The Medical Decoder Fall 2014 by The Medical Decoder

MD THE MEDICAL DECODER

Hippocrates, Not Hypocrisy: Practice What You Preach

Establishing A Nexus Between Public Health and Clinical Practice

The Anti-Vaccination Campaign: A Retrospective Look

“May I Have Your Attention?” The Misconceptions Among College Students Surrounding Adderall Use

Produced by Phi Delta Epsilon IL Gamma

Volume 4

IN THIS ISSUE Human Interest

Science & Technology

6 Hippocrates, Not

Hypocrisy: Practice What 25 The Drug Development You Preach Odyssey Nicholas Martin Kevin Zhao

Rutgers University ‘16

9 Early Intervention for

Autism Treatment Sarah Laudon

University of Wisconsin-Madison ‘16

Northwestern University ‘16

32 The Misconceptions Among College Students Surrounding Adderall Use Elbert Mets

Health Care and Policy

Cornell University ‘17

38 The Fusion of Medicine

17 Establishing a Nexus

Between Public Health and Clinical Practice Jane Wang

Northwestern University ‘14

20 The Effects of the Anti-

Vaccination Campaign: A Retrospective Look Danielle Yin

Indiana University ‘15 2 ■ The Medical Decoder ■ Phi Delta Epsilon IL Gamma

and Technology Elizabeth Zborek Northwestern University ‘16

Editors-in-Chief

Aditya Ghosh Sarah Smith

Editing Staff

The Pre-Medical Experience

43 Blood-Injection-Injury

Phobia

Stephanie Lo

Northwestern University ‘15

The Medical School Experience

49 Global Perspectives on

Health: Treat Patients, Not Diseases Paulo Tabera-Tarello

Anisha Arora Brianna Cohen Tricia Cruz Andy Donaldson Jay Mainthia Jenna Stoehr Alec Straughan Jane Wang De’Sean Weber

Creative Director Svetlana Slavin

Designers

Nicholas Giancola Lauren Kandell Carlos Mucharraz Lan Nguyen

Photographers

Jordan Fleming Bryan Huebner Alexis O’Connor

Online PR Director

Cynthia Stamelos

Universidad de Monterrey ‘16

Volume 4 ■ Fall 2014 ■ 3

Dear readers,

LETTER FROM THE EDITORS

Welcome to the fourth edition of The Medical Decoder (MD). As Editors-in-Chief of this rapidly growing publication, we wanted to take the time to reflect upon the whirlwind journey that has culminated in the great success of this journal. The MD was founded just over a year ago by three pre-medical students with a vision and a Microsoft Word document. This vision was a powerful one: to help busy students stay aware of the changes occurring in the fields of medicine and health care and to provide an outlet to share concerns, passions, and experiences. The Word document was less impressive; the first draft employed uninspired fonts and simple Clip Art. As often happens with new ideas, translating our original vision to a reality took time, patience, and hard work. However, the most pleasant realization along this journey was that our vision was a shared one; students were excited to get involved on all fronts, whether through writing, editing, designing, or just spreading the word. Throughout the development of the MD, we have learned that when a diverse group of students shares a vision, they can empower each other to generate a voice that resonates louder than any one could have individually. As students who plan on entering health-related fields, it is important to express ourselves and connect with others who have similar aspirations. Learning more about our fields and keeping up with contemporary medical practices through easyto-read and engaging articles empowers us to “decode” information related to health care. This will allow us to become better leaders and doctors in the future. As the world around us continues to change, it is crucial that we fully understand the fields that we will be entering, continue to share our concerns, and advocate for change when it is necessary. This fourth installment of The Medical Decoder will be the last edition for both of us as Editors-in-Chief. It has been a joy to see how this publication has grown, and we are very excited to see where the next Editors-in-Chief will take the journal. Thank you for your continued interest in our publication. Your support over the past year has been vital to our success, and we greatly appreciate your help in spreading our message. On behalf of Phi Delta Epsilon IL Gamma as well as the rest of the MD team, we would like to welcome you to the fourth edition of The Medical Decoder.

Sincerely, Aditya Ghosh & Sarah Smith

Editors-in-Chief, Co-Founders

(AdityaGhosh2011@u.northwestern.edu, SarahSmith2015@u.northwestern.edu)

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human interest

Human Interest ■ Volume 4 ■ Fall 2014 ■ 5

Hippocrates, Not Hypocrisy: Practice What You Preach By Nicholas Martin

magine this scenario: you are a tain their health, but what happens smoker sitting in the waiting room when physicians fail to heed their of your doctor’s office because you own advice? have been having trouble breathing. Doctors often tell their patients You gaze out the window and notice to lose weight or to quit smoking. your doctor take one final drag be- However, a double standard can fore discarding the ashy remains of lead to strain on the patient-doctor his cigarette. When he comes back relationship and mistrust of future to his office, medical recSome physicians involved you can still ommendawith this initiative could smell the tion.1 Rebenefit from following the smoke on search has his clothes shown that movement themselves. and on his physicians breath. He takes one look at his failing to practice what they preach notes before stating his expert med- can negatively affect patient health.1 ical opinion: you need to quit smok- According to the Center for Dising because it is detrimental to your ease Control (CDC), a shocking 69% health. Health care professionals ad- of adult Americans ages 20 and oldvise patients on how to best main- er are either overweight or obese.2

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These individuals are at risk for de- likely to change medical providers if veloping complications such as dia- their doctor is overweight.5,6 betes, hypertension, arthritis, and When it comes to smoking, phycancer. As part of the Healthy People sicians are much better at practicing 2020 initiative, a platform designed what they preach. Between 1974 and by the federal government to build 1991, smoking prevalence among a healthier nation, a large-scale plan physicians dropped from 18.8% to is being implemented to promote 3.3%. Furthermore, in 2011, 18% health and wellness in Americans of Americans were self-identified within the next few years. The plan as smokers, while only 2% of male includes health care professionals and 1.28% of female physicians working to encourage people to be- smoked.4 Physicians seem to be come physically gaining a greatA double standard active and develer understandcan lead to a strain op healthier lifeing of either on the patientstyles.3 the negative doctor relationship Coinc idenhealth conseand mistrust of tally, some phyquences, or future medical sicians involved the professionrecommendation, which with this initiaal consequenccan further compromise tive could benefit es of smoking. a patient’s health. from following Although the the movement themselves. The CDC number of physician smokers is low, reports that 37% of male physicians patients who are aware that their and 26% of female physicians are physicians smoke are still less likely classified as overweight.4 Further- to heed medical advice.7 more, a study at Yale University Because physicians, as health identified that obese physicians face care professionals, are at the front a stigma of lacking willpower, disci- lines of the battle against smoking, pline, and intelligence in the eyes of it is imperative that they set good extheir patients. The study found that amples for their patients. The Medadults are less likely to trust their scape Physician Lifestyle Report physician’s medical advice and more stated that approximately 25% of

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Human Interest ■ Volume 4 ■ Fall 2014 ■ 7

physicians see around 100 patients per week, and many see thousands of patients annually.4 Therefore, it is imperative that doctors practice what they preach, not only so that patients will heed their medical advice, but also to serve as role models. Physicians, however, are only human. With lengthy shifts and packed schedules, it is understandable why they may occasionally overlook their own health. One of the best examples of this can be seen during a doctor’s residency. Second-year residents can work for up to 28 consecutive hours.9 This workload, along with expensive student loans and a salary averaging at about $50,000, can limit both the time and resources one needs to maintain a healthy lifestyle.10 These factors also contribute to stress. One physiological response to long-term stress is

the release of cortisol, which can lead to excess fat accumulation over extended periods of time.11 This added weight could put a physician at a risk for a slew of chronic diseases, just as it could for his or her patients.1 As we continue moving forward with wellness initiatives in health care, it is necessary that the next generation of doctors is mindful of maintaining healthy lifestyles. There is also an important takeaway for patients: busy work hours, salary, and stress are all contributing factors to why certain physicians may fail to follow healthy behaviors. Like many sensitive issues, the importance of physicians practicing what they preach has two sides. Patients should acknowledge the importance of following their doctors’ recommendations regardless of their doctors’ physical appearance. Additionally, physicians must also recognize the negative impact that their actions can have, and their potential to inspire positive behaviors in their patients by leading healthy lifestyles. ÌMD For references, see page 52.

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Early Intervention for Autism Treatment By Sarah Laudon

utism spectrum disorder (ASD), according to the Centers for Disease Control (CDC), is a group of developmental disabilities that can cause significant social, communicative, and behavioral challenges.1 These challenges can range from difficulty maintaining a conversation or eye contact with somebody to struggling with transitions to new things. Autism contains a wide spec-

trum of symptoms that often comes with co-diagnoses of developmental, psychiatric, neurological, chromosomal and genetic conditions.1 Because ASD covers a vast array of conditions and symptoms, multiple fields including pediatrics, primary care, psychology, and neurology are involved in the treatment of this disease. Therefore, it is all the more important that future health care providers become cognizant of this disorder and its available therapies. Human Interest ■ Volume 4 ■ Fall 2014 ■ 9

Due to better diagnostic tools, diagnosis. Autism centers provide children with ASD are being diag- very direct, individualized services, nosed at a younger age, some as as each child comes with his or her young as 18 months.1 According to own set of symptoms. the CDC’s Autism and Developmen- The Rochester Center for Autal Disabilities tism (RCA) in Because of the Monitoring NetRochester, Minwork, it is estinesota, where I prevalence and mated that 1 in have worked for 68 children have complexity of autism in the past three ASD. 1 Because of children today, autism summers, is a the prevalence and center that praccenters are becoming complexity of autices Applied Bemore common in tism in children tohavioral Analysis day, autism centers (ABA) therapy. America. are becoming more ABA is known common in America, offering both to be an effective treatment for inin-home and center-based therapies dividuals with autism, especially for children and adults with an ASD young children.2 This method aims to reinforce positive and appropriate behaviors, such as focusing on tasks, engaging in social interactions (i.e. eye contact, playing with a friend), and completing academic programs.3 There are many ways to reinforce desired behavior including giving students snacks, letting them play with toys that they were previously engaged with, singing songs or praising them for their great work. Providing the students

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with something that they want increases the likelihood that these behaviors will continue.2 All therapy at the RCA is performed with one therapist and one student paired together during the day. The training process for therapists at the RCA is intensive. Before a therapist and child are paired together, the new therapist must spend several days shadowing an experienced staff member, playing with the child, observing all academic programs and behaviors, and learning the behavior plans. When the new therapist is ready, he or she is observed by a trained therapist and given constructive feedback. An essential component of the pairing

process is for the child to recognize, before he or she is subjected to any demands, that the therapist is a fun person to be with. As the relationship builds between the new therapist and child, the therapist slowly places demands. This creates a positive relationship and sets the child up for success. One of the most important skills the center teaches is how to “mand” items. The term “mand” is commonly used in autism therapy, and it simply means to request. Teaching an autistic child how to request helps develop language and communication skills. American Sign Language or pictures will often be used to ask for items such as a ball, swing, or water. As the student becomes familiar with requesting what he or she wants, the therapist begins to work on developing vocal skills. Many of the students, including one of my own, begin at the center with sign language and later develop vocal skills. Getting a child to mand is not difficult. Before giving a child what he or she wants, the therapist has Human Interest ■ Volume 4 ■ Fall 2014 ■ 11

him or her request it. An example of this is stopping a swing and having the child request “swing” before giving him or her another push. Most of the students at the center require a daily mand track, where therapists write down their mands and prompt levels. Prompt levels vary for the types of manding - vocal, sign language, and pictures. Here are a few types prompt levels: Independent: When the child requests the item all on their own; this can be with pictures, vocalizations, and sign language. Vocal prompt: When a child requires the therapist to tell them vocally to request the item; this can be with pictures, vocalizations, and sign language. Partial physical prompt: Having to assist the child in a sign placement or slightly moving their hand to the desired picture; this can be with sign language and pictures. Full physical prompt: This requires full help from the therapist to select the picture of the item or create the desired sign; this can be with sign language and pictures.

By tracking mands and prompt levels daily, it is easy to see the child’s progress. The therapist records the student’s speech so he or she can monitor the child’s improvement in word clarity. An example would be saying the word “computer” to have the therapist turn it on or play a game. A child might start out saying “puter” and then as time progresses, will begin saying “caputer” and eventually “computer.” There are many different programs at the center, ranging from social to academic. The style of teaching utilized is unique in that it is built into 15 minutes intervals. Programs are designed to be completed in 15 minutes, so that the programming can be broken up into smaller time chunks with breaks in between. In order to monitor the progress of a child, a baseline is established by collecting data on how the child per-

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forms on their first program of the behaviors, it is equally important to day, a test that is referred to as a acknowledge the improvements and “cold probe.” Programs are targeted positive behaviors he or she displays. throughout the day to continually Learning these skills and philosobuild a given skill and observe any phies, working with these children, performance changes. and realizing the prevalence of ASD Academic programs can also today inspired me to pursue a career run off of the table with natural en- where I can continue to work with vironment teaching (NET). The NET autistic patients. training method allows for a vari- With the increasing rates of ation of proautism, it is critical With the increasing that future healthgrams to proceed while the care providers, rates of autism, it is child is movincluding physicritical that future ing around the cians, PAs, and health care providers, nurses, have an center, from counting, sharincluding physicians, understanding of ing with peers, how to best work PAs, and nurses, have with these paimitating a therapist, and an understanding of how tients. Not only kicking a ball. is it important to best work with these Counting and to provide aupatients. social skills, for tistic individuexample, can easials with the rely be taught while a child is playing sources that can help them become on a slide with peers or jumping on a productive member of society, but a trampoline. it is also essential to recognize the The Rochester Center For Au- significant positive impact that intism has taught me to always con- terventions at a young age can have sider the best interest of a child and on a child’s life. to help them achieve their highest level of potential. While it may be necessary to track a child’s negative

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Human Interest ■ Volume 4 ■ Fall 2014 ■ 13

A Typical Schedule at the

n order to portray an average morning for a student at the center, I followed around one of my students, Cheyenne, from 9:00am-noon. Cheyenne is 6 years-old and has been at the center for a couple of years. I was put on her team this summer, and it has been a joy to watch her develop! 9:00-9:05am: Cheyenne checks into the center, just like one would at school. Cheyenne takes her lunch box to the kitchen and puts it in the fridge. 9:05-9:20am: After a morning bathroom break, the therapist begins playing with Cheyenne before running morning programs. These games are fun for Cheyenne! 9:20-9:35am: The cold probe is run and Cheyenne takes part in her first program of the day. 9:40am: Cheyenne requested to use the bathroom and because she asked, she gets her highest reinforcement: the swing! 9:55 am: The therapist runs a morning mand track for Cheyenne, and Cheyenne requests the computer. Cheyenne waits in line. She later requests “Care Bears” and watches a video on YouTube. The therapist pauses the video every 20 seconds or so for Cheyenne to mand for “play” or “computer.” 10:15 am: Cheyenne requests to play in the toy room. 14 ■ The Medical Decoder ■ Phi Delta Epsilon IL Gamma

Rochester Center for Autism 10:30am: After the mand track is over, Cheyenne’s therapist runs a NET program where Cheyenne must follow instructions. This specific program requests that Cheyenne go to two different therapists on her team and complete two actions. Today, the request was to “give Ashley a hug and Sarah a high five.”

10:45am: A table session is run. Because the cold probe is finished, the therapist runs an errorless session. An errorless session consists of the same program as the cold probe, but if the student is about to make an error, the therapist will interject and prompt the correct answer. 11:00am: The therapist gives Cheyenne an option of trampoline or books. Cheyenne chooses books. The therapist waits before turning each page for Cheyenne to mand “turn the page.” 11:20am: Cheyenne requests to go to the ball pit, and then changes her mind to go to the indoor swing instead. When choosing activities, it is important to keep the 80-20 rule in mind- 80% of the activities are the student’s choice, 20% are the therapist’s choice. This is to make sure the student is learning to transition and engage in activities that are not always his or her immediate preference. Again, the therapist at the swing waits to push until Cheyenne mands “swing.” 11:40am: Cheyenne and the therapist return back to the table for another round of errorless. While the therapist is marking down a round of errorless and preparing for the program, Cheyenne reads a story. Noon: Cheyenne heads off to lunch! ÌMD For references, see page 52. Human Interest ■ Volume 4 ■ Fall 2014 ■ 15

health care & policy

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Establishing a Nexus Between Public Health and Clinical Practice By Jane Wang

he relationship between public health and clinical practice is easy to overlook. The former is often associated with an overarching, big-picture approach that addresses issues plaguing populations, while the latter is seen as more individualized and personal. However, despite such distinctions, the two are inextricably linked. This link is often apparent in the treatment of diseases, a primary duty of physicians. While treating illnesses is an important part of maintaining health, well-being stems from a complex web of factors that relate to public health issues, such as access to healthy food, neighborhood safety, exercise, stress, and education.

The mutually dependent nature of the two fields is especially apparent in underserved neighborhoods. For example, neighborhoods of lower socioeconomic status are more likely to be food deserts, areas where it is difficult to purchase nutritious, healthy produce. According to the United States Department of Agriculture (USDA), a neighborhood is officially deemed a food desert if “at least 500 people and/or at least 33% of the census [region’s] population resides more than one mile from a supermarket or large grocery store.”1 Low access to healthy food means that residents of these neighborhoods are more likely to resort to fast food for sustenance, a habit that has adHealth Care & Policy ■ Volume 4 ■ Fall 2014 ■ 17

verse short and long-term effects on ucation can make it more difficult to health. Food deserts can contribute find jobs with adequate salaries. With to an abundance of health issues like insufficient financial resources, it is cardiovascular disease, diabetes, and harder for individuals and families to certain types of cancer.2 afford healthy foods or move out of In addition to accessibility to those unsafe neighborhoods.5 food, another important public health Thus, factors that are often factor that affects overall well-being deemed “public health” issues have a is neighborhood safety. Underserved direct consequence on both individuneighborhoods typically have higher als’ health and the nature of patient crime rates. These high crime rates populations that doctors encounter can a direct threat to one’s physical in their daily practice. well-being , I was able Low access to healthy food and can be to observe the means that residents of r e l a t i o n s h i p an additional barrier to obthese neighborhoods are between pubtaining health lic health and more likely to resort to care. Those private pracfast food for sustenance, tice during who reside in dangerous a habit that has adverse an internship neighborhoods ex p er ience. short and long-term may not feel Throughout safe going outthe spring effects on health. side, limiting quarter of my mobility and exercise.4 Unsafe envi- senior year as an undergraduate sturonments can also place increased dent, I worked at a clinic in the heart levels of stress on its residents. This of South Chicago, an established food stress can lead to a variety of health desert plagued by issues like high issues such as high blood pressure, levels of crime, unemployment, and heart disease, obesity, and diabetes.3 poverty. Patients who came to the Areas of lower socioeconomic clinic often lacked basic resources to status are also more likely to be in- achieve and maintain a healthy lifehabited by people with less access to style. For example, I regularly saw pahigher education. Lower levels of ed- tients who needed assistance locating

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soup kitchens because they did not have sufficient food for themselves and their families on a day-to-day basis. Other patients could not afford transportation to and from doctor appointments; it was not uncommon to see people miss appointments for this reason. To address these issues, the nonprofit organization (NPO) that placed me at this clinic forged a partnership with the physicians there. After the doctors saw patients for their medical needs, volunteers from the NPO would speak to patients to address any non-medical resources they needed, including food and employment. In this way, fundamental necessities that impact health were addressed in addition to the actual illness. To see people from all areas of the health care sphere – physicians, MBA grad-

uates, college students, and social workers – work together to improve the health of patients was humbling. It made me realize that physicians, although immensely important for maintaining health, are ultimately part of a wider web of support for their patients. Health cannot be viewed through a narrow lens that only focuses on the immediate problems presented by a patient. Well-being is impacted by a myriad of factors and circumstances, all of which combine to weave a complete picture of patient health. Choosing to only treat immediate health concerns rather than to address overarching issues allows fundamental problems to go unnoticed. Thus, although the domains of public health and clinical practice are often viewed as separate spheres, it is imperative that a nexus between the two be established in order to address issues that impact both individuals and populations. ÌMD For references, see pages 52-53.

Health Care & Policy ■ Volume 4 ■ Fall 2014 ■ 19

The Effects of the Anti-Vaccination Campaign:

A Retrospective Look By Danielle Yin

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never enjoyed receiving shots at the doctor’s office. Although I can handle that painful prick of the needle without causing a scene, I cannot help but feel a momentary spark of anger at my parents and my doctors whenever I have to endure that uncomfortable experience. Still, my dislike for receiving vaccinations is outweighed by my appreciation for what they have done for society, as they have virtually eliminated many preventable diseases. However, not everyone shares my appreciative sentiment. The recent uprising of anti-vaccination campaigns has alarmed physicians across the United States and the United Kingdom. As the facts regarding the harmful effects of these campaigns emerge, it is essential to educate ourselves on the origins of these movements and on the importance of public vaccination. Health Care & Policy ■ Volume 4 ■ Fall 2014 ■ 21

While skeptics who oppose vacci- miological studies failed to find a casual nations have always existed, our gener- relation between the MMR vaccine and ation has bore witness to an anti-vacci- autism.1 Unfortunately, this false infornation campaign that could have lasting mation had already taken its toll. Many consequences. The start of the modern parents took Wakefield’s research as fact, movement can be attributed to Dr. An- and soon the anti-vaccination campaign drew Wakefield, a British surgeon and of the 21st century began to spread. Ceresearcher. In 1998, Wakefield published lebrity activists like Jenny McCarthy an article in The Lancet that claimed that supported the claim that vaccines could the MMR (measles, mumps, and rubella) cause autism, ushering the anti-vacvaccine could cination campaign cause autism into the public eye. The harmful effects spectrum disorMcCarthy used her of anti-vaccination ders and bowel son as an example campaigns have problems.1 He of the dangers vacinsisted that the cinations pose to manifested in the rising vaccine led to auchildren. She pasrates of preventable tism symptoms sionately claimed in eight of the that one of her illness. From 2011 twelve children son’s vaccinations to 2012 in the US, that he studied, consisted of thiand he concluded merosal, a merwhooping cough cases that the vaccinacury-containing increased more than tion program was compound prenot safe. Wakeviously used as threefold in 21 states.6 field’s assertions a preservative in raised controversy in the UK, leading to vaccines. She argued thimerosal caused a sharp decline in the country’s vacci- her son to develop autism. Despite the nation rate. Overall immunization rates lack of a reputable scientific connection dropped to 84% in 2002, an 8% decrease between thimerosal and autism, many from the national immunization rate be- anti-vaccine parents protested its use in fore the publication of Wakefield’s arti- commonly administered shots. As a precle. In London, rates of vaccination for cautionary measure, all childhood vacMMR hit an unsettling low of 61% in cines, with the exception of some flu vac2003.1 cines, are now created without the use of Wakefield’s research was soon thimerosal.2 proven to be false, as subsequent epide- Anti-vaccine parents have chosen

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to evade the vaccination requirements set by many schools, citing personal or religious reasons. Despite evidence supporting the effectiveness of vaccines, many parents also doubt the effectiveness of vaccines, calling into question whether or not these immunizations actually prevent the diseases they claim to. Studies have found that the chance of outbreaks of diseases such as pertussis, commonly known as whooping cough, is 2.5 times greater in areas that permit personal-belief exemptions.3 The decline in vaccination rates has also caused an increase in mumps cases. In early 2005, almost 5,000 cases of mumps were reported, a dramatic increase compared to the few cases that were present in the late 1990s.4 While some parents claim that it is their right to choose whether or not their children get vaccinated, they fail to comprehend the nature of how infectious diseases are spread. By sending their unvaccinated children into the general population, parents damage the concept of herd immunity. In order to protect those who cannot be vaccinated for reasons such as pregnancy, age, or health, 95% of the population must be immunized.5 When this percentage falls, previously avoidable diseases like polio or measles can re-emerge. This has already been seen in California, where only 91% of kindergarteners were vaccinated in 2010. These lower vaccination rates played a major role in a massive pertussis outbreak.5 The harmful effects of anti-vacci-

nation campaigns have manifested in the rising rates of preventable illness. From 2011 to 2012 in the US, whooping cough cases increased more than threefold in 21 states.6 Looking forward, easily preventable diseases may re-emerge, causing unnecessary danger to both patients and the health care system. It may be time to make changes to the way doctors approach the topic of vaccines with their patients. Instead of waiting until the typical two-month checkup, a pediatrician can address the subject during pregnancy so expecting parents can have time to do research and make an informed decision regarding vaccinations. To emphasize the necessity of vaccination, doctors should share facts as well. For example, recent studies involving children in Colorado showed that unvaccinated children were nine times more likely to contract chicken pox and six times more likely to end up hospitalized with pneumonia.7 Parents need to be reassured of the quality of testing utilized in vaccine safety studies, a system that operates independently from the pharmaceutical companies that manufacture them.7 As the next leaders in health care, it is our responsibility to educate future parents in order to prevent the anti-vaccination trend from causing lasting harm. ÌMD For references, see page 53.

Health Care & Policy ■ Volume 4 ■ Fall 2014 ■ 23

science & technology

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The Drug Discovery Odyssey A Glimpse Into Pharmaceutical Academic Drug Development

and

By Kevin Zhao

Endorsed by Professor Richard B. Silverman

enicillin. Ibuprofen. Aspirin. These are just a few examples of drugs that have benefited our society. It is incredible how far drug discovery has come; we can manipulate biology and use organic molecules as vehicles to treat and cure various diseases. With these advancements, we can selectively target various symptoms and extend the average lifespan. While these treatments have greatly contributed to society, they also are tremendously costly to develop and produce. This applies not only to consumers who purchase these drugs,

but also to the researchers and pharmaceutical companies that spend years trying to develop effective medications. The process of discovering and developing pharmaceuticals is extremely complex. It encompasses fundamental understandings of human biology to recognize how the body’s functions can be modified, utilizes organic chemistry to seek a man-made

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cure, and requires biochemistry to times, this involves making minute develop the various properties and structural adjustments, like changing mechanisms of a drug. Drug discov- a fluorine atom to a bromine atom. ery begins by first utilizing a biologi- Next, the chemists send the comcal model that reflects the properties pounds back to the biologists who of the disease or condition of interest. run another assay to see if the new Then, the model’s activity is probed chemical has any effect. This is one with various chemicals from a large of the most time-consuming steps in chemical library. This enormous ar- the entire drug development process ray of compounds is selectively fun- because of the many possible changes neled throughout the development that can be made. Sometimes, a single process to an end product of one carbon can be the difference between FDA-approved drug. One of the most a toxin and a cure. common mod Advancements Each stage brings a new els used in this in technology have method is a celhad major imlayer of complexity, lular-based drug progressing from a single pacts on drug disassay, in which covery. Chemists cell model, to an animal, often use comcells that mimic and eventually to a the main condiputerized modeltions of certain ing programs to human being. diseases are culpredetermine tured and run through a large chemi- how certain structural changes may cal assay. affect a compound’s activity. Howev After running this chemical test, er, many properties of the targeted scientists are able to select a few com- protein or enzyme must be known pounds that show potential in treat- to perform such a study. If the necesing the disease. These compounds are sary data are available, the program the ones that appear to reduce symp- is able to visually plot the protein and toms of disease in the biological mod- fit various chemical shapes into a tarel. The compounds are then sent to geted pocket. This will predict chemthe organic and medicinal chemists ical interactions with the protein. who modify the compounds’ chemi- Although this technology has been cal structures in various ways. Many extremely helpful for researchers, it is

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still developing. Sometimes, the program may predict activity, while in reality the chemical is inactive. The program might also fail to predict certain chemicals that could effectively treat a disease. Even with this technology, hundreds of chemicals still need to be synthesized before finding the one that has the desired activity in a biological model. When a drug has shown promise, it is tested in animal studies to further examine the properties of the compound. One important step towards achieving a better understanding of the compound’s characteristics is determining the pharmacokinetics of the drug, which means determining what happens to the drug once it enters an animal’s body. To comprehend the pathways a drug follows, researchers must investigate its absorption rate into the bloodstream, distribution to the various tissues, degradation, and elimination from the body. It is also important to note that even if the drug shows activity in the initial biological model, this does not guarantee that the compound will show activity in the animal model.

Each stage brings a new layer of complexity, progressing from a single cell model, to an animal, and eventually to a human being. If the drug is successful in the animal models and is shown to be nontoxic, it is then moved on to clinical trials. From the hundreds of thousands of chemicals in the initial chemical library, only a handful of compounds actually enter this stage. However, many do not make it through the clinical trial. With each phase, the number of patients tested increases, and the drug has to pass more rigorous tests. While drugs may have shown promising results in the animal studies, they may fail to produce similar results in human trials. For example, some drugs have ap-

Science & Technology ■ Volume 4 ■ Fall 2014 ■ 27

peared to “cure” diseases such as ALS in animals, but fail to have the same effect in clinical trials. The process of drug discovery can be long and tedious, with countless obstacles prior to introduction into the market. Unsurprisingly, such a process requires a great deal of money to fund the work and time it entails. A recent Forbes study has shown that larger pharmaceutical companies spend up to $6.3 billion

per drug, while smaller companies spend up to $2.8 billion.2 Due to the extremely high cost in researching and developing medicine, most of the research is performed industrially, as opposed to in an academic environment. Large pharmaceutical companies such as Johnson & Johnson and Pfizer, Inc. dominate this industry, as they possess the money to fund this type of research.

Developing LyricaTM: Silverman Strikes Gold Success stories in the realm of academic drug development do exist. Dr. Richard B. Silverman’s discovery of LyricaTM, also known as pregabalin, serves as an example of academic drug research that made the leap into industry. Silverman’s path to successful drug discovery highlights the time, effort, and potential payoff of academic drug research. Silverman joined the chemistry department at Northwestern University in 1976 and began researching various small molecules that affect the level of gamma-aminobutyric acid (GABA) in the body. It has been shown that “when GABA levels fall too low in some people, it can trigger epileptic seizures.”3 Therefore, Silverman’s lab developed various compounds to increase GABA production in the body. However, the drug that brought acclaim to Silverman and his research did not actually alter GABA levels. In fact, the discovery of LyricaTM was a surprising one. According to The Chicago Tribune, “Silverman’s experience suggests finding a chemical that turns into a billion-dollar drug takes as much luck as winning the lottery.”4 While it did not affect

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GABA levels as was initially hypothesized, LyricaTM still showed incredible efficacy in the treatment of epileptic seizures as well as other illnesses, such as neuropathic pain and fibromyalgia. In November 1990, Silverman applied for a patent, which was not approved until March 2001. When Silverman first noticed a few compounds that showed great results in affecting GABA levels, he began to look for companies that would be interested in partnering with him to continue the study of these chemicals. Two companies demonstrated interest in this study: Upjohn Pharmaceuticals and Parke-Davis Pharmaceuticals.6 Upjohn only asked Silverman for the compound with best activity, whereas Parke-Davis asked for all of the compounds. The drug initially thought to be the best candidate was not effective when studied further. However, one of the compounds in the library of chemicals sent to Parke-Davis showed high potential. Though Dr. Richard Silverman of Northwestern University its official mechanism of action was not yet fully understood, the performance of the compound proved to be so convincing that Parke-Davis and Northwestern proceeded to sign a patent option agreement in December 1991. Over the next six months, Parke-Davis used the compound to perform many animal studies such as pharmacokinetics and metabolism experiments. Afterwards, another two years were spent on studying an-

Science & Technology ■ Volume 4 ■ Fall 2014 ■ 29

imal toxicology and on synthesizing a specific enantiomer. In December 1995, Parke-Davis filed an investigational new drug application, which allows for clinical studies on a compound before approval by the US Food and Drug Administration (FDA). Phase I of clinical trials started in late 1995 and lasted for two and a half years. A combined Phase II/III trial was then performed from 1999-2003, which involved 100 different clinical trials and tested over 10,000 patients. In 2000, Pfizer bought Warner-Lambert, which had acquired Parke-Davis in 1970, so Pfizer continued studies on the compound. It was also around this time that the compound started being referred to as “LyricaTM”. When PfizThe Richard and Barbara Silverman Hall for Molecular er took control of Therapeutics and Diagnostics at Northwestern University. the research, they pushed aside Silverman, the initial inventor. As Silverman said, “I became an outsider... There was no longer the possibility to talk with their scientists. No comments. They had a launch party for the drug, and I asked to come. Nope. No party for me. They take your stuff and tell you to go away.”4 This is where academic and industrial research part paths and utilize different ideologies. Large pharmaceutical industries are able to research new

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medications as long as they have exclusive profit rights, which requires secrecy about what they are doing. In academia, innovative science, which includes collaboration and publication, is the principal driving force. After continuous success, Pfizer filed a New Drug Application in October 2003 to request approval for LyricaTM to become a commercial product. This was approved by the FDA in 2004. In 2006, during the drug’s first full year on the market, LyricaTM had $1.2 billion in global sales. The next year, Northwestern sold a sizable amount of the royalty interest of LyricaTM to Royalty Pharma for $700 million. With this, Silverman donated part of his royalties to Northwestern to help build a new building for molecular therapeutics and diagnostics. His goals were to broaden the research environment and continue to bring great professors from around the world to the university. Although Silverman hit a scientific jackpot, he continues to perform outstanding research on drug development and hopes to help find treatments for various neurodegenerative diseases such as Parkinson’s, ALS, and Huntington’s. In a competitive research environment dominated by major pharmaceutical companies, Silverman’s development of LyricaTM serves as a source of inspiration to other academic drug researchers. While few drugs go on to become blockbuster drugs like LyricaTM, advancements in technology and a greater understanding of the human body offer promising developments. Drug development, whether academic or industrial, offers hope for the future of medicine to cure disease and even extend longevity. With creativity, imagination, hard work, diligence, and perhaps a little luck, major drug discoveries can be made in an academic setting. ÌMD For references, see page 53.

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“May I Have Your The Misconceptions Among College Students Surrounding Adderall Use

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Attention?” By Elbert Mets

Photo courtesy of flickr.com/sterlic Science & Technology ■ Volume 4 ■ Fall 2014 ■ 33

“F

inally! Schoolwork that matches from 2003 to 2011.1 By 2011, at least 6.4 his intelligence,” reads the tagline million, or 11%, of American children in to an advertisement for Adderall, fea- this age group had been diagnosed with turing a young, smiling boy in the back- ADHD.2 ground. Another ad reads, “In the man- The prevalence of ADHD treatment agement of ADHD, reveal his potential. has mirrored the rising rate of diagnoAdderall XR® improves academic per- sis, with 60% of diagnosed children reformance.” Pharmaceutical companies ceiving treatment.4 The disorder is typand popular media often characterize ically treated using stimulants such as Attention Deficit Hyperactivity Disorder Adderall (amphetamine-dextroamphet(ADHD) medications such as Adderall amine), Ritalin (methylphenidate), and as wonder drugs that can supercharge Dexedrine (dextroamphetamine).5 A patients’ academcontrolled trial comDespite the ic and social lives. paring stimulant Because these consequences of the medication, comdrugs can enhance munity care, behavillegal distribution and performance in ioral therapy, and ADHD patients, combined medipossession of these many people, escation-behavioral drugs, students report pecially college stutherapy revealed dents, incorrectly that stimulant that prescription assume that these medication was stimulants are readily drugs should work in a very effective undiagnosed individmethod in mitavailable on college uals too. It is importigating ADHD campuses. ant for students to s y m p t o m s . 4,6,7 gain awareness of the misconceptions However, it was also observed that comsurrounding the use and abuse of these bining stimulant medication with medidrugs in order to avoid health and legal cation-behavioral therapy resulted in an risks. even stronger social and behavioral im In recent years, the rate of ADHD provement compared to the medication diagnosis has risen sharply.1,2 ADHD, a alone.7 Despite these observed benefits, condition marked by inattention, hyper- pharmaceutical companies have largeactivity, and impulsive behavior, often ly disregarded the study’s results, marappears during childhood and can con- keting medication alone as the superior tinue into adulthood.1,2,3,4 In the US, the ADHD treatment.8 rate of ADHD diagnosis in children ages 4 ADHD symptoms are thought to to 17 has seen more than a 40% increase result, in part, from a shortage of dopa-

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mine, a neurotransmitter important in the nervous system’s pathways responsible for producing feelings of satisfaction and fulfillment.4,9 This shortage in ADHD patients is caused by a high density of active transporters that remove dopamine from the brain. Prescription stimulants raise dopamine levels in the brain by in-

hibiting the ability of the transporter to remove the dopamine, thus improving focus in ADHD patients.4,10 Unfortunately, these medications, touted to bolster concentration, are frequently abused by nonprescription users. Improper use of ADHD medications, like Adderall, is especially observed among college students. Misuse of prescription stimulants on college campuses is a major concern.4 Abuse rates range across colleges; 6.9 to 34% of undergraduate students report illicit use of prescription stimulants during their lifetimes.5,12,13 Frequently cited reasons for stimulant misuse include improving concentration and alertness when studying and attaining a “high” akin to that of cocaine.4,13 Despite widespread use in universities, many illicit users of prescription stimulants are unaware of the effects of these drugs.11 Students who use stimulants often rely on friends’ testimonials rather than medical literature in their assessments of the drug’s risks.11 Furthermore, the prescription of these medications for ADHD patients by doctors can lead people to falsely believe these drugs are safe for anyone to consume.11 The United States Drug Enforcement Agency rates medications and recreational drugs on a scale of Schedules Science & Technology ■ Volume 4 ■ Fall 2014 ■ 35

from 1-5. Schedule 1 drugs (e.g. hero- benefits. A survey of 689 undergraduates in, LSD) have the highest potential for from the University of Michigan revealed abuse and no accepted medical use, while that 58% of stimulant misusers do so to Schedule 5 drugs have defined medicinal enhance concentration, 43% to increase purposes and lower potential for abuse.14 alertness, and 43% abuse the drugs to Despite the drugs’ benign portrayal, the achieve a stimulant-induced “high.”13 Drug Enforcement Agency classifies A Brigham Young University examinaprescription stimulants as Schedule 2, tion of tweets mentioning Adderall use grouping them with the likes of cocaine showed an increase in stimulant-related and methamphetamine.14 This classifica- tweets during December and May – coltion underscores the fact that stimulants lege final exam periods.16 have a “high potential for abuse” and can Among college students, prescriplead to “severe psychological or physical tion stimulant misuse differs across dedependence.”14 Additionally, the penalty mographic groups. It is highest among for distribution or possession of these Caucasian fraternity and sorority memmedications without prescriptions can bers who are struggling academically and be up to twenty years of imprisonment attend selective colleges in the northeastand up to one million ern United States.12 The effects of dollars in fines.15 In Students who abuse practice, a conviction stimulants are also Adderall on the heart for small-scale distrimore likely to abuse are similar to those bution or possession drugs and alco12 of these stimulants hol. of cocaine. would likely be less se Although popular vere, though such a conviction can still culture often portrays ADHD medicabe damaging to aspiring professionals. tion as harmless, prescription stimulant Despite the consequences of the misuse can have significant health conillegal distribution and possession of sequences. Side effects include seizures, these drugs, students report that pre- heart problems, and trouble sleeping.4,11 scription stimulants are readily available Additionally, the effects of Adderall on on college campuses.11 Surveys indicate the heart are similar to those of cocaine.17 that over 20% of undergraduates with Both drugs can injure the endothelium, prescriptions for stimulants have sold the inner lining of the blood vessels, and them to their peers, and more than 50% in combination with several other harmof these students have been asked to do ful effects, can cause heart attacks.17 In so.4,12 addition, alcohol consumption coupled Students use prescription stimu- with Adderall use can further increase lants largely for their perceived academic students’ risk for heart attacks.4,17 The

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Brigham Young University study also found that the most frequently reported adverse effects of Adderall use on students were sleep deprivation and loss of appetite.16 Nonprescription consumption of stimulants for academic advancement is also of questionable integrity. For this reason, the use of stimulants to heighten performance in academic settings is now seen as being comparable to the use of anabolic steroids in professional sports.11 In line with this thinking, Duke University recently listed “the unauthorized use of prescription medication to enhance academic performance” under “cheating” in its classification of academic dishonesty.4,18,19 This ban could reduce the incidence of these medications’ misuse and in turn limit the frequency of negative side effects. So, does using stimulant medication without an ADHD diagnosis really improve academic performance? The short answer is no. The majority of studies exploring stimulant use by nonADHD patients have shown little to no performance gains. Recently published research has demonstrated that stimulants are effective primarily in patients with ADHD and serve to bring patients back to “baseline” rather than bolster already normal performance.4 Additionally, studies have shown that there is a placebo effect among nonprescription users of Adderall. According to a 2011 study published in Experimental & Clin-

ical Pharmacology, certain students became more attentive after receiving a placebo, because they believed they were being given stimulants.4 However, a lot remains unknown about the effects of stimulants in nonADHD patients, largely due to the fact that stimulant abuse for the sake of enhancement has been stigmatized in medical circles.20 There seems to be a common misconception between concentration and performance; while stimulants may increase alertness or concentration, experiments have failed to show a clear correlation to increased performance. Furthermore, the dangers incurred by stimulant abuse seem to far outweigh possible benefits. While possible gains from drug abuse remain hazy, the risks, both medical and legal, are real. Ultimately, the nonprescription use of ADHD stimulants such as Adderall is not effective in improving academic performance in individuals without the disorder. Misusing these medications exposes students to medical and legal risks with minimal benefit. It is important that students gain insight into the misinformation that circulate on college campuses regarding the use of ADHD stimulants in order to protect their health, avoid potential legal problems, and maintain academic integrity. ÌMD For references, see pages 53-54.

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The Fusion of Medicine and Technology What can we envision for the Future of Health Care? By Elizabeth Zborek

he past decade has seen a rise in the use of electronic health records (EHR), electronic referrals to specialists, and e-prescriptions to pharmacies. This transition towards a more electronically-focused approach to health care demonstrates the growing influence of health information technology (HIT). HIT encompasses any technological advancement that is employed to collect, store, analyze, and share health information.1 HIT has manifested through many technological innovations, such as the digitalization of medical diagnostics and the advent of mobile health applications. The HIT era emerged as a means to address the issues of health care costs, medical errors, and the disconnect between health care providers.2 Its growth can be traced to the 1960s when the Medicaid and Medicare programs were enacted, and the need for an organized

billing process was met with mainframe computers and centralized processing.3 Smaller and more affordable microcomputers (PCs) emerged in the 1980s, and became increasingly used for clinical information systems and for maintaining billing information.3 The 1990s saw the dawn of the Internet, and health care workers took advantage of it as a potential form of communication between providers.3 More recently, The American Recovery and Reinvestment Act and The Health Information Technology for Economic and Clinical Health Act (HITECH) of 2009 introduced financial incentives for professionals who demonstrated proficiency in a certified EHR program.5 These incentives were offered in hopes of achieving improvements in care delivery, enabling patients to be engaged in the health care process, and helping providers avoid preventable medical er-

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rors.9 Consequently, many clinics and era will likely entail the widespread imhospitals have made the transition from plementation of health care apps. paper health records to electronic health New health care apps are being derecords. The transition can be laborious, signed to help physicians provide better but once health care workers learn how care and increase patients’ involvement to operate the EHR systems, they can in the health care process. Such apps inappreciate the benefits that moderniz- clude iTriage, HealthTap, Doctor on Deing offers. mand, palmEM, and InQuicker. The iTri Moreover, the implementation of age, HealthTap, and Doctor on Demand electronic health records directly bene- apps connect patients with information fits patients in addition to providers by about local doctors and clinics, while assisting patients with their own health also providing patients with more informanagement. Patient portals, secure on- mation about their symptoms. Doctors line websites and residents can The HIT era emerged as a that allow paemploy palmEM tients to acmeans to address the issues as a quick refercess their perence for clinical of health care costs, medical sonal health decision makerrors, and the disconnect records, have ing; InQuicker become comhelps patients between health care monplace. and doctors providers. These portals save time in the provide patients with more control and emergency room by allowing those a better understanding of the health with non-life threatening illnesses to care process overall by allowing them to check into the emergency room from manage their appointments and medi- their homes. Although these apps have cations all in one place. Most important- already improved the care patients rely, these sites improve patients’ health ceive, there are still opportunities for literacy by providing them with more further development. information about their diagnoses and The HIT era has also led to the cretreatments. ation of the telemedicine industry. Tele The transition to EHR programs is medicine is the utilization of telecomreflective of a larger shift towards tech- munications technology such as email, nology in the field of medicine. More Skype, and smartphones to assist in imcreative and accessible ways to improve proving a patient’s health.7 A combinapatient health are constantly being in- tion of health information technology vented, and the next phase of the HIT and electronic communications, tele-

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medicine is increasing health care cover- can attempt to access personal health age in underserved areas. For example, information.11 While these issues must the residents of the Chakrajmal village be addressed, the potential that health in India were able to consult with a doc- information technologies have to revtor via telecommunications technology olutionize and improve the health care in 2008.6 system will very likely outweigh these Telemedicine is already being em- costs. ployed to transmit diagnostic images Health information technology has amongst providers, share medical data greatly influenced health care during its between providers and patients, moni- short existence, and new ways to utilize tor patient vital signs from various lo- it are constantly being invented. The US cations, and educate patients remotely.4 electronic medical record market alone As of now, most of these transmissions is predicted to grow from $2.177 bilare taking place via computer, but in the lion in 2009 to $6.054 billion in 2015, future, we will illustrating the see them ocrising demand The transition to EHR cur via apps on for health inprograms is reflective mobile devices, formation thus streamlintechnoloof a larger shift towards ing the patient gy.8 Though and provider technological advancement there will alcommunication ways be an in the field of medicine. process.6 adjustment Despite all period when of the potential benefits of fusing med- new technologies are being standardicine with technology, there are also ized, advanced health information techdrawbacks. As observed with EHRs, nologies can increase both quality and adoption implementation and mainte- efficiency of health care. With this imnance costs exist.10 Furthermore, fail- mense potential comes a responsibility ure to learn how to correctly utilize the for the next generation of health care technologies can lead to interrupted professionals to invent, implement, and workflow, reduced productivity, and in- utilize technology in ways that improve creased medical errors.10 Another op- patient experience. posing argument to health information technology is the risk for patient privacy violations.10 Technology users face sophisticated malware and hackers, who

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Recently Developed Apps

iTriage

iTriage helps patients narrow down the cause of their symptoms, identify local providers, clinics, and hospitals, and stay up to-date-with latest health news.

HealthTap

This app helps doctors and clinics attract and educate new patients while improving the quality of health information online. Additionally, it connects patients with doctors to give them the best health information.

palmEM

palmEM covers hundreds of the most commonly encountered conditions in emergency medicine. The app contains quick medication references and helps doctors with clinical decision- making. Many similar apps have appeared on the market, in order to help physicians and residents quickly and efficiently give a patient a diagnosis.

InQuicker

Not exactly a typical mobile app, InQuicker is a site that can be used on all mobile devices, much like Patient Portal. It reduces the time that hospital personnel spend on data input by allowing patients with non-life threatening illnesses to check into the emergency room from home. Patients can wait at home instead of a crowded waiting room until they are called in to be seen by a health care provider.

Doctor on Demand

Patients utilize this app in order to get in contact with board-certified doctors for non-emergency medical purposes. They pay a $40 fee for each video visit, and doctors are able to diagnose patients and prescribe medications when clinically appropriate. ÌMD For references, see page 55.

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the

: experience pre-medical

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: a i b o h P y r u j n I n o i t c e j n I d o o l r B o r o r r e T e l b a l i a s s a n U ? n r e c n o C e l b a t Tre a

By Stephanie Lo

research participant enters a room and takes a seat in a reclined chair. She gazes nervously at the computer screen in front of her. She is about to begin a standard, decades-old procedure for ameliorating fears associated with blood, injection, and injury, referred to as BII phobia. The researcher displays photos on the computer screen for the participant. These images begin with a photo of a syringe and progress towards more fear-inducing images, such as pictures of open wounds and surgical procedures. After viewing each photo, the research participant is asked to rate her level of distress and to describe her physiological symptoms. Her palms be-

gin to sweat when staring at the photo of the syringe, she averts her gaze when viewing the open wound, and she feels dizzy and faint when presented with the photo of a scalpel slicing through bloody tissue. This participant was part of a psychology research study conducted at Northwestern University by Ph.D. candidate Nehjla Mashal in order to observe the effects of BII phobia.1 According to the DSM-IV-TR, a manual that health professionals use to classify mental diseases, BII phobia is an anxiety disorder characterized by a marked and persistent fear induced by the presence or anticipation of blood, injuries, wounds,

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or receiving an injection.2 Although the person recognizes that the fear is excessive or unreasonable, the individual attempts to avoid situations that will instigate this phobia. If unavoidable, he or she endures the phobic stimulus with intense anxiety or distress.2 About 4% of the population in the US has the BII phobia.3 Unlike other disorders and phobias, which simply result in high levels of anxiety, the BII phobia can actually induce fainting. When confronted with the feared stimuli, a person with this condition usually undergoes a two-phase reaction. In the first phase, the person experiences the sympathetic fight-or-flight response, which is typical in most anxiety disorders and phobias. This response is accompanied by an increase in blood pressure and heart rate. The second phase is unique to BII phobia and consists of a rapid fall in heart rate and a rapid decrease in blood pressure that causes a reduction in blood flow to

the brain.3 This second phase produces the symptoms that can lead to fainting. Slightly more than 50% of people with needle phobias and 70% of people with blood phobias have a history of fainting during an injection or during exposure to blood, respectively.4 Although the BII phobia includes fear of blood, injury, and receiving an injection, the specific triggers depend on the person. Additionally, studies have shown that not all patients with BII phobia have identical physiological responses.3 According to Mashal, those with BII phobia “come to associate stimuli, like needles and blood, with that unpleasant physiological response, which potentiates the phobia.”1 Although the phobia may not immediately interfere with one’s life, suffering from BII can create substantial problems for individuals as they get older. “One of the motivations for people to get help is that it’s getting in the way of getting medical care. It may not be a big deal in your twenties, but it’s a big deal when you get older and need more regular tests,” Mashal explained.1 In addi-

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tion to causing the avoidance of regular fessor at Southern Methodist Univercheck-ups and important surgeries, BII sity, conducts research on the psychophobia may also cause people to avoid physiology behind and the autonomic pursuing health-related professions. It nervous system response to BII phobia. is therefore crucial to understand this Ritz says he encountered difficulties phobia and discover ways to overcome in recruiting participants for the studit, whether you are a student pursuing a ies because people who have the phohealth care-related career, a person try- bia attempt to avoid the feared stimuli.7 ing to avoid injections and surgeries, or “Many people have the phobia but don’t a physician treating patients who have see it as something they need treatment BII phobia. for,” said Ritz. “They will avoid it at all For students who fear blood but costs, but sometimes the cost is so high still want that it would The BII phobia is an anxiety benefit them to pursue a health-related disorder characterized by a to seek treatcareer, Northment.”7 Peomarked and persistent fear western Uniple with the induced by the presence versity Health phobia often Professions encounter or anticipation of blood, Adviser Nancy intense anxinjuries, wounds, or Tapko emphaiety from 2 receiving an injection. sizes the importhe antictance of clinical ipation of experience and exposure. Tapko advises the feared stimuli in addition to the sitstudents who are afraid of blood but are uation itself. “Patients are relatively disconsidering the pre-health track to “talk tressed after fainting,” Ritz said. “After to health care professionals and volun- the psychology study, we need to deteer in the field. Different health profes- brief them and help them find follow-up sions will have different levels of [expo- treatments.”7 sure to] blood and bodily fluids. A lot of According to Mashal, the most times exposure to something helps you well-known treatment for BII phobia get over your fears of it.”6 Additionally, is the “applied tension” technique comthese students can work with psycholo- bined with exposure to the feared situgists who have experience with treating ations and stimuli.1 The applied tension anxiety disorders.6 technique consists of the patient tensing Dr. Thomas Ritz, a psychology pro- up the muscles of their arms, legs and

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trunk when encountering the feared are exposed to the feared stimuli. “The stimuli.5 Next, the patient releases the applied tension technique would not tension slowly, which elevates and then really help against hyperventilation,” he maintains elevated blood pressure to explained. “Hyperventilation is probcounteract the slow heart rate and low lematic for this patient group because it blood pressure that lead to fainting. constricts the cerebral blood vessels so Mashal said that this specific tensing the blood flow to [the] brain is reduced. and releasing technique can impede the It makes patients dizzy and could consecondary response of BII phobia and tribute to their fainting, so we have tried prevent the person from fainting.1 to evaluate an intervention based on Although research has focused reducing the hyperventilation.”7 While on the applied tension technique, Ritz respiration-focused techniques seem to points out that it be promising alAwareness about the might not be efternatives to the implications of BII phobia fective for all paapplied tension tients. Because is important for individuals technique, Ritz researchers do ack now le dges with the phobia who fear not understand that large clinmedical treatments and for ical trials have its precise mechanism, it is difficult physicians seeking to help not been conto know exactly ducted to study their patients overcome this when the applied their effectivephobia. tension technique ness.7 will work. Addi There is tionally, this technique is not effective also a cognitive facet that must be adfor all aspects of BII phobia. Other treat- dressed to help those who suffer from ments, including respiration-focused BII phobia. An important component techniques, are currently being studied of treatment for BII phobia is exposure to help people who suffer from various to the feared stimulus, Mashal claimed. permutations of the phobia. With enough exposure, people can be Respiration-focused techniques gin counteracting their intense anxiety. aim to counteract hyperventilation by “Repetition is key,” said Mashal, “and slowing breaths rather than breathing you increase the intensity in exposure deeply.3 Ritz claims that these tech- so that people stick with the treatment. niques are focused on the subgroup of If they’re willing to go straight to the patients who hyperventilate when they blood draw, it will be equally effective

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and more efficient.”1 no longer meet [the DSM-IV-TR] cri In addition, some researchers have teria.”1 Although people who have BII hypothesized that disgust plays a maphobia may feel powerless against their jor role in BII phobia. “Evolutionary feared stimuli, research has shown psychologists believe that disgust that the majority of people overcome sensitivity helps us stay away from their fears through the applied tenthings that make us sick, like bad sion technique and targeted expofood. All these traits are normalsure sessions.5 ly distributed on a bell curve and Awareness about the implications people with BII just happen to be of BII phobia is important for inat one end of this spectrum,” said dividuals with the phobia who fear Mashal.1 medical treatments and for physi Although there is a strong cians seeking to help their patients association between people’s overcome this phobia. Although self-reported dizziness and their the distress and fear of fainting may actual physiological symptoms, deter people from seeking treatRitz explained that a major misment, psychological researchers conception of BII phobia is that pasuggest that a two to three hourtients think the condition signifies long session of exposure is sufweakness or fragility. “They are ficient to overcome BII phobia. actually well-functioning people Though the phobia may iniwho can lead a normal life and are tially seem like an unassailas resilient as anyone else. There’s able terror to those who are a bit of stigma around this disorvictims of it, with the proper der and psychological disorders therapy, Blood-Injection-In7 in general,” said Ritz. This stigma jury Phobia has a chance to may prevent people from seeking be reduced to nothing but a out treatment for their phobias. treated concern. ÌMD Another misconception regardFor references, see page 55. ing BII phobia is that it is untreatable. “People think that if they’ve had something for a really long time that it must take a long time to get rid of it,” said Mashal. “It’s natural logic. However, eighty to ninety percent of people will respond to treatment such that they The Pre-Medical Experience ■ Volume 4 ■ Fall 2014 ■ 47

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Global Perspectives on Health:

Treat Patients, Not Diseases By Paulo Tabera-Tarello

s medical students, it is easy to believe that after years of undergraduate study and hard work, we are ready to be great physicians. However, becoming a successful doctor is not something that can be achieved solely through studying textbooks or scoring well on exams. While these are certainly important components, some of the qualities that make physicians great are acquired through observations and experiences in a hospital. I will recall my time in medical

school as an anthology of experiences and clinical tales that will allow me to shape my judgment as a physician. Thus far, I have learned that failure can instruct better than success, and a single bad decision can shape you in a way that fifty good decisions never could. I will look back on these memories, both the good and the bad, when the time comes for me to treat patients on my own. As a medical student in Mexico, I recently had the opportunity to complete my surgical rotation. This expe-

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rience was eye-opening and changed firmed a diagnosis of inflammatory the way I want to study and practice breast cancer. After receiving the bimedicine. opsy results, the resident informed One morning while rotating at the woman that she had a rare type a local hospital, my attending physi- of breast cancer, which had spread to cian told me to go assist a resident her lungs, and that she had approxiwith a patient examination. In the mately six months to live. exam room, I saw a woman wearing The woman was understandably an obvious look of discomfort, but I devastated; soon she would have to could not immediately ascertain what say goodbye to her two sons, her huswas causing her pain. The resident in- band and all her family and friends. troduced the patient to me: she was She would be leaving so much behind, a thirty-eight but her doctor We start learning how year-old woman never had the who had consultcourtesy to to be doctors without ed her doctor belook her in the understanding the cause of pain in eyes, hold her patient perspective. her breast after hand, or even a fall two weeks say “I’m sorry.” ago. Her doctor prescribed painkill- The resident acted indifferently about ers and anti-inflammatories and then the impact that the diagnosis had on sent her home. Three weeks later, she his patient. He skipped the sympathy returned to her doctor with worsen- and moved on to options of palliative ing pain and explained that she was care. He scheduled an appointment having difficulty sleeping and breath- for the woman three days after the ing. She was promptly referred to the initial consultation so that she would surgical department, which is where have time to decide her desired treatI met her. ment plan. In an almost cruel fashion, After the interview and physical he asked the patient to leave, because exam, the surgeon found inflamma- he was falling behind on his consults tory signs on her left breast and up- for the day. per arm, so he ordered a chest x-ray As medical students, we learn to and a biopsy. The x-ray showed liq- observe, diagnose, and treat diseases uid in her lungs, and the biopsy con- through years of medical school, so

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that by the end of our education, we are capable of caring for our patients while always trying to achieve the best outcome for their health. However, we learn to do all this from a perspective that can fail to accurately depict the effects that diagnoses have on patients and their families. To a busy doctor, the pain that a difficult diagnosis brings upon a patient and his or her family can all too often become abstract and distant. Physicians must realize that when they take the time to truly empathize and identify with their patients’ situations, they can provide more holistic care.

The medical profession is not just a typical nine-to-five job; this profession is about understanding the complex systems of the human body in order to ultimately come to the aid of the patient and ease his or her pain. However, throughout all the years of medical school training in Mexico, we still do not have a class where we learn how patients cope with these unfortunate circumstances. We start learning how to be doctors without understanding the patient perspective. Though my experiences as a student in Mexico may be unique, medical students and doctors universally may not fully comprehend the scope of a patient’s experience with illness. When we choose to realize the crucial role that empathy for the patient has in health care, we can start changing the paradigms of the health profession. These changes to the overall mindset of doctors will be essential because, after all, we treat patients, not diseases. ÌMD

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REFERENCES

Hippocrates, Not Hypocrisy: Practice What You Preach

1. “Overweight Doctors Lose Credibility on Health Advice.” - Amednews.com. Web. 4 Sept. 2014. <http://www.amednews.com/article/20130401/health/130409982/4/>. 2. “Obesity and Overweight.” Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 14 May 2014. Web. 10 Sept. 2014. <http://www.cdc.gov/nchs/fastats/obesity-overweight.htm>. 3. “Healthy People 2020.” Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 23 July 2013. Web. 4 Sept. 2014. <http://www.cdc.gov/dhdsp/hp2020.htm>. 4. “Medscape Physician Lifestyle Report: 2012 Results.” Medscape Physician Lifestyle Report: 2012 Results. Medscape. Web. 4 Sept. 2014. <http://www.medscape.com/features/slideshow/lifestyle/2012/ public>. 5. Bleich, Sara N., Wendy L. Bennett, Kimberly A. Gudzune, and Lisa A. Cooper. “Impact of Physician BMI on Obesity Care and Beliefs.” Obesity. Print. 6. Puhl, R, et al. “The effect of physicians’ body weight on patient attitudes: implications for physician selection, trust, and adherence to medical advice.” International Journal of Obesity (n.d.): 1415-1421. 7. Foulds, J. “How Many Medical Doctors Smoke?” Medical Information & Trusted Health Advice: Healthline. Web. 4 Sept. 2014. <http://www.healthline.com/health-blogs/freedom-smoking/how-many-medical-doctors-smoke#3>. 8. Nelson, D. E., G. A. Giovino, S. L. Emont, R. Brackbill, L. L. Cameron, J. Peddicord, and P. D. Mowery. “Trends in Cigarette Smoking Among US Physicians and Nurses.” JAMA: The Journal of the American Medical Association (1994): 1273-275. Print. 9. Cohen, I., C. Czeisler, and C. Landrigan. “Making Residency Work Hour Rules Work.” Journal of Law, Medicine, & Ethics. Print. 10. Kuther, T. “The Fun Doesn’t End with Med School: About Residency Training.” About. Web. 4 Sept. 2014. 11. Greenberg, M. “Why We Gain Weight When We’re Stressed-And How Not To. “Psychology Today: Health, Help, Happiness Find a Therapist. Web. 4 Sept. 2014. <http://www.psychologytoday.com/blog/ the-mindful-self-express/201308/why-we-gain-weight-when-we-re-stressed-and-how-not>.

Early Intervention for Autism Treatment

1. Data & Statistics. (2014, March 24). August 4, 2014. <http://www.cdc.gov/ncbddd/autism/data.html>. 2. Applied Behavior Analysis (ABA). (2014). August 2, 2014. <http://www.autismspeaks.org/whatautism/treatment/applied-behavior-analysis-aba>. 3. ABA Resources: What is ABA? August 3, 2014. The Center for Autism and Related Disorders: Globalizing Autism Treatment and Awareness <http://www.centerforautism.com/aba-therapy.aspx>.

Establishing a Nexus Between Public Health and Clinical Practice

1. USDA Defines Food Deserts. American Nutrition Association. 2010, <http://americannutritionassociation.org/newsletter/usda-defines-food-deserts>. 2. The Health Effects of Overweight and Obesity. Centers for Disease Control and Prevention. December 6, 2013. <http://www.cdc.gov/healthyweight/effects/index.html?s_cid=tw_ob245>. 3. Stress Symptoms: Effects on your body and behavior. Mayo Clinic. July 19, 2013. <http://www.mayoclinic.org/healthy-living/stress-management/in-depth/stress-symptoms/art- 20050987>. 4. Janke, K., Propper C. & Shields, M. (2013). Does Violent Crime Deter Physical Activity? Institute for 52 ■ The Medical Decoder ■ Phi Delta Epsilon IL Gamma

REFERENCES

the Study of Labor: Discussion Paper No. 7545. 5. Haan M., Kaplan G., & Camacho T. (1987). “Poverty and health: prospective evidence from the Alameda County Study.” American Journal of Epidemiology: 125:989-998.

The Anti-Vaccination Campaign: A Retrospective Look

1. Murch, S. (2003). “Separating inflammation from speculation in autism”. Lancet 362 (9394): 1498–9. 2. Frequently Asked Questions About Thimerosal (Ethylmercury). July 30, 2014. <http://www.cdc.gov/ vaccinesafety/concerns/thimerosal/thimerosal_faqs.html> 3. Shute, N. (2013). Vaccine Refusals Fueled California’s Whooping Cough Epidemic. September 13, 2013. <http://www.npr.org/blogs/health/2013/09/25/226147147/vaccine-refusals-fueled-californias-whooping-cough-epidemic> 4. “England and Wales in grip of mumps epidemic”. May 13 2005. <http://www.nzherald.co.nz/world/ news/article.cfm?c_id=2&objectid=10125382> 5. Community Immunity (“Herd Immunity”). November 27,2013. <http://www.vaccines.gov/basics/ protection> 6. Changes in Pertussis Reporting by State from 2011 to 2012. <http://www.cdc.gov/pertussis/images/ pertussis-graph-2012-lg.gif> 7. Daley, M and Glanz, J. (2011). Straight Talk about Vaccination. August 16, 2011. http://www.scientificamerican.com/article/straight-talk-about-vaccination/?page=3 8. Shute, N. (2013). Vaccine Refusals Fueled California’s Whooping Cough Epidemic. September 30, 2013. < http://www.npr.org/blogs/health/2013/09/25/226147147/vaccine-refusals-fueled-californias-whooping-cough-epidemic>

The Drug Discovery Odyssey: A Glimpse into Pharmaceutical and Academic Drug Development

1. Benmohamed, R.; Arvanites, A. C.; Kim, J.; Ferrante, R. J.; Silverman, R. B.; Morimoto, R. I. Kirsch, D. R. Amyotrophic Lateral Sclerosis. 2011 Mar; 12(2): 87-96. 2. Herper, M. (2013) The Cost of Creating a New Drug Now $5 Billion, Pushing Big Pharma To Change. <http://www.forbes.com/sites/matthewherper/2013/08/11/how-the-staggering-cost-of-inventing-newdrugs-is-shaping-the-future-of-medicine/2/>. 3. Northwestern University Innovation and New Ventures Office. Lyrica. <http://invo.northwestern.edu/ news/2011/lyrica>. 4. Van, J. (2008) Drug find worth $700 million. March 10, 2008. Chicago Tribune. <http://articles.chicagotribune.com/2008-03-10/business/0803090219_1_gaba-richard-silverman-drug-companies>. 5. World Events Forum. Plenary: The Story of Lyrica-Academic Discovery to Commercial Success. 8th Annual Drug Discovery Neurodegeneration Conference. <http://www.worldeventsforum.com/addf/ drugdiscovery/notes8/oral-presentations/79-2/>. 6. Silverman, R. B. From Basic Science to Blockbuster Drug: The Discovery of Lyrica. Angew. Chem. Int. Ed. 2008, 47, 3500-3504.

“May I Have Your Attention?” The Misconceptions Among College Students Surrounding Adderall Use

1. Center for Disease Control and Prevention., Increasing prevalence of parent-reported attention-deficit/hyperactivity disorder among children --- United States, 2003 and 2007. MMWR Morb Mortal Wkly Rep, 2010. 59(44): p. 1439-43. Volume 4 ■ Fall 2014 ■ 53

REFERENCES

2.Visser, S.N., et al., “Trends in the parent-report of health care provider-diagnosed and medicated attention-deficit/hyperactivity disorder: United States,” 2003-2011. J Am Acad Child Adolesc Psychiatry, 2014. 53(1): p. 34-46.e2. 3.National Institute of Mental Health. Attention Deficit Hyperactivity Disorder (ADHD). [cited 2014 June 29]; Available from: <http://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd/index.shtml>. 4.Lakhan, S.E. and A. Kirchgessner. “Prescription stimulants in individuals with and without attention deficit hyperactivity disorder: misuse, cognitive impact, and adverse effects.” Brain Behav, 2012. 2(5): p. 661-77. 5. DeSantis, A.D., E.M. Webb, and S.M. Noar. “Illicit use of prescription ADHD medications on a college campus: a multimethodological approach.” J Am Coll Health, 2008. 57(3): p. 315-24. 6. Wang, S.S., ADHD Drugs Don’t Boost Kids’ Grades, in The Wall Street Journal. 2013. 7. A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. The MTA Cooperative Group. Multimodal Treatment Study of Children with ADHD. Arch Gen Psychiatry, 1999. 56(12): p. 1073-86. 8. Schwarz, A., A.D.H.D. Experts Re-evaluate Study’s Zeal for Drugs, in The New York Times. 2013. p. A11. 9. Cherkasova, M.V., et al.. “Amphetamine-induced dopamine release and neurocognitive function in treatment-naive adults with ADHD.” Neuropsychopharmacology, 2014. 39(6): p. 1498-507. 10. Wilens, T.E. “Mechanism of Action of Agents Used in Attention-Deficit/Hyperactivity Disorder.” Journal of Clinical Psychiatry, 2006. 67(8): pp.37-39. 11. Varga, M.D. “Adderall abuse on college campuses: a comprehensive literature review.” J Evid Based Soc Work, 2012. 9(3): p. 293-313. 12. McCabe, S.E., et al. “Non-medical use of prescription stimulants among US college students: prevalence and correlates from a national survey.” Addiction, 2005. 100(1): p. 96-106. 13. Teter, C.J., et al. “Prevalence and motives for illicit use of prescription stimulants in an undergraduate student sample.” J Am Coll Health, 2005. 53(6): p. 253-62. 14. United States Drug Enforcement Agency. Drug Scheduling. [cited 2014 June 29]; Available from: <http://www.justice.gov/dea/druginfo/ds.shtml>. 15. The University of Chicago. Table A: Federal Penalties and Sanctions for Illegal Trafficking and Possession of a Controlled Substance. [cited 2014 June 29]; Available from: https://commonsense.uchicago. edu/page/table-federal-penalties-and-sanctions-illegal-trafficking-and-possession-controlled-substance. 16. Hanson, C.L., et al. “Tweaking and tweeting: exploring Twitter for nonmedical use of a psychostimulant drug (Adderall) among college students.” J Med Internet Res, 2013. 15(4): p. e62. 17. Jiao, X., et al. “Myocardial infarction associated with adderall XR and alcohol use in a young man.” J Am Board Fam Med, 2009. 22(2): p. 197-201. 18. Carroll, L. “Conduct policy changes reflect drug abuse.” in The Chronicle. 2011. 19. Duke University Student Affairs. Student Conduct: Academic Dishonesty. [cited 2014 June 29]; Available from: http://studentaffairs.duke.edu/conduct/z-policies/academic-dishonesty. 20. Oremus, Will. “The New Stimulus Package.” Slate (2013): n. pag. Web. <http://www.slate.com/articles/technology/superman/2013/03/adderall_ritalin_vyvanse_do_smart_pills_work_if_you_don_t_ have_adhd.html>.

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REFERENCES

The Fusion of Medicine and Technology: What Can We Envision for the Future of Health Care?

1. “Basics of Health IT” 15 Jan. 2013. Web. 30 June 2014. http://www.healthit.gov/patientsfamilies/basics-health-it 2. Bates, D., Cohen, M., Leape, L., Overhage, J. M., Shabot, M. M., & Sheridan, T. (2001). Web. 27 Jun. 2014. Reducing the frequency of errors in medicine using information technology. Journal of the American Medical Informatics Association, 8(4), 299 -308. http://www.ncbi.nlm.nih.gov/pubmed/11418536 3. “History and Evolution of Health Care Information Systems” Web. 30 Jun. 2014. instructional1. calstatela.edu/prosent/CIS%20581/chapter4.pptx 4. Puskin, D. Johnston, B. Speedie, S. May. 2006. Web. 30 June 2014. http://www.americantelemed.org/ docs/default-source/policy/telemedicine-telehealth-and-health-information-technology.pdf?sfvrsn=8 5. “EHR Incentive Payment Timeline” 4 Mar. 2014. Web. 30 June 2014.http://www.healthit.gov/providers-professionals/ehr-incentive-payment-timeline 6. “Can Telemedicine alleviate India’s Health Care Problems?” 08 Mar. 2012. Web. 30 Jun. 2014. http:// knowledge.wharton.upenn.edu/article/can-telemedicine-alleviate-indias-health-care-problems/ 7. “What is Telemedicine?” Web. 28 Aug. 2014. http://www.americantelemed.org/about-telemedicine/ what-is-telemedicine#.VATVLPldUS4 8. “U.S. Electronic Medical Records (EMR- Physician Office & Hospital Market- Emerging Trends (Smart Cards, Speech Enabled EMR), Market Share, Winning Strategies, Adoption & Forecasts till 2015” June 2011. Web. 28 Aug. 2014. http://www.marketsandmarkets.com/Market-Reports/us-emrmarket-401.html 9. Blumenthal, D., Tavenner, M. 05 Aug. 2010. The “Meaningful Use” Regulation for Electronic Health Records. Web. 28 Aug. 2014. http://www.nejm.org/doi/pdf/10.1056/NEJMp1006114 10. Menachemi, N., Collum, T. 11 May 2011. Web. 28 Aug. 2014. “Benefits and drawbacks of electronic health record systems”. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3270933/ 11.Halamka, J. 01 Sept. 2011. Web. 28 Aug. 2014. “The Rise of Electronic Medicine” http://www.technologyreview.com/news/425298/the-rise-of-electronic-medicine/ Images gathered from: iTriage –Accessed 8/15/14 https://www.itriagehealth.com/facilities/il/chicago; HealthTap - Accessed 8/15/14 https://www.healthtap.com/what_we_make/overview; PalmEM - Accessed 8/15/14 https://itunes.apple.com/us/app/palmem-emergency-medicine/ id481034047?mt=8;InQuicker - Accessed 8/15/14 https://inquicker.com/; Doctor on Demand - Accessed 8/31/14 http://www.doctorondemand.com/

Blood-Injection-Injury Phobia: Unassailable Terror or Treatable Concern?

1. N. Mashal, Personal Communication, June 12, 2014. 2. American Psychiatric Association. (2010). Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.). doi:10.1176/appi.books.9780890423349.11547 3. Ritz, T. Meuret, A.E. & Ayala, E.S. (2010). “The Psychophysiology of Blood-Injection-Injury Phobia: Looking Beyond the Diphasic Response Paradigm.” International Journal of Psychophysiology: 78, 50-67. 4. Öst, Lars-Göran. (1992). “Blood and Injection Phobia: Background and Cognitive, Physiological, and Behavioral Variables.” Journal of Abnormal Psychology: 101, 68-74. 5. Antony, M.A. & Watling, M.A. (2006). Overcoming Medical Phobias. Oakland: New Harbinger Publications, Inc. 6. N. Tapko, Personal Communication, July 17, 2014. 7. T. Ritz, Personal Communication, July 20, 2014. Volume 4 ■ Fall 2014 ■ 55