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Medicine Without Borders

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Compassion and respect for patients are universal practices.

In an overlooked corner room of Webuye County Hospital in western Kenya, I am seeing patients with Dr. Hussein Elias in clinic as part of his third-year residency outpatient rotation. A fifth-generation Kenyan who completed medical school in Russia (after only a few months of intensive Russian classes), he maintains an infectious enthusiasm for his work despite the many anxious and ill-appearing patients waiting to see him.

As is common in Kenya, Hussein worked for several years as a general practitioner in various settings around the country after his internship year, before he decided his career was “stagnating” and chose to pursue his family medicine residency (Master of Medicine degree) at Moi University. As the only residency based at this rural community hospital, Hussein and his co-residents manage complex cases every day across the clinics, wards, and operating rooms using limited and unpredictable resources.

I am privileged to be in Webuye working with my Kenyan family medicine resident counterparts as part of the AMPATH (Academic Model Providing Access to Healthcare) consortium—an almost-three-decade-old partnership among Moi University School of Medicine, Brown University, and several other North American institutions that work together to deliver health services, conduct health research, and develop health care leaders in North America and Africa. This collaboration has provided a transformative experience for Brown trainees. Despite the confidence gained in my clinical skills back home with each year of residency, seeing patients with Hussein in his clinic is a humbling opportunity to reflect on my own practice.

Our next patient is a 53-year-old female with stage III cervical cancer here for follow-up. Her prognosis is poor, despite several rounds of chemotherapy in neighboring Uganda, made possible by selling her only piece of land. With low rates of cervical cancer screening and awareness, the disease ranks as the most frequent cancer among women in Kenya, and survival rates are generally low because by the time many women see a doctor, the disease has advanced. Hussein is acutely aware of her dire situation, yet his eyes light up in anticipation when her paper chart is handed to him.

Earlier this year, Hussein’s program director chose him to head the hospital’s fledgling hospice and palliative care program. With no hospice facility in the county and only one dedicated staff nurse, this was not an easy task. He quickly realized the significant need for palliative care in the hospital’s catchment, and through his own initiative he applied for and received a grant to train health care workers across the county to improve awareness and create linkage to care.

Hussein steps out to invite the patient, accompanied by several family members, into his office. She appears frail but smiles warmly as she takes a seat. He greets her affectionately in Swahili. At the last visit, she had learned for the first time about the terminal nature of her illness. Hussein tells me she was upset but also relieved to find out she could choose to continue aggressive treatment or not. She returned today with her family to meet the doctor who was honest with her and helped bring some happiness to her life again.

Many thousands of miles away from my own clinic, I am reminded how some moments in medicine seem to transcend all borders.


Amber Waves

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For Alan Muney ’75 MD’78, P’04, photography is all about capturing the art in ordinary life. This majestic image in green and gold, for example, is a close-up of Boston’s steel and glass Hancock Tower. Muney says he began taking photographs in junior high, and his technique has evolved over time; he first shot on film and then moved to digital about a decade ago. “I haven’t spent time in the darkroom in about 10 years,” he says. Though his role as chief medical officer and executive vice president of Total Health and Network for Cigna doesn’t leave much time for photography, Muney still enjoys the avocation. An exhibition of his work opens Commencement-Reunion Weekend and is on view at the Warren Alpert Medical School through August. All of the framed images are for sale, with proceeds benefiting the Medical School.

Special Guest

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Marc K. Siegel, MD ’78, Fox News medical correspondent and associate professor of medicine at NYU Langone Medical Center, moderated “The Opioid Crisis: Brown’s Approach to Prevention and Treatment,” a panel discussion held at the Warren Alpert Medical School on February 8. Four faculty members described efforts to educate medical students on opioid prescribing and referral to treatment for patients abusing opioids, treating different populations such as veterans and people who are incarcerated, and expanding access to the overdose-reversal drug naloxone.

The Comfort of Your Living Room

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TV shows allow premed students to ponder ethical dilemmas.

Is it ethically permissible for parents to refuse vaccinations for their children? The question prompted a heated debate after students in the course Primetime Bioethics watched an episode of the ABC show Private Practice in which a mother rejects a vaccine—and her son gets the measles (and, spoiler alert, ultimately dies). While some of the undergraduates argued that individual choice must always be prioritized, others said the safety of all should come before anything else.

The argument was just a taste of what many of these students will face as they continue their education. Their Program in Liberal Medical Education (PLME) course covers a wide variety of medical ethics questions, using TV shows as a jumping-off point. Topics include everything from designer babies to physician-assisted death. Every class period is focused on one issue, which centers the student-led presentation and theory-based class discussion.

“I’ve always liked philosophy. In medical school, I was the one who was excited whenever we did ethics,” says Deirdre Fearon MD’96 F’02 AM’04, an associate professor of emergency medicine and of pediatrics, who teaches the course. “I always wanted to do something like this, because I like to teach, I like medical ethics, and I watch these shows and the ethical dilemmas are usually not subtle in them. I thought it would be a fun way to teach and learn.”

Fearon got the chance to kick-start the idea in 2012 when Hailey Roumimper ’15 approached her to collaborate on an Undergraduate Teaching and Research Award (UTRA). Fearon didn’t have any ongoing research, so she and Roumimper created a basic curriculum for a course. When it was first offered two years later, it was an instant hit.

“It’s a great class,” Kevin Chen ’19 MD’23 says. “I like that we incorporate papers, articles, and fun TV shows in a more applied way.”

Each week, students watch one show around the given topic, read a few articles or papers, and write a response. A group of students creates that week’s presentation and leads the discussion. One week, when discussing vaccine refusal, students created a Mafia-like game for the entire class to demonstrate the concept of herd immunity.

“I love that each class is student run,” Sabrina Saeed ’19 says, because it makes it more exciting and engaging.

The subject matter is increasingly relevant for physicians, Fearon says. “I deal with ethics problems every day,” she says. “Every shift, something comes up.” She began including a “case of the week” in each class to get students thinking about real-world problems.

Students say they love getting to consider deeper topics in medicine. “Most premed classes are hard science,” Natasha Richmond ’20 says. “We can’t think about the bigger picture. This class gives us access to think about those ideas in a more relaxed setting.”

Fearon lets them make tough calls, in the safety of the classroom. “In medicine, we have to make hard decisions. Some people criticize bioethics because there is sometimes no single right answer. But we still have to thoughtfully choose a right answer for a given case,” she says. “We have to act. And we want to feel good about our decisions and be able to defend our choices.”

Micropractice with a Difference

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Is direct primary care the remedy to physician burnout?

Hour-long office visits with your primary care provider. The ability to email or text your doctor 24/7. The occasional house call. They’re the hallmarks of service at Direct Doctors, a North Kingstown, RI, family medicine practice co-owned by Lauren Hedde, DO RES’14 and Mark Turshen, MD RES’15.

Direct Doctors is the only micropractice in the state that doesn’t accept insurance. “Because we cut that whole thing out, we can see a lot fewer patients and spend much more time with each one,” Hedde says. Taking insurance means more staff; “In order to pay for this extra staff you have to see more patients, and in order to see more patients you need more support staff. There’s a snowball effect,” she says.

Hedde and Turshen are the only staff at Direct Doctors, which operates on a subscription model: an affordable monthly fee set according to the age of the patient. Overhead is low: when you enter the waiting room, no receptionist checks you in. A sign directs patients to ring a bell and their own physician greets them.

The pair, who met as family medicine residents at Memorial Hospital of Rhode Island, wanted to practice direct primary care to focus their time and energies on caring for patients, rather than filling out checklists to satisfy insurance requirements. And, as occasional patients themselves, they understood that many patients find their interactions with providers unsatisfying.

“It takes a long time to get an appointment, and then you sit in the waiting room for an hour to see the doctor for 10 minutes, and the whole time they are typing on their computer so they can get ahead of their charting. It doesn’t feel very personal,” Turshen says. “When we were residents, it felt like we were doing a lot of things to help the insurance and the billing, rather than the patient. That didn’t make sense.”

Hedde started the practice in August 2014 and says she broke even by about four months. But “break even” doesn’t necessarily equate to the six-figure salaries offered to doctors right out of residency. Hedde and Turshen each have between 400 and 500 patients, compared to perhaps 2,000 patients per primary care doctor in a typical practice. They could take more patients and earn as much as their conventional counterparts, Turshen says—“or you can make less, but you work the way you want to.”

Instead they place a high value on having flexibility and control of their schedules. “Both of us have three children; my youngest is 6 months,” Hedde says. “We want to be with our families, and we can schedule around that.” And patients don’t take advantage of the access. “We have rarely been called in the middle of the night, and when we have, it’s been warranted,” she says.

They say their model enables better medicine because they can spend more time with their patients. Turshen describes one patient who came to the practice with type 1 diabetes that had not been well controlled for 11 years. After nine months, the patient’s blood glucose levels were in a healthy range. They also say their increased availability has saved patients money, like keeping a patient out of the emergency room, or helping another patient with a rare disease get a timely diagnosis instead of bouncing from one specialist to another.

Hedde says their approach isn’t for everyone: “You have to like running a business and you have to accept business risk.” But she says physicians frustrated by overbooked schedules and insurance demands might consider it as an alternative to quitting their profession.

“Doctors are burning out because they aren’t getting those rewarding moments that keep us invested and enjoying what we are doing,” she says. The Direct Doctors model might just be the antidote.

Protecting Patients

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The Warren Alpert Medical School leads the country in training students to provide trauma-informed care.

Sadie Elisseou ’06 MD’10 calls her next patient’s name into the primary care waiting room on the first floor at the Providence VA Medical Center on a cold, clear morning last December. As he approaches, she greets him with a broad smile and a warm “Good morning! So great to see you.”

The patient is a burly, broad-shouldered, middle-aged man who served in Korea, Afghanistan, and Iraq and has diagnoses of depression, anxiety, a traumatic brain injury, alcohol use disorder, and symptoms of post-traumatic stress disorder. For the next 40 minutes, Elisseou, an internist at the VA and assistant professor of medicine at the Warren Alpert Medical School, takes the patient’s history, gives him a high five to congratulate his sobriety, performs a physical exam to identify the source of the persistent pain in his lower back, and works with him to develop a treatment plan that takes into account his wariness of medications and the changes in VA coverage for a massage therapist he’s found particularly effective.

Elisseou asks each question, performs each maneuver, and gives each directive with professional precision and compassion. As she explains later, she considers every aspect of the encounter an opportunity to maximize her patient’s feeling of autonomy and safety. “I am going to reach behind you to get the otoscope,” she says, while maintaining a firm hand on his shoulder to establish her presence. After discussing his options for medication, massage therapy, and yoga, Elisseou walks him to the checkout desk, thanks him, and wishes him happy holidays.

Her carefully executed patient interactions fit into a named set of practices that are gaining recognition in the medical community. In September 2017, Elisseou introduced the trauma-informed physical exam framework, upon which these exam maneuvers are based, to the MD Class of 2021. She says there have been no published reports of curricular incorporation of trauma-informed practices at other medical schools—meaning the Warren Alpert Medical School may be the first in the country to include them in an undergraduate medical curriculum.

Family Values

The concept of trauma-informed practice emerged in the late 1980s and early 1990s as providers began to observe the association between mental illness and previous trauma, particularly among women receiving public mental health services. At the same time, researchers were beginning to understand the biological effects of trauma and stress. Trauma-informed practices initially gained traction in the fields of education, psychology, and behavioral health, but the concept is now taking hold in the broader medical community. Both the National Council for Behavioral Health and the Substance Abuse and Mental Health Services Administration (SAMHSA) have invested significant resources in trauma-informed care programs, and the Centers for Disease Control and Prevention addresses trauma and trauma-related care on its website. The National Council consults with health care organizations around the country to help improve trauma-informed practices, by ensuring that all staff can screen for and identify trauma in a patient’s history, understand and respond to trauma, and avoid re-traumatization. SAMHSA refers to this paradigm as the four Rs: realization, recognition, response, and resistance to re-traumatization.

Elisseou didn’t know all of this when she began incorporating trauma-informed care into her practice. Maybe it came naturally to her; her father has an internal medicine practice in Connecticut, and her mother manages the office. She says her parents taught her and her brother and sister the importance of love and affection for one another and for others, making them kiss each other good night—“something which we despised at the time, but are now grateful for it, since we’re best friends,” she says—and to greet adults “with eye contact and a firm handshake.” As an undergrad and then a medical student in Brown’s Program in Liberal Medical Education, Elisseou began to see how she could apply these values of kindness and communication in her interactions with patients. “I made it a priority to do everything I could to make my patients feel as comfortable as possible in the interview and, particularly, during the physical exam,” she says.

As Elisseou gained appreciation for the patient interaction and information-gathering components of the physical exam during her internal medicine residency at Yale, so did her understanding of the hazards it posed to people who had previously experienced trauma. “It has the potential to expose patients to shame and vulnerability and triggers of previous trauma,” she says. Now, working with veterans, she sees patients daily who have experienced combat-related trauma, military sexual trauma, homelessness, adverse childhood experiences, and other challenging backgrounds. She recalls performing a cardiac exam on one of her first patients at the Providence VA: “I brought my stethoscope from behind my neck to in front of my face, I kind of swung it around, and the patient jumped. He almost jumped off of the exam table.”

Her work with a patient population suffering from PTSD, anxiety, and depression helped Elisseou understand the possible benefits of a trauma-sensitive approach. “[The physical exam] has the potential to reinforce the sentiment of care and establish rapport between physician and patient,” she says. “I wanted to create a safe space in the examination room where all patients felt comfortable, so we could establish a therapeutic alliance and work toward healing.” When she began teaching a small group section in the first-year Doctoring course in 2014, she incorporated many of the techniques she had developed.

Though she worked hard to use exam techniques specifically tailored to avoid re-traumatization of patients in her practice, Elisseou didn’t hear the term “trauma informed” until last year, when Meghna Nandi MD’20 and Srav Puranam MD’20 approached her after she led a workshop about the physical exam in trauma survivors. They explained to Elisseou that many of her clinical techniques fit into the formal conception of trauma-informed care: fostering feelings of safety, autonomy, and trust in the patient-physician relationship. “There was so much alignment,” Puranam says.

Shared Goals

Nandi and Puranam had discovered their mutual interest several weeks before that workshop, as they discussed one of their classes in the anatomy lab locker room. “In our Health Systems Science course, we were learning about a lot of really difficult topics like elder abuse, child abuse, intimate partner violence,” Nandi says. She felt the course often didn’t acknowledge that these issues may have affected people in the room. “Providers and health practitioners are also humans who are just as susceptible to experiencing all these things,” she says.

Puranam agreed, and they began to look for more places in the first-year curriculum that could better prepare students to care for patients affected by trauma and cope with the widespread phenomenon of vicarious trauma among physicians and trainees. Ultimately they decided a preclinical elective about trauma-informed care would be the most comprehensive way to introduce these concepts, and they asked Elisseou to be their faculty adviser as they developed the course.

While trauma often conjures images of extreme violence and physical injury, the range of events that can trigger adverse biological reactions and avoidance behaviors is much broader. A 2013 study published in the Journal of Traumatic Stress defined a traumatic event as one that produced physical injury, one that elicited fear of physical injury or death, or “any [other]extraordinarily stressful situation or event.” Using these criteria, plus follow-up questions to determine the context and severity of any such event, the authors concluded that 89.7 percent of participants had experienced at least one trauma. However, fewer than 10 percent of these participants showed signs of PTSD, which is a hurdle that Karen Johnson, MSW, LCSW, the senior director of Trauma-Informed Services at the National Council for Behavioral Health, sees in medical practice. “Only looking for
diagnosable PTSD or another mental illness is a mistake,” Johnson says. “Trauma manifests itself in many different ways.”

Evidence points to an association between adverse childhood events and poor health outcomes later in life. In a survey-based study of 9,500 respondents from a single HMO group, published in the American Journal of Preventative Medicine in 1998, people exposed to traumatic events during childhood were found to have a tremendously increased risk for smoking, alcoholism, drug abuse, depression, suicide attempts, sexually transmitted disease, obesity, heart disease, cancer, lung disease, liver disease, and fractures.

So-called “high-risk behaviors” and their associated negative health effects only tell half of the story, however. Fears of re-traumatization during medical encounters, such as the physical exam, can cause traumatized patients to avoid the health care system altogether, compounding the effects of their physical ailments. Empowering patients by reestablishing feelings of safety, autonomy, and trust could help them overcome these fears. “When you experience something traumatic, you lose your sense of control over what’s happening,” Nandi says. Ideally, a trauma-informed approach restores these feelings to the patient in the medical environment, mitigating the cause of some of these negative health outcomes.

A New Framework

After Nandi and Puranam introduced her to the field of trauma-informed care, Elisseou began to assemble her physical exam maneuvers into the standardized framework she would ultimately teach in the Doctoring course. Though the concept of trauma-informed care has been around for decades, such a specific framework, focused on its application to the physical exam, did not exist. Elisseou’s framework includes specific language and behaviors to employ before, during, and after a routine medical exam in order create a safe environment and avoid triggers of prior trauma.

For example, in a traditional thyroid exam a physician will stand behind the patient, outside of the patient’s field of vision, and wrap their hands completely around the patient’s neck. Such a maneuver can trigger sensations of violent choking, she says. “This instead can be done with the practitioner standing at the patient’s side, within their eyesight, with the fingers extended, the thumbs away from the neck, and saying to the patient: ‘I am going to place my hands on the neck in order to examine the thyroid. When you can, please swallow,’” Elisseou says. “This lets the patient know exactly what you’re doing and why, and it avoids the sensation of choking.”

Elisseou’s thyroid exam highlights some of trauma-informed care’s basic tenets: remaining in the patient’s field of vision; explaining the procedure and its purpose clearly; and employing maneuvers that are intentional and sensitive to the feelings they cause. Similarly, Elisseou says having patients sit slightly upright during a pelvic exam both minimizes the patient’s physical vulnerability and allows them to maintain visual contact with the provider.

She also emphasizes the deliberate use of language in creating a trauma-informed atmosphere during the examination. “We hear physicians and trainees say ‘for me’ all the time when they’re giving patients instructions,” Elisseou says. “Sometimes this phrase can enhance the power differential between physician and patient, and can even, in certain cases, be sexually suggestive and inappropriate. For example: ‘swallow for me,’ ‘bend over for me,’ ‘lower your gown for me,’ ‘take off your shirt for me.’” She instead refers to parts of the patient’s body using the article “the,” rather than the more personalizing “your.” “It feels different to hear, ‘I’m going to look at your vagina,’ versus ‘I will now inspect the vagina,’” she says. She gives clear explanations and instructions as another way to enhance the patient’s feelings of safety, autonomy, and trust.

In spring 2017, Elisseou introduced her framework to students in an optional workshop, with hands-on practice. Student feedback was overwhelmingly positive. Sukrit Jain ’16 MD’20 says the workshop made him aware of his body positioning and language choice during patient encounters. “I always place myself in the patient’s line of sight now, and I try to inform my patients of the reasons behind my physical exam maneuvers,” he says.

Nandi, Puranam, and Elisseou were moved by such responses. “We’ve been so humbled by our peers, our colleagues,” Puranam says. “People we respect and look up to are finding value in this. It shows that our medical community is seeking a framework like this.”

The team is also excited about the potential of this framework to help providers cope with some of the insidious challenges of practicing medicine. A 2011 meta-analysis published in Academic Medicine found that students enter medical school with, on average, more empathy than the general population. Four years later, after completing undergraduate medical training, they are less empathetic than their peers outside of the medical world. More than ever, physicians identify the broad notion of “burnout” as the enemy of empathy. Elisseou sees a framework for trauma-informed care as a potential antidote. “I think that burnout inhibits our function on many levels,” she says. “However, when empathy is hard to call up and compassion is hard to find, we can rely on learned skills in the form of a trusty framework or a checklist that can still get the message across.” Puranam and Nandi add that helping providers better understand the contexts, histories, and environments of their patients could enable tired and frustrated students, residents, and physicians to harness empathy.

Last year Elisseou, by then the course leader for first-year Doctoring, decided to integrate trauma-informed care into the standard curriculum. She says the response has been positive: “I have gotten feedback from first-year medical students that this is an exciting subject that they look forward to practicing with patients at their mentor sites.” Vivian Chan MD’21 says that she has employed the skills she learned from that lecture during her weekly mentor sessions at the Providence VA. “It is a more empowering, and more comfortable, kind of approach,” she says.

Baby Steps

Elisseou’s framework fits into a wider scope of practices that create a trauma-informed environment within an organization, many of which occur outside of the exam room. “In a trauma-informed primary care setting, we know that all staff are equipped to identify and address trauma among the people they’re working with. They understand, recognize, and respond to all types of trauma and they always avoid re-traumatizing anyone,” the National Council’s Karen Johnson says. “People understand and embrace cultural competence and humility.” But this requires buy-in from all employees at a care center: custodians, receptionists, medical assistants, nurses, case managers, and physicians. The criteria for and implementation of these practices is not yet uniform, which has hindered their widespread adoption. The National Council is assembling a “change package” to guide primary care organizations seeking to become trauma informed, Johnson says, and she’s considering including Elisseou’s physical exam guidelines. “The goal is to create this tool that is actionable, usable, and consumable that primary care providers and everyone working in that setting will be able to take and use to move forward trauma-informed primary care,” she says.

Such comprehensive organizational change is not without its challenges. In primary care settings, “staff are often overwhelmed, and may feel ill equipped to meet the needs of people with long-term complex health issues,” Johnson says. “How do we create a tool that people can take and use and not put on the shelf? That’s our biggest challenge. We want it to be as usable as and as relevant as possible.” In her mind, a major component of overcoming this obstacle is the collection and analysis of data that prove that this slow and complicated process can lead to tangible impacts on patient health outcomes.

Recently, small studies have shown such benefits. In December 2016, the McSilver Institute for Poverty Policy and Research released their evaluation of the Trauma-Informed Primary Care Initiative (TIPCI), a small pilot program sponsored by Kaiser Permanente and the National Council. TIPCI tested the implementation of comprehensive trauma-informed practices at 14 federally qualified health centers using small Core Implementation Teams, each composed of employees in various positions at each site. After 10 months of on-site implementation, the 10 sites that responded to organizational self-assessment questionnaires at the beginning and end of the trial period all showed improvement, with the greatest progress associated with the largest time investments in data collection, patient screening, and workforce development. Critically, patients who received care at the centers participating in this brief trial showed some improvements in health outcomes, most impressively in management of diabetes. In one clinic, 75 percent of people categorized as having “high-risk” diabetes at the beginning of the trial were classified as having it “controlled” by the end.

“It’s very difficult for organizations to take the long view, to understand this is baby steps. This is years in the making—I would argue decades in the making,” Johnson says. “Some of the work is about making sure we do have the data to prove that this is what providers need to invest in.”

Ripple Effect

Elisseou will continue to refine the framework and, with Puranam and Nandi, collect data on its effectiveness in the medical education and patient care settings. They will publish a description of their workshop this month in Medical Education as part of the journal’s series on innovation in medical education. The team also will present the data they’ve collected at internal medicine grand rounds at the Providence VA; run a webinar for the SAMHSA-HRSA Center for Integrated Health Services; and plan to publish their findings in a peer-reviewed academic journal in the near future.

Already, Nandi and Puranam have noticed a cultural shift at school. They say their peers regularly share observations of the impact that the new practices have on their interactions with patients. Ultimately they envision trauma-informed care becoming an integral part of medical education beyond a single lecture or workshop. Nandi hopes it will be “the lens through which the Doctoring curriculum looks.”

Elisseou echoes that hope, finding inspiration in a potential ripple effect across the medical field. “That’s what makes me wake up early and go to bed late working on this—knowing that this can have an impact on real patients,” she says. The development, refinement, and integration of the trauma-informed physical exam framework will achieve a much simpler mission, she adds. “As long as we approach our patients with love, the outcome will usually be OK,” Elisseou says. “My hope in teaching the trauma-informed physical exam is to promote skills that communicate compassion, to have an impact on the way our patients feel when they are with us—I want them to feel safe, to feel loved. The mission of my life is love.”

Health on the Hill

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A Brown alumna returns to the fold.

Vanessa Britto, MD RES’89 F’91 MMSc’96 says she “backed into” college health. Early in her career, she divided her time between her private internal medicine practice and duties as a college physician at Stonehill College in Easton, MA. Then she accompanied a group of undergraduate students on a service mission in Peru, and her passion for working with students deepened. She subsequently became director of health services at Wellesley College, a position she held for 16 years.

Now she’s back on her old stomping ground. A graduate of Dartmouth and the University of Illinois College of Medicine, she completed the primary care internal medicine residency program, General Internal Medicine Fellowship, and a master’s at Brown, and she met her husband, neurologist Galen Henderson MD’93, here. “We got married on Commencement Weekend—25 years ago,” she says.

In January Britto returned to campus as assistant vice president of campus life and student services and executive director of health and wellness. She says her attraction to student health services aligns with her study of community health as a graduate student. “I got a taste of how to think about populations and population health and how to steward over a community; about the issues they grapple with, and social determinants of health,” she says. For college health, this means the factors that support or challenge students in meeting their goals of academic success, a prosperous life, and staying healthy.

That mission goes well beyond sick visits. “This is the time to talk to people about issues such as the importance of sleep and not pulling all-nighters,” Britto says. Stress reduction is also important, especially since the second decade is when many previously undiagnosed mental health issues emerge, exacerbated by stress.

“How can we help the student with a heavy work schedule and an emerging thyroid issue that keeps him up at night? And how can we teach that student to advocate for himself?” she says. University health and counseling services are not silos of care; they’re deeply integrated into the life of the school and play a fundamental role in shaping how effectively students are supported and engage in their academics. “It’s a unique type of medicine,” she says.

Against the stereotype that college health revolves around sore throats, mono, and contraceptives, Britto says she’s seen a greater variety of things than she would have in private practice, in part because of the diversity of college populations. One student presented with a rash, which turned out to be an African tick-borne disease; she had just returned from her home in Africa. “I have a saying,” Britto says: “‘This is not your grandmother’s health service.’”

The Dealmaking Doctor

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With a master’s in healthcare leadership from Brown, an ob/gyn refines cancer care in his hometown.

When Pedro Escobar Rodriguez, MD, moved back to his hometown of San Juan in 2013 to take care of his sick father—after long ob/gyn stints at Northwestern University and the Cleveland Clinic—he was shocked to find out how much Puerto Rico lacked in terms of health care.

“The technology was behind, the insurance landscape more challenging, and affordable medical choices limited,” he says. He wanted not only to practice medicine there but to attain a deep understanding of the systems he’d need to upgrade services on his native island.

So he applied and was accepted to the Executive Master’s Program in Healthcare Leadership within Brown’s School of Professional Studies. Students are working adults who come to campus only a few times over about an 18-month period; the rest of the work is done remotely. “I liked the program’s blend of finance and management with classes on policy, quality, and leadership,” says Escobar, who chose it over postgraduate health-management programs at Harvard and Dartmouth. “It just felt more balanced.”

But once he was in, things got crazy. He found himself working in oncological ob/gyn at San Jorge Children’s Hospital in San Juan, performing women’s cancer-related surgeries in the middle of last fall’s Hurricane Irma, during which he all but lived at the hospital because the power was out in his own home, where he lives with his wife and kids. (He also needed the Internet at work for his many Brown papers due.)

“I was going nonstop from about 5 a.m. to 3 a.m.,” he recalls. “My program director at Brown said that I could take the year off, but I wanted to graduate with my own classmates.”

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A Question of Honor

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If you happen to have a seatbelt, now would be a good time to put it on.

Things started getting bumpy for Mike Zahalsky on Episode 9 of Survivor: Heroes vs. Healers vs. Hustlers. But first, it was reward challenge time. The castaways were randomly divided into two teams of five and had to perform a series of maneuvers then shoot balls into baskets. Zahalsky’s team won the reward: a pleasure cruise around the Fijian islands while dining on gourmet sandwiches, wine or beer, and chocolate cake.

Once back on land, the dirty business of alliances, strategy, and backstabbing was on. The alliance of seven — the “round table” — was carrying on with its plan to vote off the remaining Healers. Former Marine Ben took charge, ordering the members to split their votes for Cole and Zahalsky. That way, if a hidden immunity idol was played, they’d be assured that a Healer would be eliminated either way.

But some members bristled at Ben’s dictator-like edict, and questioned why plan B should be the affable Dr. Mike when the always-annoying Joe was ripe for picking. Lauren won the immunity idol, keeping her safe from elimination, though as one of the seven, she was presumably safe anyway.

At tribal council, things got even more interesting. Zahalsky openly questioned the alliance’s strategy, calling it immoral to leave a player in the game that everyone hates. That led to a philosophical debate about the game of Survivor. All of it was Zahalsky’s attempt to draw some fire his way, with the intention that he would then play his immunity idol, nullifying any votes that he received. In the end, just two votes were cast for him. Ultimately, Cole was eliminated, making him the second member of the jury who will choose the sole survivor.

That means Zahalsky is one of two Healers left. But will the alliance of seven hold? Find out next Wednesday at 8 p.m. EST on CBS.

The Rise and Fall of the Coconuts

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In a doubleheader, Dr. Mike’s closest ally is double-crossed.

This week we were treated to two episodes of Survivor: Heroes vs. Healers vs. Hustlers—which consequently meant two eliminations.

Episode 10 opened with the castaways discussing Mike Zahalsky ‘95 MMS’98 MD’99 playing a surprise immunity idol at tribal council. They questioned his logic, since there was no imminent plan to vote for him, and no one knew he had the idol, making it a valuable commodity in later rounds.

In his confessional, Zahalsky said he was trying to play the game his own way, and he also didn’t want to be “the idiot who goes home with an immunity idol in his pocket.” While the move perplexed his fellow Healer Joe, ultimately it solidified their alliance of two. They even created a short-lived comedy act, dubbing themselves the Coconuts—a nod to Joe’s Jamaican heritage, and to Zahalsky’s—well, he’s a urologist.

Zahalsky demonstrated his pedidexterity, nearly winning a reward challenge that involved building a puzzle with his feet. But he eventually lost to Lauren. She used her reward of a cheeseburger lunch with three castaways of her choice to completely turn the game on its head.

Long story short: the alliance of seven is over, with Joe and Mike joining with Lauren, Devon, Ashley, and Ben to oust the presumably invulnerable Chrissy, Ryan, and J.P. Ben is playing double agent, though, letting those three think he remains tight with them.

At tribal council, Ashley won immunity, teeing up the blindside nicely. While the majority thought the plan was to vote for Joe, the turncoats voted for J.P., sending him to the jury. Jaws dropped and multiple choruses of “what just happened?” followed the tribe back to camp.

On Episode 11, the rattled Chrissy and Ryan sought to make new alliances. Ryan reached out to Zahalsky, who rebuffed him, saying he had wanted to work with Ryan all along and Ryan didn’t want to. Now that Ryan needed him, Dr. Mike wasn’t going along with it.

Chrissy won the immunity challenge, keeping her safe. But the new alliance wasn’t done with blindsides. After assuring Joe and Mike that they would be voting for Ben in this super-tight alliance, they ultimately voted for Joe. Cue more looks of surprise.

And where does this leave Dr. Mike? We’ll find out next Wednesday at 8 p.m. EST.

Burn, Baby, Burn

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Alliances are in ashes after a particularly stormy episode of ‘Survivor.’

Some episodes of CBS’s Survivor: Heroes vs. Healers vs. Hustlers play out like a smooth sea, others like a dangerous ocean swell. Episode 12 was more like a hurricane for which a category has not yet been designated.

After a rehash of Joe being voted out in episode 11 (seriously, it’s been brewing for ages), the reward challenge offered a heartwarming prize: a barbeque with a loved one from home.

While every tearful reunion was touching, Mike Zahalsky ’95 MMS’98 MD’99 introducing his wife, Bari, to his competitors would have made the Grinch’s heart grow three sizes.. When Zahalsky thanked Bari for supporting him in playing Survivor―“the most selfish thing I’ve ever done,” he said―she quickly added, “This is the only selfish thing he’s ever done.” Awww.

Chrissy won the chance-based challenge and picked Zahalsky, Ashley, Lauren and Ryan­—along with their family members—for an afternoon barbecue. Being Survivor, there was a healthy dose of plotting at the reward gathering, wherein Chrissy tried to forge an anti-Ben coalition.

Back at camp, Ben encouraged the “alliance of four” (Ben, Lauren, Devon, and Ashley) to oust Chrissy, while the secret “alliance of three” (Lauren, Devon, and Ashley) debated whether Ben or Chrissy should be next to go. Meanwhile, Lauren found the first half of an immunity idol, with a note that the second half was waiting at the immunity challenge. Sound confusing? We had no idea what we were in for.

After Ashley won an immunity challenge, which stretched pain tolerance to the limit, and Lauren gathered the second half of her idol, it was back to camp to scheme.

Ben overheard the secret alliance’s plans and tried to get the remaining players (Zahalsky, Ryan, and Chrissy) to axe Lauren. But Dr. Mike had had enough of being double-crossed by Ben and immediately conveyed Ben’s no-longer-secret plan to the no-longer-secret “alliance of three.”

All pretense and diplomacy were eschewed: it was open season on Ben, Chrissy, and Lauren.

As tribal council opened the players were on edge, with alliance members taking swipes at one another. Zahalsky threw Lauren’s bridge-building idol into the fire, and chaos erupted. Players shouted, Ben declared he’s voting for Lauren, Zahalsky and Ryan openly talked shop, Chrissy and Devon ran over to whisper in Dr. Mike’s ear. It was pandemonium.

Everyone was finally ushered into the voting booth. Just as the host, Jeff, was about to read the results, Ben pulled out a secret immunity idol. Cue Jeff reading vote after vote for Ben, none of which counted due to the idol. The lone vote for Lauren was enough to eliminate her.

Be sure to rest up before next Wednesday’s episode at 8 p.m. EST on CBS.

He’s a Survivor

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Alum Mike Zahalsky heads into the finale (mostly) unscathed.

Despite the nail-biting suspense of this week’s tribal council on Survivor: Heroes vs. Healers vs. Hustlers, there’s still a doctor in the house—er, on the island—as Mike Zahalsky ’95 MMS’98 MD’99 managed to hang on.

After last week’s prime target, Ben, used an immunity idol to escape elimination, the mood at camp was edgy. Ben spent the whole episode searching for another idol as the rest of the tribe openly discussed trying to vote him out. Again.

The reward challenge saw random partners navigating an obstacle course while tethered to a rope, and while Zahalsky and Ryan put in a good showing, winners Chrissy and Devon were whisked away to a plush resort with their chosen guest, Ryan. Perplexingly, Devon accepted Chrissy and Ryan’s pitch to leave his old alliance behind and join up with his former betrayer, Ryan. Survivor comes at you fast.

Dr. Mike boosters may recall his hope of winning an immunity challenge before his time comes to a close, but this week didn’t go his way. After navigating an obstacle course, tossing balls to operate ladders, and completing a gear puzzle, Chrissy was victorious—and rapidly refocused her aim from Ben to Ashley.

Going into tribal council, it was unclear who agreed with Chrissy’s shift or whether Ben had found an immunity idol. After tribe members aired their grievances against Ben, he revealed—and played—a newly found idol, meaning he could not be voted off. With some dramatic explosion sound effects and giddy giggles, Ben literally pointed fingers at Zahalsky. Ashley and Devon seemed to be nodding along to Ben’s plan, while Chrissy and Ryan remained inscrutable.

Luckily for Dr. Mike, all but one vote was for Ashley.

Tune in next week when the season wraps with a two-hour finale, Wednesday, Dec. 20, at 8 p.m. EST on CBS.

End of the Line

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In Survivor‘s wild finale, urologist Mike Zahalsky doesn’t make the cut.

The second half of season 35 of Survivor: Heroes vs. Healers vs. Hustlers dished out ample erratic behavior, unexpected twists, and lawless tribal councils, Mike Zahalsky ’95 MMS’98 MD’99 managed to survive them all.

But the “Survivor gods” squirreled away even more surprises for Wednesday’s season finale. In addition to two more player eliminations and a chance for the final three survivors to plead their case to a jury of former tribal members, the final winner was announced in front of a live audience in Los Angeles.

After Ben, the prime target for two weeks running, slid through last week’s tribal council by the grace of a second immunity idol, his teammates opted for some shut-eye. This left Ben free to search for a third idol—his only hope for surviving another elimination. Which he did. Again.

Unaware of Ben’s success, Chrissy, Devon, and Zahalsky planned to convince Ben they’d found an idol at the reward meal. But when Ben takes the “news” of Chrissy’s “idol” surprisingly well, Devon suspected he possessed yet another #BenBomb and decided to vote for Zahalsky at tribal council.

Removing all the votes for Ben left one vote for Devon and one vote for Zahalsky. After a re-vote, the tenacious Brown alum bid farewell to Survivor as a competitor, though he did get to stick around to vote on the season’s winner.

Finally, with no more idols for Ben to find, Chrissy won a last, fiddly immunity puzzle and got a new-to-the-series secret advantage: the power to pick one person to join her as a member of the final three, with the remaining member to be determined by a fire-building challenge.

Chrissy, Devon, and Ryan all agreed that Ryan is fairly useless at challenges, so she selected Devon to challenge Ben. Despite being the camp’s de facto campfire starter, Devon was unable to start a spark in the time Ben nurtured a big, burning flame, and he once again narrowly escaped elimination.

Before a jury of their former teammates, the final three pleaded their cases to be crowned Survivor and take home the $1 million prize: Ben, as a military veteran who overcame post-traumatic stress disorder to inspire his family and fellow veterans; Chrissy, as a mom who pushed beyond her physical limits and never gave up on her dreams; and Ryan, a superfan who insists that most of the power moves that happened were indirectly due to his machinations. Some arguments were more convincing than others.

Flash-forward to a live audience and a nicely cleaned up cast along with enthusiastic families: each of the final three received at least one vote from the jury, but Ben won in a landslide—and was promptly engulfed in hugs.

Keep an eye on Brown Medicine for Zahalsky’s inside scoop on the whole season.

Drug Extends Progeria Survival

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A therapy originally developed to treat cancer could help children with this rare, fatal disease to live longer.

A study published in the Journal of the American Medical Association suggests that an experimental drug therapy can extend the lives of children with progeria, a rare genetic disorder that causes premature aging and death.

The research showed that children with progeria who were treated with lonafarnib, a drug originally developed to treat cancer, were more likely to survive over the course the study compared with children with progeria who did not receive the drug. The study is preliminary, but the researchers say the results suggest a promising avenue for treating a condition for which there are currently no approved therapies.

“This study provides supporting evidence that we can begin to put the brakes on the rapid aging process for children with progeria,” says Leslie Gordon ScM’91 MD’98 PhD’98, lead author and a professor of pediatrics (research). “These results provide new promise and optimism to the progeria community.”

The study took place at Boston Children’s Hospital, Brown University, and Hasbro Children’s Hospital.  Researchers followed 27 children with progeria who had taken twice-daily doses of lonafarnib in a clinical trial at Boston Children’s. The study group was compared to a group of 27 children of similar age who had progeria but were not part of the trial and did not receive the drug. The study showed a significantly lower mortality rate in the group receiving lonafarnib treatment. After two years, mortality in the treatment group was 3.7 percent, compared to 33.3 percent in the untreated group.

Francis Collins, MD, PhD, director of the National Institutes of Health, led the lab that first identified the mutation that causes progeria.

“My lab did some of the original research on cellular and mouse models that showed potential benefit of this class of drugs for progeria,” says Collins, who was not involved in the new study. “It was encouraging to see those results translated into a clinical trial.”

Gordon is medical director of the Progeria Research Foundation, which funded the research. She and her husband, Scott Berns, MD, MPH, clinical professor of pediatrics, cofounded the nonprofit organization in 1999 after the couple’s son, Sam, was diagnosed. Sam died in 2014 at age 17.

Read the full story here.

Center Stage

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How did humans evolve to have reason, consciousness, and free will? An excerpt from Kenneth Miller’s latest book, The Human Instinct.

I’m hoping for a clear sky tonight. It’s expected to be the peak of the annual Perseid meteor shower, a chance to glory in streaks of sudden fire as fragments of a comet come crashing through the Earth’s atmosphere. In between those moments of spectacle, there will be a chance to lie still in the darkness and absorb the quiet beauty of the nighttime sky. The experience has always made me feel small against the vastness of space, but it’s also one that has helped me, as a biologist, appreciate what it means to be human. Although I expect to be alone in my small backyard, I’m not the only one who will be looking up tonight. Tens of thousands of people will be watching around the world, a quiet and widely scattered assembly of those who remain fascinated by such events year after year.

Consider the setting. Joined by these many others, I’ll lie back against the surface of a small, rocky planet, peering up in wonder at the twinkling riot of forms and colors and patterns. The sparkling fire of the meteors is new, generated only a fraction of a second before it flashes across the sky. The tapestry of starlight, however, is a sampling of history, some of it unimaginably ancient. I orient myself by Polaris, the north star, fully aware that the stream of steady light it provides is more than four hundred years old. Sirius is much brighter, owing to its nearby position. Its light took just eight and a half years to reach me.

Of all the creatures, of all the forms of life that grace the surface of this small planet, there is only one that looks this way into the nighttime sky. Only one knows the Perseid spectacular is coming. Only one plots the distances to stars. Only one contemplates the age of its universe, only one is aware of the mysteries to be solved in starlight. While all of life is one, while all of life is linked by ancestry, structure, and design, only the human creature seeks answers to questions in the stars. This is what makes it worthwhile to consider how this creature came to be, and what its presence on this planet means.

Adam’s Promise
For people in Western cultures, the character of Adam once defined the essence of human nature both in promise and tragedy. As author Marilynne Robinson ’66 has noted, the story of evolution brought on the collapse of the Genesis narrative, and with it, in her view, the enlightened humanism that produced Western civilization and gave birth to the very science that would, ironically, lay waste to the myth of Eden itself. To her and many others, Adam was much more than a pseudo-explanation for the origin of our species. He was the metaphorical source of man as a moral creature with obligations to family, community, and ultimately to the righteousness of truth. While evolution is surely true, as Robinson admits, what it put in Adam’s place was hardly a satisfactory image to replace these fine qualities:

For old Adam, that near-angel whose name means Earth, Darwinists have substituted a creature who shares essential attributes with whatever beast has recently been observed behaving shabbily in the state of nature. Genesis tries to describe human exceptionalism, and Darwinism tries to discount it.

I think Robinson is fundamentally wrong about the implications of what she calls “Darwinism.” That is, in fact, my reason for writing this book. But she is surely right about the conclusions many have drawn from the emerging story of human evolution. We could begin with the very exceptionalism she tries so valiantly to defend. Henry Gee, in his book The Accidental Species, also discounted such exceptionalism. Nothing, he wrote, is uniquely present in our species, including attributes such as language, toolmaking, intelligence, mathematics, or even self-awareness. So, we have no reason to presume ourselves special, unique or, as Gee gleefully points out, the “pinnacle of Creation.” We’re just not that big a deal, and we have no business thinking otherwise.

Gee’s gospel of insignificance states that evolution was not bound to produce us or anything like us. The drama of evolution plays out not in an irresistible rise to perfection, but in a random walk through endless possibilities, none more significant than the other, none especially worthy of our attention.

If these constructions tend to devalue human life just a bit, in the eyes of many interpreters of “Darwinism,” there are even more depressing findings to deal with. Our bodies, our minds, our behaviors have all been shaped by the harsh demands of survival in the face of the relentless pressures of natural selection. As a result, however sophisticated we may seem, we are rude creatures at heart, motivated by drives and values that serve principally to propagate our genes and ensure our own survival and that of our kin. As Richard Dawkins once wrote, “Let us try to teach generosity and altruism, because we are born selfish.” The endowments of evolution apparently include a surplus of ruthless greed and aggression, but a deep and telling absence of love and kindness, virtues that, according to Dawkins, are not inherent in our species and can only be passed along by deliberate effort.

To all too many, the answers that emerge from the Darwinian narrative are dark, foreboding, and deeply unsettling. First among these is the conviction that our minds are not our own. They surely were not formed in the image and likeness of a supreme being, and they were not even fashioned in a way that allows us to seek the truth of our own existence. Rather, our brains are organs like any other, only one component of a survival machine designed to resist death just long enough to push its genes forward into the next generation of struggling, highly socialized primates. Evolutionary psychology can explain our moral values as instinctive behavioral patterns hewn only by selection for life within the group. Art is made to attract mates, altruism is practiced for selfish reasons, even if we “think” otherwise, and “truth” is a constructive illusion connected only loosely to an unknowable reality. Freedom of thought and action is part of that illusion, a lie the brain tells itself to allow the human animal to function in a way that enhances its chances of success. High culture is not the work of genius, but the product of chance adaptations working in many brains to sculpt a veneer of beauty around the mundane realities of life and struggle. Beauty itself is defined only by its ability to produce such illusions as allow us to go on under the absurd circumstances of personal futility and ultimate death.

Seen by those who would explain every impulse, from anger to joy to love, in Darwinian terms, the human project seems worthy of neither pride in past nor hope for the future. If even consciousness is an illusion, then it is pointless to contemplate that future, seek wisdom in the past, or celebrate human achievement. By contrast, the myth of Adam once affirmed a genuine humanity. It told us that choices were freely made, that their consequences were genuine, and that rebellion made possible by truly independent thought was an essential part of human nature. It was for such reasons that Marilynne Robinson lamented the “death of Adam” in terms like these:

Our hypertrophic brain, that prodigal indulgence, that house of many mansions, with its stores, and competences, and all its deep terrors and very right pleasures, which was so long believed to be the essence of our lives, and a claim on another’s sympathy and courtesy and attention, is going the way of every part of collective life that was addressed to it—religion, art, dignity, graciousness.

While certainly not a creationist in the sense of denying evolution, Robinson perfectly articulates the profound concerns of those who recoil from extremes of the “Darwinism” she describes in such chilling terms. But her view of evolution as a denial of human nature, as a nihilistic project that devalues not just religion, but art, music, literature, and even science, is, I believe, profoundly wrong. What evolution tells us about human nature projects an entirely different vision of our species. It invites us to revel in the living world of which we are a part and to see ourselves as central characters in the greatest drama the universe has yet brought forth. It is a story that fully matches the sense of grandeur with which Charles Darwin once tried to endow his greatest theory, and we should delight in telling it.


Always Faithful

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A doctor on deployment treats more than the individual.

Looking out across the vast desert, I see a massive wall of sand and dust rapidly approaching our position. This colossal and ominous force of nature is one of the bigger sand storms we have experienced while deployed to the Middle East.

It is exhilarating to be halfway across the world in a land invaded by countless nations over time. The climate is oppressively hot and the wildlife almost alien. Although seemingly devoid of life in most places, this region is rich in cultural history. Even so, I sometimes wonder how humans have managed to live here for so many years.

My unit is deployed here for six months. We are on an Air Base that has supported US and coalition military forces for nearly two decades. I am one of several medical officers on base, but I am attached to the only Marine Corps infantry battalion deployed to this region.

Deploying for the first time with my unit to this part of the world has been a culture shock. It is certainly different than practicing medicine in a hospital setting. At the same time, I have learned so much in my few months on the ground. It has been more than just keeping the sand out of my eyes; more than just seeing patients in clinic. Practicing medicine in an operational and deployed setting presents unique challenges and has forced me to learn lessons I could learn nowhere else.

Battle Ready
Having to work with limited resources forces a provider to decide whether they can give adequate care on site or must transfer a patient to another facility. I have run into this issue multiple times. I recall one patient whom I believed had a kidney stone. He was in quite a lot of pain, and his blood work showed signs of kidney injury. Normally I would send him to the emergency department for a CT scan. Here, however, transferring a patient to a hospital with imaging capabilities would be a four- to five-hour process requiring much coordination: putting together a mission summary memorandum, requesting command approval, obtaining vehicles for transport, and making sure the weather will permit ground movement. Until now, I had never been involved with the logistical side of medicine. But without a logistical framework in place, adequate medical treatment cannot be provided here.

Another challenge has been the sheer volume of men and women who fall under my care. We deployed with almost 1,000 Marines and sailors who are now spread out across multiple countries in the region. Preparation and pre-screening alone are difficult: pre-deployment HIV testing, mandatory neurocognitive examinations for all personnel, screening for disqualifying medical conditions, and more. Travel to different countries also requires certain vaccinations, such as polio. Prophylactic malaria medications are required for others. This process is necessary to prepare our troops for battle, but it can certainly be cumbersome and time consuming.

One of the more interesting differences in practicing medicine in the military is the way patient privacy is treated, especially while deployed to a combat zone. Until now I had considered this a fundamental, relatively unbreakable principle of patient care. What is discussed in the exam room stays between patient and provider. In this setting, however, there is some gray area when it comes to privacy.

More than once a Marine has approached me wanting to discreetly discuss a medical issue. Usually their first question is whether any information will be shared with command leadership. The response to this question is not a simple “yes” or “no.” Privacy must be respected, but the command needs to be notified if a patient presents a risk to themselves, others, or the mission. Often there is a lot of discretion left to the provider on how to handle these situations.

What do you do when someone discloses a preexisting medical condition? Take, for example, a Marine who admits he was diagnosed with Wolff-Parkinson-White syndrome several years before. He is fully functional and exercises every day but sometimes experiences palpitations. By regulation, this is a disqualifying condition and he should not be deployed. From a medical perspective, he warrants evaluation by an electrophysiologist and possibly an ablation procedure, which could be curative. At the same time, the chances of him developing a fatal arrhythmia while on deployment are small. In all likelihood he could finish out this deployment without any problems. Additionally, this particular Marine’s absence would create a significant leadership gap if he were to be sent home, not to mention the tax dollars that would then be spent to fly out a Marine to replace him. In the end, there is no way to reliably predict what will occur, but a judgment call must be made.

Perhaps it is wrong to consider what effect medical decisions will have on a unit’s operational readiness. Some would argue that medical decisions should be made solely with the patient in mind. While there is some merit to this, I believe military medical providers must strike a balance between what is good for the unit and what is good for the patient. I cannot make my decisions in a vacuum: I have to consider how my decisions and interventions will affect my unit’s warfighting ability. Sometimes this means going against a patient’s wishes. Sometimes it involves bending regulations in extenuating circumstances. Just as often, though, I must make medical decisions that my command leadership does not support. Going against a superior officer is difficult but can be necessary for a patient’s sake. In many ways I act as a liaison between the medical and operational communities, which means I need to be well-versed on both sides.

Working with a Marine Corps infantry battalion has been an eye-opening experience. Some days are difficult, physically and emotionally. Learning to navigate between the medical and military communities has been an exercise in adaptability and mental fortitude. The greatest reward is becoming part of a brotherhood that has stood the test of time for more than 200 years. I am not a Marine. I do not hold a rifle in battle. In reality, I am an outsider within my unit. But I feel a sense of belonging here that I have felt nowhere else. My career as a military medical provider is only just starting, and I consider it an honor and a privilege to be where I am now. I would exchange this experience for nothing. Semper Fi.

Tell Me About Your Hair

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Bad hair day.

“From an early age I understood that hair had power,” Rohina Gandhi-Hoffman ’90 MD’94 says. “At the age of 7, my own two ponytails were chopped off very unceremoniously and for a good part of my childhood I sported a boy’s haircut. … The trauma of losing control of my identity has stayed with me my entire life.” Gandhi-Hoffman explores women’s relationships with their hair in her “Hair Stories” project. She photographed and interviewed almost three dozen women of varying ethnicities and ages about their hair. She discovered that “hair is a language, a shield, and a trophy,” she says. “Hair is a construct reflecting our identity, history, femininity, personality, our innermost feelings of self-doubt, aging, vanity, and self-esteem.” A neurologist in California, Gandhi-Hoffman took her first photography class at the Rhode Island School of Design while a student in the Program in Liberal Medical Education at Brown. Her photography will come full circle in January 2019 when “Hair Stories,” Hoffman’s first solo exhibition, will be mounted at the Warren Alpert Medical School. You can see her work and read her subjects’ stories at womenshairstories.com.

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