Ignite Magazine | Spring 2017 by NEOMED

A P U B L I CAT I O N O F N O R T H E A S T O H I O M E D I CA L U N I V E R S I T Y â&#x20AC;¢ V O L 18 .1 S P R I N G 2 017

THE POINT DIFFERENTIAL

uring the recently played historic Super Bowl LI, the New England Patriots not only had to score several unanswered touchdowns in their unlikely comeback; they also had to make two, 2-point conversions. A single, customary extra point (kick) on either occasion would have made a difference. In fact, it would have cost the Patriots the big game. In health care, points and differences matter quite a bit, with the former serving as indicators of conditions that may cost lives and the latter compelling health professionals to better understand populations to help save lives. Most of the time, both require a deeper dive. In this issue’s “On Living Forever…” the impact of a point one (.1) drop in life expectancy is explored, particularly as it relates to underserved rural and urban communities. This seemingly small number represents thousands of lives. Paying attention to even slight measurable changes, such as bone density loss, could also save lives. Dr. Christine Dengler-Crish’s fascinating findings reveal bone mineral density’s possible link to Alzheimer’s. Advancements in science such as this gives us the kind of hope that only high-risk, high-reward research can bring. There’s a lot of talk about big data’s enormous influence on health care these days. Indeed, the numbers and resulting descriptive and predictive analytics have informed the entire sector, enabling significant improvements to our quality of life. But the essential human experiences encountered by contributing writers/medicine students Smile, Goel and Hill are more prescriptive and have helped them to better understand the multiple realities of disparities in health care and the barriers for the underserved. Their stories show how their human interactions from Mexico to the Midwest have helped them come to appreciate and rely on the humanities, ethics and reflective practice training they received in Human Values in Medicine courses at Northeast Ohio Medical University. If “Rural Medicine, Revisited” takes us back to where community-based health care began, and contributing writer/pharmacy student Angela Goodhart shows us what’s needed to serve the underserved in the near future, what will it take for us to finally understand what Dr. Joe Zarconi calls “the multifaceted nature of the causes underlying such disparities?” Dr. Zarconi’s post-Freddie Gray article proposes a 2-point conversion of a different kind: a point-counterpoint that says that the cultural competency that is now being taught universally may help us understand how diverse groups experience health and health care, but we also need to teach structural competency if we really want to understand how health and health care are related to social, economic and political structures that lead to inequalities. This type of 2-point conversion isn’t necessarily about winning the game, because life isn’t as simple as football. Instead, Joe’s point differential is about giving humanity a chance, with hopes that one day, we’ll all be on the same playing field.

Jay A. Gershen President 02 I G N I T I N G

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VOL 18.1 SPRING 2017 Northeast Ohio Medical University is a communitybased, public medical university with a mission to improve the health, economy and quality of life in Northeast Ohio through the medicine, pharmacy and health science interprofessional education of students and practitioners at all levels. The University embraces diversity, equity and inclusion and fosters a working and learning environment that celebrates differences and prepares students for patient-centered, teamand population-based care. Ignite magazine (Spring 2017, Volume 18, No. 1) is published twice a year by the Office of Public Relations and Marketing, 4209 St. Rt. 44, P.O. Box 95, Rootstown, OH 44272-0095 Email: publicrelations@neomed.edu Jay A. Gershen, D.D.S., Ph.D., President NEOMED Board of Trustees: Daisy L. Alford-Smith, Ph.D. E. Douglas Beach, Ph.D. Paul R. Bishop, J.D. Carisa E. Bohnak, Student Trustee Sharlene Ramos Chesnes James M. Guirguis, Student Trustee Joseph R. Halter Jr. J. David Heller, CPA, Chair Robert J. Klonk, Vice Chair Chander M. Kohli, M.D. Richard B. McQueen

Editor: Elaine Guregian Contributing Editors: Gabrielle Biltz; Dana Goehring; Roderick L. Ingram Sr.; Jared F. Slanina Publication Design: Scott J. Rutan Illustrations: Kels Damicone, Kent State University School of Visual Communication Design for Glyphix Studio; Christopher Darling, assistant professor of illustration, KSU School of Visual Communication Design; Doug Green, KSU School of Visual Communication Design for Glyphix Studio; Taylor Harvey, University of Akron Mary Schiller Myers School of Art; Branden Vondrak, B.F.A., KSU School of Visual Communication Design Photography: Phil Masturzo, Lew Stamp As a health sciences university, we constantly seek ways to improve the health, economy and quality of life in Northeast Ohio. The Accent Opaque paper used for this magazine has earned a Forest Stewardship Council (FSC) and a Sustainable Forestry Initiative (SFI) certification. Strict guidelines have been followed so that forests are renewed, natural resources are preserved and wildlife is protected. Ignite was printed by Printing Concepts in Stow, Ohio, using soy inks. No part of this publication may be reproduced without prior permission of the editors. Copyright 2017 by Northeast Ohio Medical University, Rootstown, Ohio 44272.

DEPARTMENTS 22 HEALTHY AGING

30 CLASS NOTES

24 FOOD FOR THOUGHT

33 RESEARCH AT NEOMED

26 INTERPROFESSIONAL EDUCATION

34 WHALE WATCHING

28 ALUMNI AT WORK

FEATURES

04 WITH JUSTICE FOR ALL: MEDICAL EDUCATION, POST-FREDDIE GRAY An educator says the way cultural competency is taught doesn’t go far enough.

08 THE INFANT MORTALITY CRISIS: A TALE OF TWO STATES Two medicine students set out to save young lives.

12 RURAL MEDICINE, REVISITED ON THE COVER Artist Branden Vondrak, a graduate of NEOMED partner school Kent State University, captures the constellation of reasons for health disparities among different populations. What will it take to bring about change?

A new pathway at NEOMED trains students to fill a critical gap.

16 A REFLECTION ON REFLECTING Learning how to cope with health care’s most uncomfortable topics changed one student’s perspective.

18 ON LIVING FOREVER, LIFE EXPECTANCY AND DISPARITIES IN HEALTH CARE Turns out, it’s possible to buy time. Who can buy it is another question.

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FEATURE

WITH JUSTICE FOR ALL: MEDICAL EDUCATION, POST-FREDDIE GRAY

BY JOSEPH ZARCONI, M.D. (’81)

ince his highly publicized death in Baltimore in the spring of 2015, Freddie Gray’s name has become inextricably linked to the ever-expanding and highly volatile conversations between minority communities — in particular, African-American communities — and the law enforcement officials who serve them. Tensions arising from how Freddie Gray died, as well as the deaths of numerous other African-American boys and men since killed by police officers, have erupted into sometimes orderly but at other times hostile and unruly protests and acts of violence that have included the killing of innocent police officers. A common theme in the national discourse that followed has been that our country needs better police officer training aimed at mitigating unfair treatment and misunderstanding toward

Illustration: Branden Vondrak

minority communities. Understanding the manner in which minority lives have been lost as a result of unjust practices perpetuated upon minority community members by some law enforcement officers, it should perhaps surprise us that these same minority communities haven’t similarly erupted into angry protests and acts of violence against their local hospitals or doctors’ offices. Given what is known about the alarmingly prevalent health care disparities that exist for minority communities as their care is compared to that received by their Caucasian counterparts, it seems clear that the number of minority lives lost as a result of unjust and uninformed health care practices is many orders of magnitude greater than what has been reported in the arena of law enforcement. It would follow then, that the need for better ways to train health care practitioners aimed at mitigat-

ing the injustices of health care practice is much more acute. Reducing or eliminating health care disparities is decidedly complicated, given the very complex and multifaceted nature of the causes underlying such disparities. If we are to adequately prepare physicians to provide wholly equitable care for all patients — those like them, as well as those who are particularly and disproportionally affected by societal inequities and injustice — their education must address the difficult and uncomfortable realities that lead to disparities in care. Medical education needs to be directed toward providing a deeper understanding of societal inequities and social justice. To memorialize Freddie Gray and countless other black individuals killed unjustly, my colleagues Delese Wear, Ph.D., Julie Aultman, Ph.D., Michelle Chyatte, Dr.PH., and Arno K. Kumagai,

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FEATURE

M.D., and I wrote “Remembering Freddie resist being characterized as racist. Yet, it cy is aimed at inculcating in students a Gray: Medical Education for Social Jus- is imperative that learning experiences degree of so-called cultural humility, the tice,” recently published (online in 2016, explore the race and class-based biases goal here is to foster a sense of structural ahead of print) in Academic Medicine, to — conscious as well as unconscious — that humility as well. argue for medical education that address- impede physicians from providing equies these concerns openly, honestly and table care to all patients. A COMMITMENT courageously. Such curricular efforts enTO SOCIAL JUSTICE gage students and faculty in looking more STRUCTURAL COMPETENCY When students begin their medical deeply into themselves, the culture of The traditional concept of cultural com- education, they join, at least provisionalmedicine, and the greater structural con- petency is now universally taught in U.S. ly, a profession that requires them to make texts in which they and their patients live, medical schools, exposing students to how certain commitments: to place the needs to foster a more rigorous of the patient ahead of their understanding of race, class own needs; to strive toward and societal injustice. Enexcellence in the care they riching medical education in provide; to always seek to REDUCING OR ELIMINATING this way requires explicit find the value in others; and HEALTH CARE DISPARITIES IS pedagogical orientation, and to consistently do what is we suggest two specific apright, what is fair, what is DECIDEDLY COMPLICATED, proaches: antiracist pedagotrue, and what is good. gy, and the concept of strucThroughout their education, GIVEN THE VERY tural competency. they need to be reminded that medicine aspires to be a BEYOND WHITE moral and a just community. PRIVILEGE: ANTIAnd they enter that commuRACIST PEDAGOGY nity, that profession, reafAntiracist pedagogy aims firming these commitments to assist students in criticalthrough the professing of a ly reflecting on the ways that sacred oath. At NEOMED, oppressive power structures these commitments are takaffect their own lives and the en seriously, and they inform lives of others. This approach moves stu- various cultural, racial and ethnic groups a curriculum that attempts to broaden our dents toward critically examining health experience health and health care in ways students’ appreciation for and understandcare from multiple perspectives, examining particular to their specific groups. The ing of their obligations to work toward a systems of power and how they create concept of structural competency, on the profession that strives collectively for that privilege for some and not for others. This other hand, explores forces beyond spe- same objective. The education of physipedagogical orientation requires, of course, cific cultures or ethnicities, and beyond cians must be, as eloquently described by an examination of white privilege, espe- the patient-physician encounter, to exam- Paulo Freire, an “education for liberation,” cially given the prevailing “whiteness” at ine how clinical symptoms are related to education aimed at liberating the patients nearly every U.S. medical school — white- social, economic and political structures we serve (and their communities) from ness that is generally invisible to white that lead to dramatic income inequalities, social injustice and oppression, education students, white faculty members and white poor food availability, substandard edu- aimed at justice in health care for all. administrators, but not so invisible to cational systems, decaying infrastructure Joseph Zarconi, M.D., is professor and people of color. Conversations about white and the like. Students must come to un- chair of internal medicine, interim associate privilege and racial biases can be uncom- derstand how such structures impact pa- dean for health affairs, and clinical director fortable. They can be steeped in defensive- tient care, and consider interventions to for humanities education at the NEOMED ness and sometimes anger, since students address the inadequacies of health infra- College of Medicine. He was a member of entering the medical profession naturally structures. And just as cultural competen- the College of Medicine’s charter class.

COMPLEX AND MULTIFACETED NATURE OF THE CAUSES UNDERLYING SUCH DISPARITIES.

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EDUCATION FOR

SOCIAL JUSTICE AT NEOMED

EOMED has a tradition of emphasizing the humanistic and professional dimensions of medicine alongside the scientific through the Human Values in Medicine (HVM) curriculum, which includes a four-year longitudinal Reflective Practice course. This course incorporates a number of educational activities that emphasize critical reflection and dialogue, often conducted in small group sessions, in which issues of privilege, power, identity and oppression may be deeply explored in “safe space” environments. These experiences aim to move students toward the development of a critical consciousness — a habit of examining their own assumptions, values and perspectives, and those of others, to uncover and grapple with sources of injustice. (See College of Medicine student Tim Smile’s “Reflections on Reflecting” in this issue.) Studying literature such as Toni Morrison’s Recitatif or Kimberly Manning’s The Nod allows students to see how multiple identities exist in all of us, or how hospital culture disproportionately isolates some ethnic groups. Film study offers opportunities to explore racism and racial politics, as so richly portrayed in Paul Haggis’s Crash. Peter Nicks’s documentary The Waiting Room offers an intense exploration of the lived

experiences of members of a low-income community as they seek emergency care in a hospital emergency department with constrained resources. The bioethics curriculum within HVM also directs students’ attention toward race and class issues. It allows for discussions of narrative medicine and narrative ethics in which students reflect on their own narratives in relation to the stories of others. Short stories like Jay Baruch’s Hug or ugh? and Irvin Yalom’s Fat Lady nudge students into sometimes uncomfortable explorations of poverty, isolation, aversion toward patients and inequities in health care. Finally, clinical and community experiences expose NEOMED students to structures and elements of health care outside the sterile halls of the hospital setting that have significant impact on the health of individuals and communities. Students can work in impoverished communities, studying health care outcomes and developing ideas for interventions to improve these outcomes. Placing students where health care disparities exist, and engaging them in thinking about how and why they exist — and what can be done about these disparities — can lead to a richer appreciation for the broader contexts of health care inequity and social injustice.

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FEATURE

THE INFANT MORTALITY CRISIS: A TALE OF TWO STATES

BY ELAINE GUREGIAN

rom the Midwest to Mexico and back again: It all started with a story about a woman who couldn’t get to her medical appointments because she didn’t have a car. No appointments, no prenatal care. No prenatal care, higher infant mortality rate. When a guest lecturer at NEOMED laid out the examples of health disparities among population groups and their connection to infant mortality, that did it. Two NEOMED students were inspired to start projects that have taken them from rural Rootstown, Ohio to the refugee haven of Tapachula in Chiapas, Mexico, beginning career paths in global health. It was more than a year ago that College of Medicine students Chandni Goel (M2) and Sarah Hill (M3) heard that lecture by Joxel Garcia, M.D., a former Assistant Secretary for Health of the United States. Dr. Garcia’s research uncovered barriers and noncompliance that contributed to African-American and Hispanic babies being much more likely than Caucasian babies to die before their first birthday. Just one example: Dr. Garcia pointed

Illustration: Christopher Darling

out that women who couldn’t afford a car also might not be able to use public transportation, because if they were carrying a stroller and an infant they couldn’t easily board a bus — and he had discovered that bus drivers were prohibited from helping them, for liability reasons. Dr. Garcia decided to see if improving access to transportation would reduce the disparity in infant mortality. Hill and Goel were fascinated by Dr. Garcia’s study. They knew that despite all the excellent hospitals and health care available for children in Northeast Ohio, the mortality rate (the number of infants out of 1,000 live births who died before their first birthday) for black infants in 2015 was three times higher than for white infants. (Source: Ohio Department of Health.) The two students started talking to Julie Aultman, Ph.D., a professor of family and community medicine, who taught their Human Values in Medicine class at NEOMED. They also began their own literature search. What they discovered was stunning in its simplicity and resonance.

“We found a paper by David R. Williams published in 1999 in the Annals of the New York Academy of Sciences titled ‘Race, Socioeconomic Status, and Health: The Added Effects of Racism and Discrimination.’ It basically said that if a patient recognizes or perceives any sort of bias from a provider, they are much less likely to return for another visit. They are much less likely to follow that doctor’s instructions. If they feel they are being looked down upon, that has a huge impact on care,’’ says Goel. Dr. Aultman encouraged the two students to apply for a NEOMED diversity initiative grant. Through their winning project, “Factors Contributing to Non-Compliance and Their Effect on Infant Mortality Rates Among Races in Cleveland, Ohio,’’ Goel and Hill made a plan. They would interview medical residents in Northeast Ohio about their personal experiences delivering care. By doing so, they hoped to uncover the unconscious biases that get between provider and patient. Hill puts it this way: “As a patient, how are you going to have your mind changed by a 15-minute visit or a two or

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FEATURE

three-day hospital stay with a person who looks different than you, talks different than you, who uses these big words, wears this pristine white coat and is of a different socioeconomic class or a different race than you?’’ “We’ve been counseled here at NEOMED on the risks: If another patient reminds you of someone that you’ve seen in the past, with a bad experience, you might carry that with you,’’ says Hill. As phase one of the study, the students interviewed residents from hospitals in Akron and Canton. (One hospital remains to be surveyed.) For the second phase of the study, Hill and Goel will survey and interview patients for their perspective on how they are treated. Their goal is to examine the impact of race and barriers that impede parents’ ability to take their infants to physician appointments. Finally, the two students will develop an intervention plan to help educate parents and improve the health care system in Northeast Ohio.

FINDING THE BARRIERS Through surveys, interviews and focus groups at multiple Northeast Ohio hospitals, Goel and Hill have determinedly pursued answers to their question: how and where barriers among certain populations lead to worse health outcomes. “A lot of times when the medical resident calls, the patients don’t pick up the phone. The resident leaves a message but there is a breakdown. Maybe the patient doesn’t get the message. Maybe she didn’t write down the appointment. Or maybe she doesn’t have a phone anymore. That’s what we’re asking: What basic resources are they missing that we overlook because as medical students, as residents, as physicians, we come from a certain lifestyle. The idea of not having a cell phone or not being able to contact people or have access to transportation doesn’t really occur to us,” Hill says.

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Another disconnect often happens after a mother and baby leave the hospital, residents told the student researchers. The health care team might not learn that a mother’s first baby had died unless she reported it when returning for a pregnancy test. Residents also told Goel and Hill about their frustration when new parents refused free car seats or sleep boxes for their infants because they thought they were unnecessary. “Parents think they know what’s best or what’s easier for their lifestyles, but practices like not using car seats, putting pillows next to their babies or letting their babies sleep in their bed put the infants at higher risk of injury or death,’’ says Goel.

GOING GLOBAL Digging for reasons behind the high infant mortality rate in Northeast Ohio raised Goel and Hill’s awareness. Goel, a second-year medicine student, plans to also earn a master of public health degree in global health. She’d like to work at a global level with the United Nations High Commission on Refugees (UNHCR) to plan and administer shelters. Goel is even more certain since last summer, when she and Hill, as co-presidents of the Physicians for Human Rights (PHR) student interest group, organized a medical service trip to Mexico related to infant mortality. Hill and Goel secured a grant, while the 10 other students helped raise money for the trip they took as members of the NEOMED chapter of PHR. Their goal? Visit three refugee shelters in Mexico to provide pre- and post-natal education and first aid — and to learn about how shelters and clinics operate, for better and worse. Over two weeks in June and July 2016, the dozen NEOMED students visited three shelters in the Mexican city of Tapachula, located in the state of Chiapas.

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Tapachula is a busy stopping point for refugees heading north to escape gang violence in Central America’s Northern Triangle region: El Salvador, Honduras and Guatemala. In November 2016, The New York Times estimated that in the most recent fiscal year, more than 77,000 migrants stopped on the southwestern American border were traveling as families — and 91 percent of them were from the Northern Triangle. “As a clinician, you need to not only take care of the disease, but take care of each person as a whole. You want to be sure they’re safe and comfortable, but at the shelters they’re always thinking and stressed,’’ says Goel. The NEOMED students lodged in hotels, in keeping with the detailed safety plan developed beforehand with Andre Burton, J.D., the executive director of diversity, equity and inclusion at NEOMED. Still, “Being with the refugees opened my eyes to what they’ve been through and how hard they have to work to survive,’’ says Hill. “It’s not just a lot of young people looking for brighter futures. They’re not thinking about ‘When am I going to get my next job.’ They’re thinking ‘Am I going to die today?’’ Or, since a high percentage of female refugees are sexually assaulted, “Am I going to get raped today?’’ In fact, separate space is set aside for the LGBT population at the Mexican shelters, because this population is often targeted for violence. Despite the frightening circumstances that brought them to the Tapachula shelters, the women there — men, too — were eager to learn from the NEOMED students, who had devised a pre- and post-test on taking care of a baby. With the help of an interpreter, the students administered the test in either Spanish and English, having the interpreter speak the questions for those who could not read. (See sidebar.) In the educational sessions, the students

focused on Sudden Infant Death Syndrome (SIDS), breastfeeding and teaching awareness of developmental milestones such as when your baby should be able to lift their head unassisted. The students taught close to 80 individuals, 49 of them refugees. Dr. Rev. Robin Hoover, whom Goel and Hill met at a diversity talk at NEOMED, helped the two students plan the trip and line up three interpreters who also helped by translating written materials before the trip. While in Mexico, Goel and Hill learned about Mexico’s legislative process by visiting the National Commission of Human Rights. They met with an official from the United Nations High Commission on Refugees to learn about how policy-makers and administrators plan and operate shelters on a broad scale. Visiting the Instituto de Salud del Estado de Mexico, shattered any stereotypes they had about all Mexican clinics being alike. Despite limited resources, the Instituto de Salud operates with all providers working together, like the Patient-Centered Medical Home model in the United States, says Goel. Hill said the experience in Mexico solidified her intent to pursue global health, perhaps as a surgeon. Back in Ohio, she and Goel are learning to deal with administrative processes as they work their way through Institutional Review Board approval for the final hospital where they will survey residents. The two students’ project will come full circle as they interview Northeast Ohio patients about any biases they may have encountered and consider what changes health care providers could make to help infants live longer. As they move forward, the two students can reflect on the patients they encountered last summer, and what they learned so many miles from home.

INFANT CARE QUIZ

EOMED students Chandni Goel (M2) and Sarah Hill (M3) created a test to measure knowledge of pre- and post-natal care. With the help of a translator-interpreter, the students administered the test to parents at three shelters in Tapachula, Mexico, that serve refugees fleeing the violence of the Northern Triangle region. By giving the test both before and after providing instruction, the students measured how much refugees had learned. Here’s a sampling of questions. 1. When during your pregnancy should you try to see a doctor immediately? (What are signs of emergency) a. Vaginal bleeding b. Fever and too weak to get out of bed c. Difﬁculty or fast breathing d. Severe headaches e. All of the above

2. What should you ﬁrst feed your baby? a. Rice water mixture b. Breast milk c. Fruits and vegetables d. Meat 3. Why should you breastfeed your baby? a. Protection from infection b. Perfect nutrition c. Bonding between mom and baby d. All of the above 4. How should your baby sleep at night? a. Next to you b. With lots of pillows and blankets c. On their stomach d. On their back 5. At what age should your baby start walking? a. 3 months b. 14-15 months c. 3 years d. 5 years

Answers: 1—e; 2—b; 3—d; 4—d; 5—b Illustration: Christopher Darling

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FEATURE

RURAL MEDICINE,

REVISITED

BY ELAINE GUREGIAN

Fresh air, fresh food, a slower pace, no crowds. It sounds good, but that bucolic vision of rural life is tempered by other realities that too often put good health out of reach for the 46 million people living in rural areas of the United States. Lack of providers. Poverty â&#x20AC;&#x201D; and its attendant shortages of health insurance, transportation, food and access to medication and treatment. Lack of reliable internet connections. All of these issues, and more, put rural residents at a disadvantage for good health.

generalist dentists per 100,000 in rural areas, compared with 30 per 100,000 residents in urban areas.

39.8 physicians per

53% of rural Americans

lack access to 25 Mbps/3 Mbps of bandwidth, the benchmark for internet speed according to the Federal Communications Commission.

100,000 people, compared with 53.3 physicians per 100,000 in urban areas.

Rural residents often need to

RURAL YOUTH ARE TWICE AS LIKELY TO

COMMIT SUICIDE.

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TRAVEL GREAT DISTANCES to reach a doctor or hospital.

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Chronic shortages of mental health professionals exist, as mental health providers are more likely to live in urban centers.

Rural communities have more uninsured residents, as well as higher rates of unemployment, leading to less access to care. % of vehicle More than crash-related fatalities happen in rural areas. In rural areas there is an additional % risk of injury-related death.

Rural residents often travel long distances to receive mental health services.

People who live in rural America rely more heavily on the Supplemental Nutrition Assistance Program (SNAP) beneďŹ ts program. According to the Center for Rural Affairs,

They are less likely to be insured for mental health services, and less likely to recognize the illness. The stigma of needing or receiving mental health care and fewer choices of trained professionals create barriers to care.

Rural areas have MORE FREQUENT OCCURRENCES of diabetes and coronary heart disease than non-rural areas.

14.6% of rural households receive SNAP beneďŹ ts, compared with 10.9% of metropolitan. Rural Americans are more likely to live below the poverty level. The disparity in incomes is even greater for minorities living in rural areas. RURAL YOUTHS OVER THE AGE OF 12 ARE MORE LIKELY

SMOKE CIGARETTES TO

% ABOUT OF RURAL CHILDREN LIVE IN POVERTY.

(26.6 percent versus 19 percent in large metro areas). They are also far more likely to use smokeless tobacco.

Source: National Rural Health Association

NORTHEAST OHIO MEDIC AL UNIVERSITY

FEATURE

RURAL MEDICINE, REVISITED

BY ELAINE GUREGIAN

or many physicians, becoming student who grew up on a cattle farm in The most extensive community traina medical doctor means fol- the small town of Farmdale, Ohio. While ing comes through a health coaching prolowing a family tradition — Zuga was growing up, NEOMED gram offered through Alliance Commubut that doesn’t fit NEOMED graduate Jeffrey Bedlion, M.D. (’95), an nity Hospital, not far from the NEOMED alumna Janice Spalding, M.D. internist in Farmdale, mentored him by campus. NEOMED’s affiliation began (’87). Not only were there no physicians welcoming him to spend time at his in- in 2014 when Christopher Shelby, in her family; in her rural community, there ternal medicine practice. Zuga realized Pharm. D. (’11), an assistant professor were also no role models of women be- he’d like to pursue primary care — specif- at the University, placed NEOMED coming physicians. It wasn’t until Dr. Spal- ically, general internal medicine. His pharmacy students in the program, ding was 32 years old which the hospital with two children launched in an effort THE CENTERS FOR DISEASE CONTROL AND that she began medto decrease barriers ical school, graduatPREVENTION DEFINES HEALTH DISPARITIES AS and improve patient ing in 1987 with the outcomes. When “DIFFERENCES IN HEALTH OUTCOMES the Rural Pathway seventh NEOMED class. began, Dr. Spalding AND THEIR CAUSES AMONG GROUPS An associate procouldn’t wait to fessor of family and bring NEOMED OF PEOPLE.” community medimedicine students cine at NEOMED, on board. For the second half of the medicine Dr. Spalding has been a key architect of dream? To work at Dr. Bedlion’s practice the University’s new Rural Medical Edu- and to take over his family’s cattle farm. students’ first year and the full second year, cation Pathway program, now completing they provide one-on-one attention for its second pilot year with a small group of HEALTH COACHES AND patients who live in the country and use hand-picked students. HOUSE CALLS the hospital frequently. Students work “I was a rural female 40 years ago, when Rural Pathway students complete the interprofessionally with Alliance Hospital women absolutely did not go into medi- same coursework and training as other teams consisting of physicians, nurses, cine. I just wanted people not to go College of Medicine students. The differ- pharmacists, dieticians, social workers or through what I went through,’’ says ence is in the additional specialized train- counselors and pastoral caregivers. Mental Spalding, invoking a favorite saying of ing and experiential learning they receive health care is notoriously scarce for rural NEOMED’S Mark Savickas, Ph.D., pro- regarding patients with health issues re- dwellers, so the Alliance team stands ready fessor emeritus of family and community lated to country living. Students take sem- to connect them to those services, too. medicine: We actively master what we inars to learn about the social determinants Here’s the retro twist that’s more needpassively suffer. of health in a rural setting, and about the ed than ever: these twice-monthly visits In many ways, the Rural Pathway is a health disparities between rural dwellers are what used to be termed house calls, at return to NEOMED’s roots, which have and their non-rural counterparts. Their which the students visit patients and help widened over the years. At the University’s teachers? Rural physicians, mental health them navigate through whatever sympfounding on farmland more than four providers and faculty members — all with toms or issues might be troubling them. decades ago, the institution was intended an interest and expertise in rural medicine. On each visit to the patient’s residence, to train physicians from the rural com- Students serve their third-year clerkship student coaches see the aspects of culturmunities surrounding Rootstown to go and fourth-year electives in rural settings, al habits, economic situation and physical back and serve those areas. and they complete a capstone project on environment that can mean the difference One enrollee in the pilot program is a pressing issue in a rural community between poor health and good health. Zack Zuga, a first-year (M1) medicine where they have trained. Rural patients may be socially isolated,

DARIAN ROBERTS,

STUDENT HEALTH COACH especially if they are older, and they are likely to live far from their physicians’ offices or a hospital. If their driving is limited, they may have trouble getting nutritious food or obtaining medicine in a timely way. Debra Lehrer, M.D., the medical director of the Alliance Health Coach Program, reports that most of the patients enrolled in the Alliance program have mental health problems. Student health coaches are taught the signs and symptoms to watch for on their visits. Through the rest of the team and their network, the students can help arrange earlier appointments, if a patient goes downhill, or change patients’ care plans. “A key outcome of health coaching is that our NEOMED students are developing communication skills to work with patients and develop a relationship with them,” says Michael Appleman, M.A. Ed., the curricular and instructional specialist for the Rural Medical Education Pathway. Students in the Rural Pathway program tend to be passionate advocates. The program has also attracted students like Darian Roberts (M3), who aren’t officially enrolled, to take seminars or to serve as health coaches. The commitment of these students touches Dr. Spalding. To cap off an extensive and satisfying career as a physician and educator, she wanted to work with an underserved population, to work with a rural population and to work with medicine students. With a big smile, she says, “This is what I’ve always wanted to do.’’

hird-year medicine student Darian Roberts visits a rural couple every other week, alternating her house calls with second-year NEOMED pharmacy student Mir Hussain. She has earned their trust and permission to talk about how health coaching helps them when she copresents with Appleman and Dr. Spalding at a medical student education conference of the Society of Teachers in Family Medicine in Anaheim, California in 2017. The rural diet Roberts knows from growing up in small-town Garrettsville is heavy on starch and red meat — not as many of the fresh fruits and vegetables one might assume, considering the farm setting, she says. The husband in the couple used to like drinking Kool-Aid. After gentle advising, Roberts persuaded him to trade the sugary drink for plain water. Besides keeping an eye on proper nutrition, Roberts tag-teams with Hussain to provide medication oversight. Many older patients take a lot of medicine, often too much, Roberts observes. In the case of her couple, the wife is suffering from cognitive decline, while the husband is legally blind. He gets frustrated when his wife can’t remember things, but he can’t see well enough to place and remove their daily allotment of pills in a weekly pill-keeper. She’s anxious about her declining control over her mental faculties. Roberts also helps monitor and question whether they are taking too many prescriptions, something so common that medical professionals call it polypharmacy. When multiple providers are involved, it’s easy for them to not be aware of what the other has prescribed, but health coaches like Roberts can be on the lookout. A situation like this couple’s, where stress or depression and anxiety result from coping with cognitive and physical declines, is common. Roberts finds satisfaction in helping the couple manage both their medications and their frustrations. She discovered when she encountered an urban setting (attending a NEOMED pathway program at the University of Akron) that she prefers the rural lifestyle, which feels like home to her. She also understands the challenges: “Especially in rural areas, I think there are barriers to health care, including reproductive care, because of religious issues,’’ says Roberts, who would like to focus on women’s health as a future family physician. As the recipient of a two-year Mercy Health Education for Service Scholarship, she will repay Mercy’s financial support by working for two years after graduation in a setting (possibly rural) where Mercy Health has facilities. So, has anything changed in a generation? Like Dr. Spalding, Roberts needed to find her own way as the first in her family to attend medical school. She says it can be harder to find opportunities shadowing physicians or doing research if you lack such family ties. But Roberts had the opportunity to attend MEDCAMP before high school, spending three days at NEOMED to learn about the health professions. For that she will always be grateful, she says, since, “Ever since I discovered medicine, I never wanted to do anything else.’’

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FEATURE

A REFLECTION ON REFLECTING

BY TIMOTHY SMILE, M.M. (M4)

edical school taught me to enjoy writing. It’s a funny thing to say, especially considering the perpetual deluge of scientific and clinical content presented throughout the curriculum. Nevertheless, through my university’s Human Values in Medicine (HVM) course, described in a recent Academic Medicine article, I learned to appreciate — and eventually rely upon — the tradition of reflective practice. Through clinical faculty-led small group sessions with my peers, HVM quickly created a culture of trust and openness that initially seemed incongruent with my stereotype of medical school. I believe part of that success can be attributed to the timing of the course. Before meeting as a group, students were assigned articles, poems, short stories, and/or other materials that examined sensitive — and often uncomfortable — topics applicable to concurrent basic science modules. These topics included race, obesity, organ donation, burnout, snap judgments, and many others. Students were instructed to read the assignments and write a reflective essay about any reactions the readings evoked, submitting it to the faculty leaders prior to the in-person group meeting. Composing reflective practice essays provided an

Illustration: Taylor Harvey

avenue for processing confusing or embarrassing thoughts/beliefs, venting frustrations, recounting an important anecdote, or exploring potentially profound thoughts related to the readings. Expressing ourselves through these essays also primed our groups for enlivened but respectful discussions, which included incredibly candid comments from the students as well as the faculty leaders. What I didn’t realize until starting my clinical rotations was the way reflective practice equipped me to process challenging patient encounters and provided prophylaxis against bitterness. Lois was one of my first — and most challenging — patients of clinical rotations. Lois was a middle-aged lady to be admitted from the ED to my inpatient service for syncope. While I performed a full history, she revealed to me that her ex-husband had returned to town, that he had sexually assaulted her in the past, and that her ED visit was actually because she was afraid to be home alone. I was deeply moved by her tearful story, immediately collaborating with the social worker to help Lois. I spent the next two hours on the phone with every battered women’s shelter within a 40-mile radius of the hospital seeking respite for Lois, none of which had room for her. Eventually, I wearily walked back into the room to discuss any other poten-

tial options. When I arrived, Lois was cheerfully finishing her hospital meal and eventually explained to us that she fabricated everything because she was hungry and had no money for food. My feeling immediately after leaving her room was an amalgamation of frustration, embarrassment, betrayal, and fatigue. This inundation of confusing feelings later found voice through a reflective practice journaling session that proved to be a cathartic and healing experience for me. The essay that unfolded helped me to imagine the life experiences that brought Lois to the hospital that night, desperate, hungry, and alone. Thanks in part to this emotional equipment cultivated by the HVM curriculum, I now recognize that the care, comfort, and warmth Lois felt during her stay were real, and I’m thankful to have been a part of that. I am fortunate to have studied at an institution that values humanism in medicine, and I anticipate relying upon reflective practice to help me grow as a caretaker throughout residency and beyond. Timothy Smile holds a master of music degree and is a fourth-year medicine student at NEOMED. This piece was first published on Academic Medicine’s AM Rounds on October 11, 2016, and is reprinted with permission.

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FEATURE

ON LIVING FOREVER, LIFE EXPECTANCY AND DISPARITIES IN HEALTH CARE

BY RODERICK L. INGRAM SR.

or the first time since 1993, the overall life expectancy for U.S. citizens has dropped, with the number of deaths per 100,000 increasing from 724.6 to 733.1. (This was the change in the overall age-adjusted death rate from 2014 to 2015 according to the National Center for Health Statistics.) That may not look like a huge number, but quick math says that’s another 25,000 or so in addition to the 2.7 million who would have died had the rate remained steady. And at a time when people are living longer, experiencing huge advances in technology and biomedical research as well as developments in equipment and devices, drugs and treatments, how is this so? The life expectancy for U.S. citizens has fallen from 78.9 years to 78.8 years! And if you’re thinking this is just a blip that won’t impact the young, well, the qualifier for this drop is that it is the life expectancy for someone born in 2015 (it differs for those who are already 65, for example). And it’s not just average reckless dudes

Illustration: Doug Green

whose life expectancy (76.5 to 76.3) has dropped. Life expectancy has also dropped for women — from 81.3 to 81.2 years. The last time life expectancy for U.S. citizens dropped was 1993. Should we be concerned? To be clear, a decrease in life expectancy for someone born in 2015 does not necessarily mean an increase in infant mortality rate — which remained virtually unchanged from 2014. In fact, the 10 leading causes of death in 2015 were the same as in 2014. But age-adjusted death rates for eight of the leading causes — 0.9 percent for heart disease, 2.7 percent for chronic lower respiratory diseases, 6.7 percent for unintentional injuries, 3.0 percent for stroke, 15.7 percent for Alzheimer’s disease, 1.9 percent for diabetes, 1.5 percent for kidney disease and 2.3 percent for suicide — increased. And the issue of life expectancy is quite different in underserved communities —areas dense with racial and ethnic minorities, or filled with the rural and urban poor.

In many underserved areas, that point one (0.1) dip in life expectancy that concerns many of us doesn’t even exist. Why? Because many in such communities don’t even make it that far. Sure, there’s evidence that these areas tend to have higher rates of cigarette smoking, less physical activity, poor eating habits and lower use of car seat belts, but before you blame behaviors, just look at several of the social determinants of health first. Better still, just look at income. According to a paper titled The Association Between Income and Life Expectancy in the United States, 2001-2014, published online on the JAMA Network, life expectancy increases continuously with increased income and so does the gap in life expectancy between individuals in the top and bottom one percent of the income distribution in the United States. It’s not just by a few years, either. The disparity can be massive: as much as 15 years for men and 10 years for women. It just doesn’t seem right that because someone makes more money that they

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FEATURE

SHOULDN’T “INCOME GAPS” OR “POVERTY” ALSO BE CONSIDERED PUBLIC HEALTH CONCERNS? 20 I G N I T I N G

can live 15 years longer. And the gap between the rich and poor is growing. Although the country’s top ZIP codes are in the midst of an economic boom (according to the 2016 Distressed Communities Index, which analyzes community well-being across the United States), many in nearby ZIP codes aren’t necessarily doing as well. Two Northeast Ohio cities — Cleveland and Youngstown — ranked among the top 10 most distressed cities in the country. So, what does that mean for the health of those in underserved communities? With eight of the leading causes of age-related deaths on the rise and states like Ohio leading in drug overdoses and experiencing more than twice as many people dying from suicide than homicide, the role the economy plays should not be overlooked. A study by Virginia Commonwealth University and the Robert Wood Johnson Foundation makes it pretty clear in comparing two Cleveland neighborhoods fewer than 10 miles apart: The life expectancy of a baby born in the Glenville neighborhood is 12 years less than one born in Lyndhurst (an outer-ring suburb). The study added that such health disparities are driven not by natural differences, but by racial and economic differences. It hasn’t gone unnoticed that other social determinants like geography, access to quality health care and health literacy, air and water quality, transportation, and so on, have a huge impact on wellness and life expectancy. The American Public Health Association (APHA) includes social determinants among its list of the 29 “most important problems and solutions of our time.” The CDC’s National Center for Injury Prevention and Control’s Prevention Status Report names the following (listed alphabetically) as the 10 most important public health problems and concerns: Alcohol-related harms; food safety; health care-associated infections; heart

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disease and stroke; HIV; motor vehicle injury; nutrition, physical activity and obesity; prescription drug overdose; teen pregnancy; and tobacco use. Many of these health concerns are disproportionately related to the circumstances of the underserved. And organizations like APHA, the Centers for Disease Control and Prevention, the National Institutes of Health and others are doing something about it. But shouldn’t “income gaps” or “poverty” also be considered public health concerns? Amy F. Lee, M.D., M.P.H., M.B.A., professor at Northeast Ohio Medical University and director of the Consortium of Eastern Ohio Master of Public Health program, says that these social determinants are indeed foremost issues for public health. “Education and medical treatment alone cannot address the roots of our declining life expectancy and health disparities. Therefore, local public health departments work with community agencies, hospitals, politicians, schools and neighborhoods to prevent injury and disease. No one group has all of the keys to improve the ‘conditions in the places where people live, learn, work and play.’ A community effort is necessary.” Consider this last thought: Only a fraction of the U.S. health budget — three percent in 2012 — is spent on public health. And this spending is uncertain, since allocations for public health agencies and programs such as the Centers for Disease Control and Prevention and the Health Resources and Services Administration must be approved through the congressional appropriations process each year. It seems as if our nation’s systems treat the diseases of the dying instead of investing in treatment of the causes from which they are perishing. Perhaps treating such causes would allow all of us to live longer — including the less fortunate people who live fewer than 10 miles away but a world apart.

THE ART OF LISTENING AND FULFILLING

A LEGACY OF GIVING

Dr. Kashayap Kansupada - pictured with green shirt in the center of his family

He always listened to his father, who wanted to be a physician himself, but couldn’t afford medical school.

Kashayap Kansupada, M.D. (’91), credits listening as the key to his success as a geriatric ophthalmologist.

As a student, Dr. Kansupada learned to really listen to patients in NEOMED’s world-class interview simulation. NEOMED listened to his keen interest in cataract research and helped him get funding to present it at Harvard. A colleague in NEOMED’s REDIzone listened to him, and is helping him launch his idea to improve retinal surgery.

Dr. Kansupada’s father fulﬁlled his dying wish to leave a bequest to NEOMED. Together, the Kansupadas are helping NEOMED Shine On. To learn more about estate planning, please contact Michael Wolff, J.D., NORTHEA S T O at H I O 330.325.6667. MEDICAL UNIVERSITY

HEALTHY AGING

BRED IN THE BONE

BY ELAINE GUREGIAN

an the strength of your bones provide a key to your risk of developing Alzheimer’s disease? NEOMED’s Christine Dengler-Crish, Ph.D., an assistant professor of pharmaceutical sciences, anatomy and neurobiology, has intriguing findings. She and her research team, including graduate students Matthew Smith (NEOMED) and Gina Wilson (Kent State University) have discovered that early re22 I G N I T I N G

ductions in bone mineral density (BMD) found in a preclinical (animal) model of Alzheimer’s Disease may be due to degeneration in an area of the brainstem that produces most of the brain’s serotonin. It’s an intriguing discovery, since the neurochemical serotonin affects our mood and sleep — two processes that are also affected early in Alzheimer’s. Since fewer than five percent of Alzheimer’s cases are clearly from genetic reasons, these new clues are especially significant and may

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allow earlier detection of Alzheimer’s disease processes. Besides indicating risk, reduced BMD can lead to osteoporosis and a higher risk of broken bones, decreasing quality of life and increasing mortality in Alzheimer’s patients. Dr. Dengler-Crish’s research bridges two focus areas at NEOMED: Musculoskeletal Biology and Neurodegenerative Disease and Aging. Here, she takes us deeper into her team’s new findings. How do you define “early’’ bone loss?

Photos: Phil Masturzo

When we talk about early bone loss, we mean that the reduction in bone density that we see occurring before or at the very beginning stages of Alzheimer’s — often before the official Alzheimer’s diagnosis or before people start experiencing the significant learning and memory issues that are typical of Alzheimer’s. In our experiments, we’ve seen bone loss before the emergence of the classic “plaques and tangles” disease markers appear in the brain. In other studies, not completed by us, reductions in bone density were measured in patients as much as five or six years before they were diagnosed with Alzheimer’s. How much osteoporosis does it take to be considered significant? Bone density loss does not even have to be as extensive as osteoporosis to be associated with Alzheimer’s risk. Osteoporosis is a severe form of bone density loss that puts a person at high risk for bone breaks. It is defined by specific measurements of bone density as compared with healthy adults of the same age. A simpler diagnosis of “low bone mineral density” is any reduction in bone density (compared with typical adults the same age), which can still lead to risk of breaks and other problems. In our preclinical studies, we saw an association between Alzheimer’s disease-like brain changes and low bone density. And yes, some of these skeletons met the more stringent criteria for osteoporosis. How might this research be applied? People over 50, especially women, are routinely prescribed bone density tests already. These same tests could be useful in assessing Alzheimer’s risk in our aging population. Low bone density/osteoporo-

sis alone can’t tell us much about Alzheimer’s risk. However, low bone density along with other major risk signs such as mood changes, memory loss, and appetite or sleep disturbances in an aging person may tell us quite a bit. Also, given how early we saw pathology, the brain region we examined may act as a seed from which pathology spreads. This motivates us to explore the serotonin system not just to improve quality of life in patients, but also as a potential new therapeutic target for this devastating disease, which currently affects more than five million Americans.

which is more about maintaining bone health as we age. So, we must be cautious in how we would implement “serotonergic” strategies for brain and bone protection. Despite this caveat, we are very interested in understanding how chronic serotonin modulation that is initiated in adulthood — either for depression, anxiety, obesity, or migraines — impacts brain and bone health. It is possible that restoring deficient serotonin levels at the time risk factors for Alzheimer’s peak (i.e. mid-life) could be neuroprotective against diseases like Alzheimer’s and any associated bone loss. Determining a mechanistic relationship between serotonin and Alzheimer’s is a major focus of my lab right now. However, with 14 or more different subtypes of serotonin receptors — all having different effects on serotonin activity —Christine Dengler-Crish, Ph.D. — the solution will likely be more complicated than simply using Prozac, Zoloft, or even Imitrex for brain Serotonin levels can be raised through protection. But with a pharmaceutical antidepressant medications, such as sciences department stocked with scientists Prozac or Zoloft, that are selective sero- who are experts in pharmacology, drug tonin reuptake inhibitors (SSRIs). In development and neurodegeneration, the future, could SSRIs be used for the NEOMED is exactly the right place to secondary or alternative purpose of pre- tackle this big challenge! venting bone density loss? “Early Evidence of Low Bone Density and There may be a role for serotonin-enhancing medications in disease progression Decreased Serotonergic Synthesis in the Dorof Alzheimer’s, but it’s too early to say. sal Raphe of a Tauopathy Model of AlzheiContrary to expectation, research has ac- mer’s Disease’’ was published in the Journal tually linked SSRIs to bone loss in healthy, of Alzheimer’s Disease, an international young patients. However, it is important multidisciplinary journal that reports progress to remember that these young folks are in understanding the causes, symptoms and still in the process of growing and building treatment of Alzheimer’s. Dr. Dengler-Crish, up their bones — processes which dra- who holds a Ph.D. in neuroscience from Vanmatically complicate the involvement of derbilt University, has now been named an the central serotonin bone mechanism, associate editor of the Journal.

Bone density loss does not even have to be as extensive as osteoporosis to be associated with Alzheimer’s risk.”

NORTHEAST OHIO MEDIC AL UNIVERSITY

FOOD FOR THOUGHT

TASTES LIKE HOME BY ELAINE GUREGIAN

irst-year College of Medicine student Cynthia Pung spends long hours at the library. She’s also busy with the Association for Women Surgeons, the Internal Medicine Interest Group and Doctors for Refugees — a special interest of hers, since her father and mother came to Ohio from Cambodia and China, respectively. She learned to make Chinese fried rice from her parents, who own and run two local restaurants. Whenever she makes rice at her apartment in The Village, she cooks a little extra so she can whip up this favorite comfort food at any time. Pung calls the dish “an absolute staple” of visits to her parents or to cook at school. She says, “It’s super quick and easy to make, which is perfect for when you’re busy studying and don’t have much time to cook. It’s totally customizable to whatever you have lying around in your kitchen or refrigerator, so the combinations are limitless!”

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CHINESE FRIED RICE Serves 3-4 people (depending on how hungry you are) Ingredients: 2½ tablespoons oil (vegetable or canola oil are both ﬁne)

1/3 cup bell pepper, ﬁnely chopped*

1-2 cloves of garlic, minced

1/3 cup of broccoli, cut into ﬂorets*

½ of a medium-sized onion, coarsely chopped* 1 egg, lightly beaten

4 cups of cold, cooked white rice (substitute brown rice if you like) 4 green onions, chopped

1 raw chicken breast, chopped or cubed

2 tablespoons soy sauce

1/3 cup carrot, ﬁnely chopped*

A pinch of salt A pinch of pepper

*If you don’t have fresh vegetables, substitute whatever frozen vegetables you might have on hand.

Directions: 1. Heat pan on high and add enough oil to thinly coat the bottom. Stir-fry onion and garlic until fragrant and golden brown. Remove from pan and set aside. 2. Lightly scramble the beaten egg until cooked. Remove from pan and set aside. 3. Add more oil to coat the pan. Add the chicken to the pan and cook until well done or golden brown on all sides. Remove from pan and set aside. 4. Lower the heat to medium or medium high, add any remaining oil to the pan, and stir-fry the carrots, bell pepper and broccoli until fully cooked. 5. Add the rice and stir-fry to thoroughly heat up. Add the cooked onion, scrambled egg, chicken breast and chopped green onion. Stir until thoroughly combined. 6. Add the soy sauce, salt and pepper to taste. 7. Serve with a side of soy sauce for anyone who would like to adjust the seasoning.

Photos: Lew Stamp

NORTHEAST OHIO MEDIC AL UNIVERSITY

INTERPROFESSIONAL EDUCATION

PHARMACISTS HELP CLOSE GAPS IN PATIENT CARE BY ANGELA GOODHART (P4)

Editor’s note: The shortage of physicians in the U.S. is growing. By the year 2025, the shortfall of primary care physicians alone will grow to somewhere between 14,900 and 35,600, as projected by an April 2016 report by the American Association of Colleges of Medicine. Are visions of waiting weeks for an appointment coming to mind? Consider this: Pharmacists can do more than ever, and they can be powerful allies to help compensate for the physician shortage and help reduce health disparities. Angela Goodhart, a 2017 Pharm.D. candidate at NEOMED, explains how.

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n the eyes of federal law, the pharmacists you know and trust are not health care providers. They can’t be directly reimbursed for providing health care services. But that could change with the passage of an act under consideration in Congress as of press time. The Pharmacy and Medically Underserved Areas Enhancement Act would recognize pharmacists as health care providers for areas judged by the government to have a shortage of primary care providers or populations judged to lack access to primary care. In the places where the differences between the haves and have-nots are the greatest, pharmacists could play a significant role in improving health. Even without the proposed new legislation, pharmacists already can do much

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more for their patients than many people realize. Consider the problems that they can help to solve.

THE PROBLEM: In a 2015 report by the Ohio Department of Health, nearly 60 percent of Ohioans reported having at least one of the following 10 chronic diseases or clinical risk factors: arthritis, asthma, cancer, chronic kidney disease, COPD, diabetes, heart disease, high cholesterol, high blood pressure and stroke. These diseases and risk factors foretell a grim future: shorter lives, poor quality of life, higher medical costs, an increased need for health care— and after all of that, more adverse health outcomes than average. Let’s say that a patient — let’s call him

Richard Wills — who lives in rural Portage County takes medicine for diabetes and high blood pressure. Wills begins having readings that are out of his normal range, but because of the scarcity of primary physicians where he lives, he can’t get an appointment for two weeks.

THE SOLUTION: Under Ohio law, pharmacists can collaborate with physicians to care for patients under Collaborative Practice Agreements (CPAs). These agreements allow pharmacists to independently provide specific, predefined patient care services under certain conditions. As of March 2016, CPAs allow Ohio pharmacists to provide a broader range of services under predefined protocols — including ordering laboratory tests and modifying medication regimens based on the results. So, instead of waiting, worrying, and perhaps developing a more serious condition, Wills could visit his pharmacist right away to discuss the problems he’s having and whether adjusting his medicine is in order.

THE PROBLEM: V.K. Shah takes a variety of medicines for his chronic conditions. The refills come due at different times of the month. Since Mr. Shah relies on his daughter to pick them up when she visits from out of town every other week, sometimes he misses doses. For Gloria Washington, it’s a different issue: The pill that has been prescribed for her heart condition is so big that she dreads taking it, and sometimes skips it altogether.

THE SOLUTION: An estimated three out of four Americans do not take their medication as directed (National Community Pharmacists Association and Pharmacists for the Protection of Patient Care Adherence Survey

Illustration: Kels Damicone

2006). Pharmacists can identify reasons patients aren’t taking their medications as prescribed and address the root cause of this lack of adherence. If it’s difficult for someone like V.K. Shah to pick up prescriptions, the pharmacist can work to coordinate his refills so his daughter could pick them up on the same day. Perhaps a mail-away prescription could be used. If a medication is too expensive, pharmacists can recommend more affordable alternatives such as different brands, generics or vouchers from pharmaceutical companies. The answer for someone like Gloria Washington could be in a different drug delivery system: If a pill is too large, perhaps another brand is smaller and easier to swallow, or there may be a patch or a liquid equivalent. If the patient notices side effects, pharmacists can suggest a different time of day or way to take the medication — for example, taking it with food to avoid an upset stomach. And if it’s hard to remember to take that evening dose, pharmacists can brainstorm creative solutions to remind patients when to take their medication, such as storing it near the coffee pot that they program each night.

THE PROBLEM: Quincy and Mary Chung are elderly and no longer drive. They are overdue for health and wellness screenings but it’s hard for them to travel to see a primary care provider.

THE SOLUTION: Although pharmacists don’t provide diagnoses (that’s the physician’s role), they can screen for health problems and check for conditions such as high blood pressure, high cholesterol or high blood sugar. They can also recommend appropriate over-thecounter options to treat common conditions such as colds or heartburn and refer patients to a physician for further evalu-

ation when necessary. In some regions, telemedicine now offers another communication option.

THE PROBLEM: Sheila Howell needs a flu shot, her 65-year-old mother needs a shingles vaccine and her young son is due for a measles vaccination. But Howell can’t take time off work to shuttle everyone to different doctors. She isn’t alone. Many patients aren’t up to date on vaccines that prevent serious infections such as the flu, pneumonia, measles and shingles. For example, only 70 percent of Ohioans over the age of 65 are up to date on their pneumonia vaccine, and only 30 percent of those over the age of 60 have received the shingles vaccine.

THE SOLUTION: Any vaccine recommended by the Centers for Disease Control (CDC) can be administered by a pharmacist right in the community pharmacy. (Some do require a prescription, but this can be done over the phone, without the patient having to go into the physician’s office.) This helps save patients the copay or fees as well as the time it takes to visit a physician — including time in the waiting room. Pharmacists are well qualified to address all these issues and more. NEOMED pharmacy students earn a doctoral level degree (Pharm.D.) in an interprofessional environment with Doctor of Medicine (M.D.) students. Yes, we have a shortage of primary care physicians in our country. But pharmacists, particularly highly credentialed NEOMED graduates with the recently changed laws behind them, stand ready to help patients knock down the barriers to accessing quality health care and wellness. Angela Goodhart is a 2017 Doctor of Pharmacy candidate.

NORTHEAST OHIO MEDIC AL UNIVERSITY

ALUMNI AT WORK

Venkatesh (“Kavi”) Krishnasamy, M.D. (’07) and Julie An (M3)

HOW FAR DO NEOMED CONNECTIONS REACH? BY ELAINE GUREGIAN

hen Julie (Yajie) An took a year off after her third year at NEOMED’s College of Medicine to spend the 2016-17 year in the prestigious Medical Research Scholars Program at the National Institutes of Health in Bethesda, Maryland, she thought she had left NEOMED and all her colleagues behind. An has been studying minimally invasive therapy for patients with hereditary renal cell carcinoma (kidney cancer). It has been fascinating stuff: this NEOMED student has been able to observe the NIH’s interventional radiology staff using a new, minimally invasive technique to remove a kidney tumor by heating (ablating) it instead of removing the entire kidney. And guess what else she discovered? Writing about life at the NIH for NEOMED’s website, An recently said, “Aside from the cool toys and the pioneering medicine, my favorite part about the experience has been the people — in particular, Venkatesh (“Kavi”) Krishnasamy, M.D. (staff clinician in interventional radiology) who relatively re28 I G N I T I N G

cently completed a fellowship in IR. Dr. Krishnasamy and I have a lot in common: We are both first-generation Americans, enjoy eating buckeye chocolates, have a 330 area code for our cell phone numbers and attended the B.S./M.D. program at the University of Akron.’’ Originally from Columbus, Dr. Krishnasamy graduated from NEOMED in 2007. He began his career in general surgery but discovered technology and innovation and subsequently switched career goals to obtain training in two specialties: interventional radiology and endovascular medicine. We asked Dr. Krishnasamy to tell us more. Tell us about your work at the National Institutes of Health. After completing my clinical fellowships, I came to NIH as a research fellow in 2014 and then transitioned to a full-time attending position at NIH’s Clinical Center. I split my time between our clinical patient population and our fascinating translational research. It’s really the best of both worlds.

T H E PA S S I O N O F P H Y S I C I A N S , P H A R M A C I S T S A N D H E A LT H C A R E R E S E A R C H E R S

Dr. Krishnasamy, Julie An and An’s co-mentor, Elliot Levy, M.D. (staff clinician in interventional radiology, National Institutes of Health Clinical Center)

I primarily treat oncology patients — a population that is very dear to me. That’s the clinical side. On the research side, NIH has numerous resources to allow us to translate our bench and lab research to early-phase clinical trials. And then the third arm is education — working with trainees like Julie An, my first NEOMED student! A large part of my background has been in interventional radiology education, so this is natural for me. How did NEOMED help to prepare you for this position? When I was an M3 or M4, I couldn’t have fathomed this is where I would be almost 10 years later. As a medical student, all I wanted to do was surgery. I didn’t really give much thought to the importance and possibilities of an academic career. The focus in school was on education, training and trying to get a residency spot. Still, NEOMED exposed me to faculty who were involved in research and gave me the foundation that I needed. This resulted in a path to my current position that wasn’t exactly standard, but it has many merits and I wouldn’t change it. And it was NEOMED that gave me my start. What advice would you give NEOMED students, whether they are focused on research, like Julie An, or have not yet considered research? The biggest thing is to keep your mind open. What interests you? What drives you? What motivates you? If it means a change of scenery or location, so be it! At that age, there’s a lot of opportunity and things to capitalize on without other con-

Photos courtesy of the National Institutes of Health Clinical Center

straints. It’s mostly seeking out the right opportunities. There are very few people in my specialty who do multiple fellowships, but they each added significantly to my skill set and enabled me to reach my current position. What’s it like to work at the NIH? When I tell people that I work at the NIH, they don’t realize that we have a 200-bed hospital here on campus, the NIH Clinical Center. The nuance is that every patient we have is on a research study. However, there is no charge to patients for the medical care they receive at the NIH Clinical Center. How could someone try to be seen at the hospital or try to have a family member seen? Our clinical trials are published at clinicaltrials.gov. Alternatively, clinicians and patients can be referred to the Clinical Center’s website, cc.nih.gov/home/clinicalstudies.html, for more information. Many of our patients have failed standard therapies or have no good therapeutic options available to them; thus, a number of our trials focus on novel therapeutics. However, we definitely still provide standard therapies. There are still so many unanswered questions we have in medicine, but this is a great institution with a lot of opportunity where hopefully we can find some of those answers. That way, we can continue to improve the efficacy and safety of treatments for patients everywhere. With the unparalleled resources and multidisciplinary collaboration, the sky truly is the limit.

NORTHEAST OHIO MEDIC AL UNIVERSITY

CLASS NOTES

1983

Serpil Erzurum, M.D., was named the chair of the Lerner Research Institute at the Cleveland Clinic. Dr. Erzurum is the Alfred Lerner Memorial Chair in Innovative Biomedical Research, chair of the Department of Pathobiology and a professor at the Cleveland Clinic Lerner College of Medicine. She has been a member of the Clinic staff since 1993, and is also a practicing pulmonologist and a staff physician in the Respiratory Institute.

1984

Francis (“Frank”) Papay, M.D., has been elected one of a class of 175 National Academy of Inventors (NAI) Fellows for lifetime achievements and leadership in innovation and scientific discovery. Dr. Papay is a professor of surgery at the Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, where he is a researcher.

1985

Duane Taylor, M.D., was honored for his service on the board of directors of the American Academy of Otolaryngology — Head and Neck Surgery, at the Academy’s 120th annual meeting in September in San Diego. He has been the recipient of the Academy’s Honor Award, Distinguished Service Award and Presidential Citation. Dr. Taylor helped to initiate and chair the American Academy of Otolaryngology — Head and Neck Surgery’s Diversity committee and helped establish the Diversity Committee Endowment and the W. Harry Barnes Endowment.

1990

Kathleen Ruffing May, M.D., is serving a five-year term on the American Board of Allergy and Immunology (ABAI). She was also elected vice chair of ABAI for 2017 and will serve as chair in 2018. Dr. Ruffing May will be the first NEOMED graduate to serve as chair of ABAI since its establishment in 1971.

Kim Stearns, M.D., was awarded the 2016 Alumni Association Appreciation Award for taking alumni on the first road trip to Phoenix and Goodyear, Arizona to watch the Indians during Spring Training. Dr. Stearns is the team physician for the Cleveland Indians, and he provided the alumni with pictures, autographs and a tour.

1987

Janice Spalding, M.D., was awarded the 2016 Distinguished Service Award in honor of her commitment to eliminating health disparities in medically underserved populations. Dr. Spalding is a significant contributor in the development of the NEOMED-CSU Partnership for Urban Health at Cleveland State University and the chief architect of NEOMED’s Rural Pathway, now in its second pilot year in Rootstown.

1988

Brian Cain, M.D., has opened his own practice, Brian R. Cain, M.D. and Associates, in Hartville, Ohio.

30 I G N I T I N G

Sergul Erzurum, M.D., and co-founder Karen Hauser established The Sight for All Foundation, a non-profit organization that provides vision care to people unable to afford it. Dr. Erzurum and the NEOMED student group Students for Sight staged a successful event called the Eye Ball of Mahoning Valley to support this foundation. Dr. Erzurum is a practicing ophthalmologist in Youngstown.

T H E PA S S I O N O F P H Y S I C I A N S , P H A R M A C I S T S A N D H E A LT H C A R E R E S E A R C H E R S

Terrence Norchi, M.D., is the cofounder, president and chief executive officer of Arch Therapeutics, Inc. (ARTH). Under Dr. Norchi’s leadership, ARTH is developing devices designed for controlling bleeding and fluid loss during surgery to provide faster and safer surgical and interventional care.

1994

Holly Benjamin, M.D., was named principal investigator for a University of Chicago research group that is participating in a national study of concussion and head impact exposure in NCAA student-athletes. The study is sponsored by the NCAA and the U.S. Department of Defense. Dr. Benjamin is a professor of Pediatrics and Orthopedic Surgery at the University of Chicago and the director of Primary Care Sports Medicine.

1996

Maribe Bangayan, M.D., was elected as chair of the Department of Medicine at Weiss Memorial Hospital in Chicago.

2004

Amina Husain, M.D., joined Premier Eye Surgeons in Oakwood, Ohio. Dr. Husain is trained in cataract surgery, cosmetic facial procedures, oculoplastic and reconstructive surgery.

1998

Michael Sevilla, M.D., was named the medical director of Care4Me Home Health Care. Dr. Sevilla has 15 years of experience as a board-certified family physician at the Family Practice Center of Salem. He is on staff at the Salem Regional Medical Center and serves as an assistant professor of Family and Community Medicine at NEOMED.

Adam Smith, M.D., joined Floyd Valley Healthcare’s new plastic surgery team in October 2016. Dr. Smith is a plastic surgeon with Tri-State Specialists.

2006

Katie Sheridan (formerly Giancola), M.D., and her husband Ben, welcomed their fifth child, a boy named Max, in August 2016. Max joins older brothers Dominic, Xavier and Hunter and older sister Gabriella. Dr. Sheridan is a faculty member for the Aultman Family Medicine Residency in Canton, Ohio.

2011

Thomas Felter, M.D., joined Firelands Physicians Group in Sandusky, Ohio as a pain management physician. Dr. Felter is board-certified in anesthesiology and has completed a residency in anesthesiology and a fellowship in pain management, both at The Ohio State University Wexner Medical Center. Dr. Felter also completed an internship in preliminary medicine at Riverside Methodist Hospital in Columbus, Ohio. He has a special interest in spinal cord stimulators.

2012

Andrew Loudon, M.D., was named the chief surgical resident for the blue trauma team at Orlando Regional Medical Center. Dr. Loudon helped save victims of the shooting at The Pulse nightclub on June 12, 2016.

2002

Summer James, M.D., was named partner at Texas Fertility Center. Dr. James is one of five partners to lead and direct patient care as part of a team of board-certified reproductive endocrinologists. She opened the San Antonio office in 2013 and has been instrumental in the program’s growth and pregnancy rates.

2003

Andrew Schoenfeld, M.D., was awarded the 2016 Distinguished Alumni Award. Dr. Schoenfeld is an assistant professor and director of spinal surgery research in the Department of Orthopedic Surgery at Brigham and Women’s Hospital and Harvard Medical School. He is an army veteran who served in Afghanistan with the 115th Combat Support Hospital, where he earned a bronze star.

LET US HELP CELEBRATE

YOUR MILESTONES! Send your news about jobs, publications, honors and appointments, marriages, babies and more to jparker2@neomed.edu. Alumni Moneal Shah, M.D., (’04), Justin Petrolla, M.D., (’04), Dee Baca-Petrolla, M.D., (’04), Bindu Raveendran, M.D., (’04), George Dimitriou, M.D., (’98) and David Chuirazzi, M.D., (’90) connected at Olive or Twist in downtown Pittsburgh in December.

CLASS NOTES

RECONNECT:

WHERE THE GRASS IS ALWAYS GREENER

2013

Hannah Cross, Pharm.D., has won the Ritzman Pillar of Your Community Award, presented to a Ritzman Pharmacies, Inc. associate who has shown long-standing empathy, devotion and commitment to improving quality of life and bringing about change for the betterment of a community. Dr. Cross is the managing pharmacist at Ritzman Pharmacy on NEOMED’s campus and a clinical assistant professor of pharmacy practice.

Hillary Sismondo, M.D., joined St. Joseph’s Primary Care Center — West in Syracuse, New York. Dr. Sismondo completed a residency in pediatrics at SUNY Upstate Medical University Hospital in Syracuse. She is a member of the American Academy of Pediatrics and is board-certified in pediatric advanced life support through the American Heart Association.

Did you know? NEOMED has nearly 4,000 alumni representing all 50 states plus Canada and the U.S.Virgin Islands. Fellow alumni hail from over 300 universities including Ivies and universities abroad. Alumni practice in 24 different specialty areas and are employed by nearly 200 health care institutions and pharmacies including many of U.S. News’ Best Hospitals of 2015-16.

Reconnect with fellow alumni in:

DUBLIN • WATERFORD • KILLARNEY LIMERICK • KINGSCOURT

2014

Nicole McCorkindale, Pharm. D., and Heather McCorkindale welcomed their daughter, a seven-pound, 20-ounce baby named Kyah Haven McCorkindale, on July 27, 2016.

2016

Kale Divers, Pharm. D., was married to Emily Stewart on September 17, 2016 in Sandusky, Ohio. Dr. Divers is a practicing pharmacist at Meijer Pharmacy. 32

on a

10-DAY TRIP TO IRELAND JULY 17-26, 2017 Contact Craig Eynon | ceynon@neomed.edu | 330.325.6663 Visit gateway.gocollette.com/link/769110

n eomed.edu

RESEARCH AT NEOMED

HALTING A CRISIS: REDUCING TEMPTATION BY ELAINE GUREGIAN

ot long ago, a friend of NEOMED student Taylor Baith went to the ER for a flag football injury to his finger. He came away with a prescription for 30 pain killers and an eye-opening example for Baith, a master of public health degree candidate. “All I could think was that a small finger injury was opening the door to a serious addiction problem,’’ says Baith. “I voiced my concerns, telling him that he would be fine without the prescription and that they had given him way too many pills.’’ Solutions are urgently needed in a region and state that keep breaking records for opioid addiction. CBS News reported on November 6, 2016 that 3,050 Ohioans died from overdoses in 2015, and “Much of the [national] opioid epidemic can be traced to rural Ohio,’’ particularly at the southern border adjoining Kentucky. From there, the epidemic has spread to the urban centers of Akron, Cleveland and other Ohio cities. Part of the problem is that nearly six out of 10 U.S. adults who used opioids had or expected to have leftover medication, according to an article in JAMA Internal Medicine. And they share it: “Nearly 68 percent of those who used prescription pain relievers non-medically in 2012-2013 got them from friends or relatives,’’ according to the 2013 Substance Abuse and Mental Health Services Administration (SAMHSA) National Survey on Drug Use and Health. It’s clear that consumers need a safe way to dispose of extra medications so that they don’t create a gateway to addiction. No one sets out to pollute the ground water by flushing pills down the toilet or putting loose pills in the garbage, either. But what’s a simple alternative? Summit County (Ohio’s) Alcohol, Drug Addiction and Mental Health (ADM) Services Board recently began offering a new way for consumers to safely dispose of extra pills through a small drug deactivation pouch called Deterra. The consumer opens the pouch, places the unwanted pills inside and deactivates them by adding tap water to the chemicals contained inside. The closed pouch can then be thrown away with other household garbage. Northeast Ohio is among a limited num-

ber of communities nationally where Mallinckrodt Pharmaceuticals is making the pouches available at no cost, as a way to combat misuse and abuse. Physicians may request bags from the company, and consumers in the region can obtain them for free at the pharmacies of a local grocery store chain. Evaluating whether the Deterra pouch could help prevent addiction is the focus of Taylor Baith’s capstone project for the master of public health degree. She is completing her study under the supervision of Amy Lee, M.D. (’88), M.P.H., M.B.A., a professor of family and community medicine at NEOMED.

PUTTING MEDICINE AT THE SERVICE OF PUBLIC HEALTH Pursuing the career path of public health appealed to Baith because it teaches a person to look at the bigger picture and treat an entire population. “If one patient comes in with a problem and you treat them and send them on their way, you might not realize that there are others like them who have untreated problems — especially mental health problems,’’ she says. So, after completing the B.S./M.D. program at Youngstown State University, Baith decided to take a year off to do a MPH program (compressing the usual two-year program into one year plus a summer) before beginning her first year as a College of Medicine student at NEOMED in Fall 2017. “With the rising numbers of opiate-related deaths, it is now clear that new methods are the only hope in stopping this epidemic,’’ says Baith. “With so many treatment options already being available to addicts, the ADM Board determined that the best line of defense was to focus on preventing the start of new addictions.’’ Baith hopes that in the fight against opioid addiction, a small disposable pouch will be a powerful tool. An earlier version of this article was published online in The Pulse (thepulse.neomed.edu) as the sixth installment of Halting a Crisis, a NEOMED series about the epidemic of opioid addiction and how the University is training future physicians and pharmacists to help.

NORTHEAST OHIO MEDIC AL UNIVERSITY

WHALE WATCHING

STUDENT ORGANIZATIONS BY DANA GOEHRING

Reducing health disparities and advancing social justice are just two of the goals of the many student organizations on the NEOMED campus.

PHYSICIANS FOR HUMAN RIGHTS (PHR) Imagine going to a dinner where everyone except you was allowed to take as much food as they wanted. Now imagine that same scenario, not as a special event but a daily life struggle.

The NEOMED student chapter of the national Physicians for Human Rights (PHR) organization recently held a hunger banquet to bring this concept to life. At the banquet, each attendee was assigned to a country. To show the difference in the quantity and quality of food available in countries or regions around the world, some attendees (countries) were limited in the amount and variety of food they could serve themselves from the buffet. Seeing the disparities was a revelation. More than 30 students belong to PHR’s NEOMED chapter. To advance the group’s mission of promoting human rights for all, NEOMED members invite speakers to NEOMED and take a medical aid trip to Mexico. Through membership activities, NEOMED students consider ethical issues. They also expand their own knowledge of health disparities through events like the hunger banquet. One day in the not-too-distant future, these physicians will remember to ask if their patients are getting enough nutritious food.

STUDENTS FOR SIGHT

Would you like to help community members who can’t afford vision care? SFS members raise money for eye procedures and services for underserved patients in Northeast Ohio. In partnership with Sight for All, a non-proﬁt foundation co-founded by NEOMED Alumna Sergul Erzurum, members of Students for Sight helped stage a fundraiser, the Eye Ball of the Mahoning Valley.

— Gabrielle Biltz is a senior at Bio-Med Science Academy and an intern in the NEOMED Ofﬁce of Public Relations and Marketing.

NOTIONS

Get ready to ponder with Notions, a group that promotes education, discussion and debate surrounding ethical issues of the past, present and future.

AMERICAN ASSOCIATION OF PHYSICIANS OF INDIAN ORIGIN

Through AAPI, a local chapter of the national organization, students learn about and honor Indian culture as they connect with an Indian community of physicians. The annual research showcase and awards dinner is a highlight.

For more information on student groups, contact Student Affairs at 330.325.6735 or visit neomed.checkimhere.com. 34 I G N I T I N G

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