another form of coded data—a string of molecules laid out in a specific order—and finding patterns in data is one of the calling cards of biomedical informatics.

“We’re using informatics tools to look at the basic biology of an individual,” Sarkar says. “Understanding that biology, combined with understanding their lifestyle choices and environmental factors, will give us a precise description of an individual before we move them through the health care system. If we have enough information about those individuals at the genomic level, we might be able to better customize their treatment.”

Sarkar is also examining genetic data to understand how certain diseases develop in the first place. He’s continuing work he started at the University of Vermont, where he developed new techniques to examine genes associated with Alzheimer’s—a disease that is exceedingly difficult to study. No definitive diagnosis can be made until an autopsy examines brain tissue, and tracking its progression in living patients is a challenge.

It’s possible to simulate the disease in specially bred mice, but that’s by no means an ideal method, Sarkar says; first, researchers must “humanize” the mouse, altering it physically and genetically, by adding genes related to Alzheimer’s into its DNA. Only then can they follow the disease as it spreads in the mutant mouse.

Instead of going through all the work of adding a gene into a tiny mammal, Sarkar says, it may make more sense to study simpler organisms that have the gene already. By carefully analyzing the gene’s evolutionary history, he was able to trace it back to animals that have been around since the evolution of metazoans—creatures like sea squirts and anemones. In their DNA, he found, they carry a close relative to the genes associated with Alzheimer’s in humans, meaning that they could be ideal for understanding how the gene itself works, and could help identify the process that causes damaging plaques to form in the brain.

Eventually, this approach could lead to new treatments for a number of conditions. Sarkar is developing similar techniques to study parturition. Better understanding of the genes associated with childbearing, he says, may offer a better understanding of certain pregnancy complications, like preeclampsia or spontaneous preterm birth.

“In many ways, we’re detectives, trying to piece together [disease]genes’ stories using informatics,” Sarkar says. “But the techniques that we use to identify which organisms to look at—data mining, machine learning—all those things are identical whether we’re looking at a clinical context or a biological context.”

From sea squirts to humans, BCBI is working to share genetic information with researchers across the nation—and just like electronic health records, Chen and Sarkar say it’s essential to set up a secure and standardized infrastructure to house those data. It may be several years before they’re ready to open up genetic and health information for national use, but right now, they’re already starting to experiment locally. Advance Clinical and Translational Research (Advance-CTR), an NIH-funded partnership between Brown, the University of Rhode Island, and several state health care systems, is already using local data to develop real-world treatments for patients in Rhode Island.

Getting the Word Out

When it comes to using biomedical informatics, however, both Sarkar and Chen feel that the next big improvement will come not through any particular research initiative, but through education. No matter how good data tools become, they’re useless unless future academicians, clinicians, scientists, and even patients know how to use them. In that sense, Chen says, promoting data literacy will be key.

“I think we have a lot of work to do when it comes to both training medical and other students about informatics and working more closely with patients,” she says. “We can develop all these tools and all these systems, but are they really useful to the patient and clinician? We have to do more about involving them, educating them, and developing solutions that are directly useful to them.”

Sarkar echoes that sentiment wholeheartedly. One of his major educational initiatives at BCBI is expanding not only a scholarly concentration for Warren Alpert medical students, but eventually creating master’s and PhD programs and hosting classes for undergraduates.

“Brown’s academic culture of letting students take their own path is a big part of why our work is thriving here,” Sarkar says. “It allows a biology major to take a computer science class, and no one raises an eyebrow. It allows a medical student to explore computer stuff. That’s baked right into the Brown culture.” These students are also incredibly self-motivated, he adds. “We showed up in July 2015, and immediately four medical students came knocking at our door, wanting to work with us. In a very short time, the original four grew to 10 students. We were just flooded.”

The immediate interest, he thinks, may stem from the fact that informatics is an interdisciplinary field, so a growing number of students’ interests—be they policy, computer science, biology, or public health—overlap widely with the work being done at BCBI.

In a student hackathon cosponsored by the center in 2016, Sarkar and Chen worked closely with students in a variety of disciplines to create new health care innovations over the course of one weekend. The ideas varied widely, from custom breast prostheses to apps that provide information to surgical patients.

Sachin Pendse ’17, an international relations and computer science concentrator, worked on software that could help patients identify the side effects of medications and offer suggestions to cope with them, like deep breathing, meditation, or alternative medicine. Informatics, he says, would play a big role in improving the app’s content. By collecting data on what helps patients in need (and what doesn’t), its code could be tweaked to make better suggestions, or to shift its focus to more successful interventions.

“Neil was an amazing mentor for that sort of thing,” Pendse says. “He ended up giving us his personal cell phone number and saying, if you want any information about how biomedical informatics works in the real world, just text me. I’ve never had that sort of access before.”

Pathway to Informatics

Until BCBI was founded, students at Brown had no direct pathway to biomedical informatics, and had to find their own way in a growing discipline. Biomedical informatics, according to the American Medical Informatics Association (AMIA), “studies and pursues the effective uses of biomedical data, information, and knowledge for scientific inquiry, problem solving, and decision making, motivated by efforts to improve human health.” BCBI is working with partners across Brown, including the Center for Computational Molecular Biology, School of Engineering, School of Public Health, and the Data Science Initiative, to develop complementary educational offerings for students at all levels. Many current giants in the field—like Isaac Kohane, MD, PhD ’81, inaugural chair of the Department of Biomedical Informatics at Harvard Medical School—started out by studying unrelated disciplines at Brown, and entered a career in informatics without the benefits of direct mentorship.

“I think having a center like this when I was a student would have caused me to focus much more rapidly on applications to medicine,” says Kohane, who studied biology as an undergraduate. “There are still only a small number of schools that have excellence in both biology and in computing in the way that Brown does, along with leaders in informatics like Neil and Liz to train people in the discipline. I’m really pleased to see that this center has been established, and I’m confident it means the next generation of leaders in biomedical informatics will be from Brown.”

That’s a goal the BCBI team is working toward. In addition to teaching and mentoring within the greater Brown community, Sarkar and Chen are also focusing on students before they even reach the undergraduate level. They’ve created summer programs and workshops for high school audiences, where they aim to seed an interest in informatics from an early age.

“Neil and Liz are pioneers in that area,” says Doug Fridsma, MD, PhD, president of the AMIA. “At first, we all thought it was a little crazy, but if you think about it, if you’re a kid interested in technology or computers, and you also want to do something that helps people and contributes to society, informatics provides a pathway to combine those interests.”

For both Sarkar and Chen, it doesn’t matter how old or young a student is when they enter the field, so long as they share a passion for positively impacting human health. Using data, they say, can unite expertise from a number of different fields, and have a large-scale impact on patients.

“We’re all on the same team here,” Sarkar says. “In the end, it’s all about providing better patient care, with the best available data, in the most efficient way, whether it be through inspiring students or working directly with researchers and clinicians.”

Gripping Sidelines

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A career in interventional radiology inspires an action-adventure fiction writer.

A lost treasure. A mysterious explorer. Bad guys chasing unsuspecting academics. It’s not the plot of the latest Indiana Jones adventure but of The Lost Book of Wonders, the debut novel of Chad Brecher ’94 MD’98.

Published this spring, it’s a fast-paced historical mystery that involves a metal chest once in the possession of the explorer Marco Polo that is unearthed by modern-day archeologists.

By day (and nights too, when on call) Brecher is an interventional radiologist at Southeast Radiology, just outside Philadelphia. He focuses on vein disease and interventional oncology, although his practice is within a health system that has a Level II trauma center, so there’s a great deal of variety in his day. He’s also an involved parent of children ages 4, 8, and 11. How does he find the time to write?

His published book has been in the works for 10 years, he says. “Most physicians have their creative outlet,” he says. “For surgeons, it might be the artistry in how they tie sutures. For me, it’s writing.” Brecher says he’s already written a sequel and several other manuscripts, although this is the first novel he’s pushed to get published.

Brecher was inspired to write about Marco Polo because of the controversies surrounding Polo’s life and legacy. “Did he really bring pasta back from China? Did he even really go to China, and what was he doing there?” Brecher says. The idea for the novel was cemented on a trip to Venice with his wife. As he contemplated how ancient the city is while peering into one of the canals, he remembers wondering, “How many things have been dropped into this water over the years?”

Brecher did much of the research for the novel after he completed his fellowship at Johns Hopkins and joined his wife, a historian who was finishing graduate school, in Boston. As a clinical instructor at one of Harvard’s teaching hospitals, Brecher gained access to Harvard’s vast library and would spend hours taking books down from the stacks to do research.

The young protagonists of The Lost Book of Wonders are Ellie, an expert in pre-Biblical and Biblical archaeology, and Alex, a graduate student in history. The two academics come into possession of a historical treasure and are thrust into an adventure when they’re pursued by murderous thugs.

Does Brecher relate to his heroes? “Maybe a little bit,” he says. “Growing up in the ’80s, I loved Indiana Jones. And, while radiology generally can be academic and scholarly, interventional radiologists do procedures that can be life threatening. There is more stress, more of an adventure.” His discipline, he notes, combines the processes of trying to figure something out and actively intervening on a disease. “Yes, it does play a role in how I view these characters,” he says.

The Lost Book of Wonders is available from Deeds Publishing and Amazon. Learn more at www.chadbrecher.com.

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