The Medical Decoder Fall 2015

MD

THE MEDICAL DECODER

A Guide to U.S. Health Care Policy

IN THIS ISSUE Science & Technology

5 From Bench to Bedside:

Bridging the Gap Between Science and Medicine Michael Rallo

Rutgers University ‘17

Health Care & Policy

9 The Sustainable

Development Goals Svetlana Slavin

Northwestern University ‘16

10 A Guide to U.S. Health Care Policy

Katarzyna Zembrzuska Rutgers University ‘17

14 Standardizing Surgical Safety Elbert Mets

Cornell University ‘17

2 • The Medical Decoder • Fall 2015

The Pre-Medical Experience

17 Intro to Medical School: Private vs. Public Alexander Straughan Northwestern University ‘16

20 To D.O. or Not to D.O.?

Michael Alvarez

Temple University ‘17

Human Interest

23 Cancerous

Consequences: The Increase, Causes, Prevention, and Misconceptions of Skin Cancer Rich Apramian Ramapo College ‘17

26 References

Editors-in-Chief Brianna Cohen Svetlana Slavin

Creative Director Lauren Kandell

Writing Staff

Michael Alvarez Rich Apramian Elbert Mets Michael Rallo Svetlana Slavin Alexander Straughan Katarzyna Zembrzuska

Editing Staff

Christopher Bayston Selina Deiparine Aayush Gupta Korri Hershenhouse Eric Kim Nathan Moxon Kelley Park Savan Patel Dane Rucker Rachel Seng Evan Sitar Alexander Straughan

Design Team

James Guo Matthew Lam Alexis O’Connor Courtney Zhu Table of Contents • Volume 6 • 3

LETTER FROM THE EDITORS

Dear readers,

Welcome to the sixth edition of The Medical Decoder! With this issue, we focused on a number of topics providing clarity to those pursuing a career in a health-related field.

The world of medicine is multi-faceted and requires future health care workers to have a firm grasp on relevant issues; with this edition, we hope to give readers with the tools they need to make informed decisions as they continue forward in their pursuit of a medical profession.

Health care in America faced shockwaves of changes with the enactment of the Patient Protection and Affordable Care Act, otherwise known as Obamacare. MD writer Katarzyna Zembrzuska co-authored “A Guide to US Health Care Policy,” detailing the political nature of these changes because we believe it is vital for all readers to understand the overlap between politics and medicine, and to remain informed about political deliberations surrounding health care.

As pre-health students, we must frequently navigate many ambiguities in choosing our paths to continuing education in the medical field. Alexander Straughan details the difference between public and private medical schools in his article “Intro to Medical School: Public vs. Private,” while Michael Alvarez offers insight into the pursuit of a degree in osteopathic medicine in his piece, “To D.O. or Not to D.O.?” With these articles in mind, we hope that pre-health students feel fully informed about their options for future education.

As the editors-in-chief of the Medical Decoder, we would like to thank you for your continued readership and support. The MD would not be the growing publication that it is today without the backing of its readers. We are pleased to present the sixth edition of The Medical Decoder. Enjoy!

Sincerely, Svetlana Slavin and Brianna Cohen Editors-in-Chief medicaldecoder@gmail.com

4 • The Medical Decoder • Fall 2015

Physicians have the unique opportunity to use their scientific knowledge to treat the sick and injured. However, as new discoveries are made every day, it is difficult for the health care community to translate new information into medical practice. Thus arises the need for translational researchers who are trained to implement basic scientific advances into clinical trials and applications.

Science & Technology • Volume 6 • 5

T

he process of actually converting significant findings into practice is quite difficult. Translational research is the field that focuses on making this process more efficient.

It involves applying advancements in the basic science realm - which is fundamental scientific research that aims to improve scientific theories and understanding of natural phenomena - to new approaches for prevention, diagnosis, and management of human diseases.

For example, translational research allows physician-scientists, or clinicians, and researchers to team up and use previously published evidence to establish clinical parameters for a similar study.1 Translational research also functions in the opposite direction, as when observations from the clinical setting get used to develop basic research projects.1 Translational research provides opportunities for advancement in diagnosis and treatment of a wide variety of diseases, with cancer as one of the primary focuses.

For instance, suppose a new experimental treatment was found to be successful in reducing the size of tumors in a mouse model of colon cancer. Further basic research would be performed to determine the mechanism of action of the treatment, and eventually translational researchers would work to evaluate its clinical potential and bring the treatment from animal study to the T1 phase of human study.

In human phase I and II clinical trials, the safety, efficacy, and

dosage of the potential treatment would be tested. If these trials are successful, the drug will progress through the T2 phase to the phase III clinical trials, which include larger populations of people. The final transitions, T3 and T4, involve further human studies in practicebased research and outcomes research.

When successful, the final outcome of this model is improved health care for patients suffering from 2 disease. In this way, clinical advancements are dependent on the success of translational research at several points in their development.

When thinking about research, students may imagine lab rats, microscopes, and test tubes. These images, while based in reality, often prevent students from seeing the true purpose of research: to advance our knowledge and to use this new information to enhance the health and longevity of society.

While many students complete research in order to bolster their medical and graduate school applications, few truly grasp the role that research plays in the evolution of medicine.

Additionally, the growing preoccupation of medical professionals with the everchanging health care system has resulted in their decreased awareness of the major advancements occurring in basic science research. As a result, new knowledge and

6 • The Medical Decoder • Fall 2015

techniques in scientific disciplines are not used to their full potential in the clinical setting.3 In fact, a recent study demonstrated that less than one in four promising biomedical discoveries result in randomized clinical trials, and less than one

in ten become established clinical practices.4 This lack of success falls partially upon basic scientists, clinicians, and translational researchers, and serves as a sign that professionals in each field must become more proficient in bringing scientific discoveries to clinical practice. Granted, some clinical trials fail to transition to everyday practice for reasons outside of physician ignorance.

It is the position of the translational researcher to assist in the clinical development of these trials along with physician-scientists. Finally, it falls upon doctors to ensure that they are practicing the most updated and effective medicine possible. They must maintain an ever-evolving medical knowledge to provide the best care to their patients.

In recognition of the important

role translational research plays in future health care improvements, organizations such as the National Institutes of Health (NIH) and American Medical Association (AMA) have taken multifaceted approaches to increase translational research’s efficiency and effectiveness.

The NIH is one of the largest proponents of translational research. In 2003, with its issuance of a roadmap for the future, the NIH proposed a redevelopment of the clinical research enterprise, specifically citing the need for more translational research centers and services.5 In addition, the NIH has recently established a specific entity, the National Center for Advancing Translational Sciences (NCATS), with the mission of understanding and

catalyzing the translational process.

Rather than focusing on specific diseases, the NCATS focuses on the principles involved in bringing basic science advancements into clinical trials and practice. This approach includes evaluating and improving upon the drug development process, investigating the most effective solutions for collaboration in translational science, and developing technologies that are useful in translational research.

Along with the NCATS, the NIH has implemented a system of financial support for investigators involved in clinical and translation research known as the Clinical and Translational Science Awards. These awards are given to investigators who demonstrate high-quality translational and clinical research to encourage further research success and professional development.6 The AMA has also illustrated the importance of translational research with its feature of the “Scientific Discovery and the Future of Medicines” article series in the Journal of the American Medical Association. This series, published throughout 2015, contains articles related to new advancements in the biomedical sciences with the objective of engaging physicianscientists in research.3 The initiatives taken by the NIH and AMA demonstrate the importance of educating researchers and clinicians, while also increasing public awareness of current research. The support of these large organizations is crucial for the advancement of translational

Science & Technology • Volume 6 • 7

research and will continue to set the foundation for the future of medicine.

While large-scale organizations are essential for navigating between scientific discoveries and clinical applications, the foundation of translational research lies in medical schools. The American Association of Medical Colleges has added a condition for medical schools requiring that “the curriculum of a medical education program must introduce medical students to the basic scientific and ethical principles of clinical and translational research”.7 Each medical education program meets this requirement in a different way, whether it is through handson involvement or coursework in clinical and translational research.

This variation in coursework may be partially responsible for the heterogeneity in the field in terms of research knowledge and participation. While some students have extensive, hands-on experience in research, others may only have classroom-based learning and therefore an incomplete perception of translational and clinical research.

Not all clinicians must be adept at performing research, but they all should have a clear perception of research methodology, understand the role of research in medical practice, and be able to critically evaluate research.

The most distinguished route for those interested in medical research is the dual-degree MD/ PhD program. This track, typically requiring seven to eight years of

education, involves completion of medical and graduate school coursework. It prepares students for a career oriented around patient care and basic science, clinical, or translational research.8 “The purpose of the MD/PhD program is to train proficient physician-scientists who are able to make a difference in medicine and science and bridge the gap between the bench and bedside” said Dakim Gaines, a student in the MD/PhD program at Rutgers-Robert Wood Johnson Medical School. According to Gaines, the physician-scientist has the unique role of serving as a mediator between two worlds: clinical and scientific.

A similar, less intensive course is the MD with Distinction in Research program that is offered at several medical schools. These programs involve training that emphasizes research more than a standard medical education does. Although the specific structure varies by school, the general layout includes completion of a research project

8 • The Medical Decoder • Fall 2015

and subsequent submission of a thesis. This project can typically be completed through summer research and research-based electives during the M3 and M4 years.

A final medical school program that includes a large research component is the dual-degree MDMasters in Translational Research program. This program, offered by several medical schools, provides students with instruction in the skills, methodology, and principles necessary to conduct translational research.9 Scientific discoveries are made everyday, but clinical advancements are slow to follow. If we want to change the face of medicine and improve the level of care that doctors give to patients, then we must focus on bridging the gap between science and medicine through improving translational research.

For references, see page 26.

The Sustainable Development Goals The United Nations enacted the Sustainable Development Goals in September 2015 to improve quality of life worldwide, with health as a component of the plan.

By Svetlana Slavin

J

ust before the United Nations gathered at the annual the UN General Assembly in New York this past September, the UN Sustainable Development Committee adopted a set of 17 global development goals to reach by 2030. Picking up where the Millennium Development Goals (MDGs) left off in mid-2015, the Sustainable Development Goals (SDGs) encompass challenges ranging from promoting gender equality and ending poverty to sustaining wildlife and ensuring access to clean energy.1 The SDGs are different from the MDGs in that they encourage more private sector involvement in achieving these goals. Private sector partnerships are crucial to global development due to a gap in resources of about $2.5 trillion.

To encourage this private sector investment, the UN is spearheading data monitoring and evaluation.1

The global health community’s “post-2015 agenda” will be governed by goal number three, which is to achieve “good health and wellbeing”. There are nine health targets under this goal, three of which stem from the MDGs: reduce maternal mortality, end preventable deaths of children under age five, and combat and eliminate epidemics of AIDS, malaria, tuberculosis, neglected tropical diseases, and hepatitis.3 Three additional targets are associated with non-communicable diseases (NCDs): reduce premature mortality from NCDs, strengthen prevention and treatment of substance abuse, and decrease the number of road traffic accidents.3 The final three targets are cross-

cutting goals: ensure access to sexual and reproductive health services, achieve universal health coverage, and reduce death and illness due to hazardous chemical air, water, and soil pollution and contamination.

Each of these nine targets has a number of specific health indicators for every country to reach.3

According to the World Health Organization, a subsidiary agency of the UN, the overarching health goal “should also be a measure of progress in many other SDGs as health is influenced by economic, social and environmental determinants”.3 That is, all of the goals are dependent upon one another to ensure their progress is complementary.

The SDGs have come under fire for being too expensive, vast, and cookie-cutter to make real, accessible changes.4 On the other hand, having a cohesive plan that the global health community can follow is crucial to ensuring a sustainable future for developing countries. Despite certain flaws in the UN’s plan for sustainable development, it is clear that countries must work together to ensure a better future for the world.

For references, see page 26.

Health Care & Policy • Volume 6 • 9

A Guide to U.S. He

By Katarzyna Zembrzuska and Svetlana Slavin

N

early 50 years have passed since the enactment of Medicare and Medicaid, public health insurance programs that aim to help those who would otherwise be left without a safety net of care. Despite aforementioned government legislations intended to provide health care to those in need, upwards of 48 million Americans remain uninsured.1 In an effort to reduce the number of uninsured individuals in the U.S., President Obama made it his mission to provide universal health care and insurance without barriers. Enacted in 2014, the Patient Protection and Affordable Care Act – also known as Obamacare – is expected to continue to decrease the number of uninsured U.S. citizens.1 Overview The United States spends more

money on health care than any other country in the world, yet it ranks 11th in quality of care, efficiency, and health outcomes. Socioeconomically comparable nations that rank higher in these categories and also maintain lower costs have systems of universal health care.2 Universal health coverage evokes heated partisanship between rightwing conservatives who argue that minimal government involvement encourages free-market capitalism that ultimately drives down health care costs, and left-wing liberals who defend the idea of universal health care and health care in general as a human right and necessity. Over the past couple of years, Republicans have vehemently opposed the Affordable Care Act and have even unsuccessfully pushed to repeal it many times.3 It can be difficult to sift through

10 • The Medical Decoder • Fall 2015

the political partisanship created

by Obamacare. In a Politico guide to Obamacare, one political analyst lamented that “you either hear that Obamacare is a lifeline to millions of uninsured people, and anyone who has a problem with it is cold-hearted, or that it’s a huge headache for businesses and doctors everywhere.”1 By understanding the basics of Obamacare and the reasons behind political stances on health care issues, one can be better informed on a major debate that inevitably affects all Americans.

Pre-Existing Conditions One of the biggest changes to insurance plans that Obamacare instituted is that companies will not be able to deny consumers coverage due to pre-existing conditions.

Previously, if an uninsured

ealth Care Policy individual was diagnosed with a condition, like cancer or multiple sclerosis, insurance companies were allowed to refuse coverage to these individuals because the cost of their care would be too high. This caused many people to avoid routine testing over the fear of being diagnosed with a condition that would prevent them from getting coverage. It also prevented people from changing jobs over the fear of having to reapply for insurance that would ultimately not cover their condition.1 This new coverage policy helps those who get insurance through an avenue other than their employer and works in the following way: during open enrollment periods, usually a couple of months out of the year, people may purchase insurance plans through health insurance marketplaces that help individuals select the right plans for their needs.

People may also sign up if they have had a “qualifying life event”, such as getting married, changing jobs, or moving out of state.

Not only can health insurance companies not deny someone coverage based on pre-existing conditions, but they also cannot charge a higher premium (the price that one regularly pays for his or her plan) based on health status.

Factors companies are allowed to consider include age, tobacco use, and the number of individuals in a family. Along the same vein, health insurance companies can no longer end coverage because of a newly acquired illness, nor can they impose caps on the health care costs a person accrues throughout their coverage cycle.1 Insuring pre-existing conditions is generally favored on both sides of the aisle. By some estimates,

anywhere from 50 to 130 million individuals may have pre-existing conditions.1 Even at the low end of this range, enough people would be covered such that the cost of insurance would stay reasonable.

However, conservatives argue that there are other ways to cover pre-existing conditions without imposing government regulations on private corporations. For example, by covering people through other large groups including alumni associations and trade groups, costs can be distributed between the healthy and the sick.1 Further bipartisan changes to America’s health care system include coverage of additional health benefits deemed essential like mental health, maternity care, emergency room visits, and diagnosis and prevention.

Furthermore, children of the insured will be able to stay on

Health Care & Policy • Volume 6 • 11

their parents’ plans until the age of 26. One reform that is facing a barrage of lawsuits from businesses that provide health insurance for employees is the requirement that health plans fully cover FDA approved contraceptives – an issue that will likely be dealt with on a case-by-case basis due to various exemptions.1

The Individual Mandate One of the most politically contentious policies under Obamacare is the individual mandate. Obamacare stipulates that all individuals who are capable of paying for insurance – so long as the cost does not cause an undue financial burden – must purchase insurance or face a fine. The full penalty is $695 or 2.5 percent of one’s income, whichever is greater.

The reasoning behind the individual mandate is to enroll enough healthy individuals to balance out the costs of insuring those with pre-existing conditions.

1 Even though the Supreme Court upheld the individual mandate in a 2013 ruling, the regulation is polarizing.

According to the Urban Institute, 86% of Americans will be unaffected by the mandate because they already have insurance.1 Some of the remaining 30 million uninsured Americans will not be subject to the mandate because they either do not have a high enough income to plausibly pay for insurance or they are part of a Native American tribe, certain religious group, or are uninsured for a short period of time.1

The individual mandate is highly debated mainly because the government is requiring individuals to complete action items. As famously stated during a Supreme Court hearing on the matter, if the government can force you to buy insurance, what’s to stop them from forcing you to eat broccoli? This slippery slope argument has been used less and less, though, because it presumes the federal government is bold enough to continue to force rules upon Americans based on the precedent of Obamacare – something that likely will not happen.

Still, House Republicans continue to use this argument when attempting to repeal Obamacare.

Democrats acknowledge that the mandate is a victory for their side, but will not push for more fines even if the current rate does not make up for losses in the marketplace.1 Program Reforms Medicaid Expansion Previously, Medicaid only benefited those at or below the federal poverty level, while the people just above it were overlooked.

With the Affordable Care Act, Medicaid coverage is extended to all people up to 133% of the poverty level, qualifying 82% of the nearly 16 million uninsured young adults.

Those who are above 133% of the poverty line but still do not make enough money to afford insurance will be eligible for a tax credit. 1 Originally, Obamacare’s Medicaid expansion was supposed to be applied to all 50 states. However, the Supreme Court ruled that each

12 • The Medical Decoder • Fall 2015

state can decide whether or not to implement this Medicaid expansion, making it only available on a stateby-state basis.

The Congressional Budget Office estimates that due to individual states opting against Medicaid expansion, about three million individuals remain uninsured. To incentivize states to partake in the Medicaid expansion, the federal government will pay for most of the states’ medical costs for three years and then scale back to covering 90 percent of costs by 2020.1 One may wonder why states would refuse to expand Medicaid to millions of uninsured individuals, especially when costs will be mostly covered. For some Republican state leaders, opting out of the expansion maintains their overall stance against Obamacare and the Democratic administration.

For others, there is fear that eventually the federal funding will run out and states will be left to cover costs on their own. Whatever their reasoning may be, the states that opt out of expansion will face higher hospital reimbursement costs in order to pay for uninsured individuals.1

Improvements in Medicare Medicare is a health care program that is specific to the elderly and the disabled. Among the key features of the Affordable Care Act is that those who qualify for Medicare will receive preventative services for little or no cost, as well as discounted prices for prescription drugs.4 Medicare reimbursement rates will steadily

decrease over the next ten years, something that will affect hospitals and the compensation of doctors.1

The Employer Mandate With the institution of Obamacare, business owners large and small now have many new rules and requirements to comply with.

Employers with 50 or more workers will have to either provide coverage or pay employees enough to purchase their own private insurance.

As with the individual insurance marketplaces, small business owners will be able to search for plans that best suit their employees on a website.

Certain small businesses will be subject to a tax credit to help cover costs.1 Many Republicans claim that this provision is a jobkiller because employers will have to lay-off workers to either cover insurance costs or to reduce their workforce such that they no longer are subject to the policy. Time will tell whether this claim is true, but thus far economists claim that job losses will be minimal.1

care; doctors would receive payments from public and private insurers for every procedure and test they performed. One can see how needless tests could contribute to runaway health care costs.

Now, the health care industry will move to “bundled payments”. This system, which will first be instituted with Medicare, reimburses hospitals and doctors a fixed amount based on certain conditions a patient presents with. “Value-based payments” are another system certain insurers are considering adopting, in which

lead to financial trouble. As a balancing measure, hospitals are encouraged to be more efficient by reducing expensive re-admission costs or facing a fine.1

Conclusion Obamacare is certainly not a health care system one would propose from scratch, but rather an addendum to a system greatly lacking the means to help those who need it the most.

Health care costs will inevitably increase as health care technology becomes increasingly modern.

Progress in decreasing numbers of financially vulnerable, uninsured Americans has already been made: in just one year the of people are insured 18.0% uninsured rate from through their employers 2014 went down to 11.4% of people are insured in 2015, and this trend is through gov’t programs predicted to continue.5 Obamacare is a step closer of people buy their own to universal health care, private insurance a system that is common Americans will remain amongst many top nations uninsured under this system4 of the world. Although the U.S. still has a long journey doctors are paid based on the quality to a better-functioning health care of care patients receive.1 system, the adoption of the policies Under Obamacare, hospitals are in the Affordable Care Act suggests set to see $155 billion in payment that the U.S. is well on its way. It is cuts from the federal government. our job as citizens to understand the Hospitals were agreeable with this policies and sift through political because of the expected increase deliberations to build our own in insured individuals that would opinions regarding our health care come their way. But with Medicaid system and make informed decisions expansion now an optional feature about coverage. for states, hospitals fear that the funding cut combined with a stagnant uninsured (and therefore more expensive) population will For references, see page 26.

How People are Insured Under Obamacare

50% 33% 10% 30m

What about Physicians?

It is important for physicians to have a firm grasp on the many changes that their profession inevitably faces due to Obamacare, both to ensure that patients understand their own treatment protocols and that they themselves understand the new reimbursement policies. Previously, the “fee-forservice” model dominated health

Health Care & Policy • Volume 6 • 13

Standardizing Surgical Safety

The World Health Organization’s Surgical Safety Checklist revolutionizes patient care with a foundational guide to operating room procedure.

By Elbert Mets

O

ver 200 million surgeries are performed around the world annually.1,2 Of these surgeries, over seven million will end in complications and one million patients will die due to these complications.1,2 The occurrence of complications, including surgical errors such as wrong-site surgery and surgical site infection, can be reduced if operating room personnel focus more intently on preventative measures.1-3

The Surgical Safety Checklist was first implemented by the World Health Organization (WHO) in 2009 as part of a global effort to improve surgical safety.1 The WHO acts as the public health arm of the United Nations and aims to increase health care quality globally through policy development and sustainable public

health interventions.4

The WHO’s checklist is a novel, standardized tool designed to improve surgical outcomes by helping surgical providers plan and recap their surgeries. Adoption of the checklist promises to help clinicians make surgery a safer practice worldwide.

Before the checklist was implemented on a large scale, its effectiveness was assessed in a landmark study conducted by the Safe Surgery Saves Lives study group, which evaluated the impact of the checklist in eight hospitals on five different continents. 2 In the study, WHO researchers collected data on over 3,000 surgeries before and after the checklist’s implementation.1,2 The eight hospitals evaluated in this study

14 • The Medical Decoder • Fall 2015

are considered representative of medical centers around the world.1,2

The study’s researchers noted marked improvements in surgical outcomes following the checklist’s implementation, with overall complication rates decreasing from 11% to 7%, and post-surgical patient mortality decreasing from 1.5% to less than 0.8%. 2

The checklist concisely fits on a standard sheet of printer paper, and is a far cry from a complicated instruction manual. There are five measures mandated in the checklist – airway evaluation, monitoring with pulse oximetry, antibiotic prophylaxis, “oral confirmation of [the] patient’s identity and operative site,” and a sponge count. 2 The checklist covers key events in the perioperative process with the

aim of increasing patient safety.

Performing these tasks could potentially save patients’ lives.

The checklist is freely accessible through the WHO’s website, and the WHO provides guidance for medical centers interested in introducing the checklist to their operating theaters.1 A number of the world’s leading medical organizations, including a number of countries’ ministries of health, have endorsed and encouraged its implementation. 5 The checklist calls for action at three perioperative stages which correspond to critical points during a given surgery. The first is before anesthesia begins, the second is before the surgeon or surgical resident makes the first incision, and the third is at the conclusion

of the operation before the patient exits the operating room. At each of these points, the checklist leader – a member of the surgical team – verifies the relevant points of the checklist aloud.

In the first stage, the patient is accurately identified, the surgical team ensures that the surgeon is performing the correct procedure, and the surgeon acknowledges that he or she is operating at the appropriate site on the patient’s body. The surgeon marks the patient’s skin with a sterile marker to indicate where he or she will operate. Additionally, the volume of blood loss is predicted for surgical staff to anticipate a blood transfusion, provided it becomes necessary.

Also in the first stage, before

induction of anesthesia, issues that could compromise the safety of the patient are addressed. Any known allergies to medications and potential airway complications induced by the administration of anesthesia are mentioned. Since a patient’s lungs are ventilated for the duration of the surgery, it is imperative that anesthesiologists are cognizant of any problems that could befall their patient’s respiration.

The adequacy of ventilation is monitored noninvasively using a pulse oximeter. As such, the checklist emphasizes checking that the pulse oximeter is connected and working before anesthesia induction.

Just before the surgeon makes the first incision, the checklist leader

Health Care & Policy • Volume 6 • 15

holds a brief “time out” in which he or she asks all members of the surgical team to state their names.

At this time, the patient’s identity is again confirmed, as is the surgical site.

Surgical site infection is a major postoperative concern. To combat this risk, the checklist directs the surgical staff to verify that antibiotics have been administered within an hour before the procedure. 3 It is also at this stage that nurses, anesthesiologists, and surgeons are required to note any difficulties they foresee in the upcoming procedure. The WHO has included a check box to verify that any pertinent scans or images are prominently displayed at the start of the procedure for the surgical team’s reference. 3 Following the conclusion of surgery, the surgical team is asked to restate the procedure that was recently completed and discuss any considerations for the patient’s postoperative care. Although one may wonder why it is important to count sponges and instruments after the procedure, leaving foreign objects inside patients during surgery can seriously hamper their recovery.

The WHO has not created the checklist as a comprehensive guide, but rather as a foundation that can be adapted and personalized by each institution. However, the WHO strongly advises against removing items from the checklist. 3 The organization also posits that the checklist is most effective when a single member of the surgical team

walks the team through the list during surgery. 3

How effective has the WHO Surgical Safety Checklist been in improving surgical outcomes? A recent Annals of Surgery article written by several physicians

stemming from use of the checklist.1

Additionally, active engagement in checklist procedures may help engender greater team spirit in the operating room and may confer a stronger sense of ownership in patient care.

Adoption of the checklist promises to help clinicians make surgery a safer practice worldwide. originally involved in the Safe Surgery Saves Lives study group indicates that the checklist has been quite successful.6 The doctors report reductions in mortality rates of up to 47% after the launch of the checklist.6 Furthermore, in their initial assessment, the study group reports a 36% decrease in the number of complications following surgery. 2 The evaluation also demonstrates the hospitals that used the checklist most successfully were those that followed the WHO’s implementation recommendations.

These recommendations include adapting the checklist to match the hospital’s needs, testing the modifications, and choosing local “champions” to encourage adoption of the checklist. 3,6 The WHO cites more effective communication among the surgical team and an “improved safety culture” as two key benefits

16 • The Medical Decoder • Fall 2015

With regards to “safety culture,” stepping through the routinized checklist during each procedure could heighten the surgical team’s awareness of potential complications during surgery. 2 The WHO’s Surgical Safety Checklist offers a standardized tool for surgical care providers globally to ensure the perioperative safety of their patients. The checklist has been shown to reduce both patient morbidity and mortality at a negligible cost. 2,6

Moving forward, the checklist will likely continue to be introduced in hospitals around the world, where it may help reduce the rates of surgical site infection and generally improve surgical safety.

For references, see page 26.

W Medical School: Public vs. Private When students begin applying to medical schools, the debate between private versus public institutions inevitably arises.

The similarities and differences should be diligently weighed and considered.

By Alexander Straughan

hile sifting through the large pool of medical schools that I was considering applying to, I found that most resources classify medical schools into two large categories: public schools and private schools. Many application materials acknowledge that differences exist between the two types of medical schools. However, what the differences are and to what extent they exist are largely ambiguous to an applicant.

Of the 140 accredited medical schools in the United States (excluding off-shore medical schools), 80 are public institutions.1,6 These schools secure significant financial support from the government in exchange for providing an established number of seats for in-state residents. Due to the in-state resident quota that public schools must reach, admissions standards for out-ofstate applicants are typically much more competitive.

Unlike their public counterparts, private medical schools have no bias towards in-state applicants as they do not receive the same government financial assistance. When applying to a private medical school, applicants can assume that they will be on an equal playing field in terms of geographic residence to everyone else. So how does a school’s public status

The Pre-Medical Experience • Volume 6 • 17

affect a student’s medical school experience?

Upon first glance, the most notable difference between public and private medical schools is the cost of tuition. Through government subsidies, public schools often boast lower tuition rates, particularly for in-state residents.

It is important to note that outof-state students will not receive the same financial subsidies that in-state students do at public schools. Therefore, they should expect to pay tuition fees similarly aligned with those of private schools. However, many students who spend their first year of education at a public school are often able to acquire state citizenship, qualifying them for in-state benefits after the first year.

For private schools, tuition rates are standardized for residents of every state. To put a numerical value on the tuition difference, the American Association of Medical Colleges’ 2015 report on medical student education found that the average public medical student pays an annual tuition of $35,000, while a student at a private school pays $55,000.4 Across four years, this amounts to a difference greater than $70,000.

However, the report also stated that the average post-medical school graduation debt difference was close to only $20,000. This could be because some private schools, such as Washington University School of Medicine in

St. Louis, allocate need-based or merit-based scholarships. This particular private institution offers qualifying students a combination of need-based scholarships, merit-based scholarships, and interest9 free loans. While the $20,000 difference between public and private schools is still significant, this smaller actual disparity in tuition payment suggests that many applicants should consider factors other than tuition price.

Many medical school applicants look into the annual class size of different medical institutions.

The average annual class size affects a medical student’s experience, as size has a large impact on the social environment, student-tofaculty ratio, and lecture dynamic.

Class sizes can range from smaller than 50 students, to larger than 300.5 This large range, however, has little correlation with private or public schools. The Medical School Admissions Requirements (MSAR), a database of admissions statistics posted by the American Associate of Medical Colleges,

18 • The Medical Decoder • Fall 2015

reports that individual schools’ class sizes vary considerably and independently of public or private schools. Therefore, class size is not an overall public or private school advantage, but rather a school-by-school consideration.

A third factor considered by applicants is ease of admission.

Similar to class size, the selectiveness of public and

private schools vary greatly.

As can be seen by comparing GPA and MCAT data on the MSAR across schools, there is no significant trend discernible between the two school types.5 While general selectiveness and application statistics might be similar across schools, it can still

be dramatically easier to obtain favorable admission odds when applying to a public school in one’s home state instead of a public school in a different state, as public universities must fill their in-state quota. The public University of Washington School of Medicine, for example, offers less than 5% of its seats to non-

considered.”8 In 2014, the University of California San Francisco received a roughly equal number of in-state and out-of-state applications, yet only about 21% of the matriculating student body was out-of-state5.

As applications cost valuable time and money, applicants may wish to focus on private schools and public schools in their home state.

This map shows the geographic distribution of public medical schools in the United States.

residents.5 The school confirms, “Out of region applicants must have an exceptional record of service or come from a disadvantaged background to be

Despite many similarities, there are trends in private and public medical schools’ areas of strength.

One possible advantage for public school over private school is in

primary care education programs.

In 2016, US News and World Report ranked all top ten primary health care programs to be public.3 On the other hand, private schools often have strong research programs; the U.S. News and World Reports’ rankings on the best medical research programs reports nine of the ten top schools to be private universities.3 Applicants with the desire to participate in research should consider the many private medical schools that are strong in this category.

Each applicant has his or her own criteria in deciding which medical programs will be an excellent fit. While in-state public school attendees might enjoy lower tuition and debt, the difference is not as great as expected, and an applicant should always carefully consider other aspects of medical school admissions. Applicants should also keep in mind that annual class size and application selectivity are not strongly correlated with public or private schools.

Applicants dedicated to the concept of primary care should more closely consider their public school options, while researchoriented individuals should investigate the myriad of excellent private institutions. Outside of these two established trends, potential medical schools should be evaluated by and large independently of a school’s public or private status.

For references, see page 26.

The Pre-Medical Experience • Volume 6 • 19

To D.O. or Not to D.O.?

Choosing your path to medicine

20 • The Medical Decoder • Fall 2015

By Michael Alvarez

F

amily care doctors, emergency physicians, hospitalists, and surgeons: we entrust our well-being to these health care professionals, finding comfort in their credentials.

Medical school, residency, and numerous board and licensing exams are accreditations that all physicians have in common. However, confusion often arises in understanding the subtle differences between the initials M.D. and D.O. following a doctor’s name. What does it mean to be a D.O.? Does it really matter if my doctor graduated from an allopathic or osteopathic medical school? How can a prospective medical student make an educated decision as to which program to choose?

approximately 200 additional hours of training in the art of osteopathic manipulative medicine.

These techniques can be used to alleviate pain, restore range of motion, and support the body’s natural functions.1 What really separates D.O.’s from M.D.’s is the way that they each view and treat their patients. In today’s medical world, we have a tendency to focus on treating acute or chronic diseases, but health care often lacks emphasis on preventative medicine.

Osteopathic medical education places more emphasis on preventive medicine, body structure and the importance of family practice.2

A strong emphasis on family care is another important aspect of the osteopathic philosophy. Many people have family care doctors, and recent statistics show that more than 75% of the D.O.’s in the United States are in family practice, as opposed to only 25% of the M.D.’s.2 Therefore, the odds of your primary care doctor being a D.O. are high. In fact, many osteopathic medical schools work to produce primary care doctors with the belief that a strong foundation in primary care makes one a better physician regardless of what specialty he or she may end up practicing later in his or her career.1 When it comes to the application process for osteopathic or allopathic medical schools, premedical students must take the Medical College Admission Test (MCAT), complete prerequisite courses, and expose themselves to volunteer work and research or clinical work. However, if someone is looking to apply to both osteopathic and allopathic medical schools, it is important to understand that each program accepts different types of applications. Traditional medical schools use the American Medical College Application Service (AMCAS), while osteopathic schools require applications to be submitted through the American Association of Colleges of Osteopathic Medicine Application Service (AACOMAS).

What really separates D.O.’s from M.D.’s is the way that they each view and treat their patients.

Allopathic medicine is associated with the traditional Medicinae Doctor, or M.D. profession. Allopathy is a system of medical practice that aims to combat disease through the use of drugs and surgery. Its counterpart, osteopathic medicine, began as a nineteenth century health reform movement that emphasized preventive care, allowing the body to heal without the overuse of medications.5 A D.O., or Doctor of Osteopathic medicine, is very much like its allopathic counterpart.

Both allopathic and osteopathic doctors participate in a similarly vigorous medical curriculum.

In fact, osteopathic medical students take

According to the American Association of Colleges of Osteopathic Medicine, D.O.’s are trained to look at the whole person from their first days of medical school.1 In a New York Times article titled “Doctor, Shut Up and Listen” the author noted a tendency for doctors to miss important details because they were not properly listening to their patients.3 If a physician approaches a patient’s problem holistically, physicians may less frequently miss important symptoms and treat patients more accurately.

After successfully completing the initial application process and gaining admission to a medical

The Pre-Medical Experience • Volume 6 • 21

school, both M.D.’s and D.O.’s are required to take a series of licensing exams commonly referred to as “steps.” M.D.’s are required to take their United States Medical Licensing Exams (USMLE), while D.O.’s take the Comprehensive Osteopathic Medical Licensing Examination of the United States of America (COMPLEX-USA).

Recently, a growing number of osteopathic medical students are opting to register for the USMLE as well as the COMPLEX exams.

Historically, osteopathic students have had a significantly lower first time attempt passing rate on USMLE step 1; however, recently this rate has improved to a 92% pass rate for D.O.

students compared to a 98% pass rate for M.D. students.6 Although osteopathic medicine is a newer and smaller field than allopathic medicine, it is important for prospective medical students to make an informed decision about the programs that they apply to.

Allopathic and osteopathic medical schools often look for different types of pre-medical students and have slightly different admission standards. With new osteopathic schools opening at a much higher rate than allopathic schools, some pre-medical applicants might begin to find more opportunities in D.O. programs.

decision not based on the difficulty of admission or prestige of the field, but rather on what one hopes to gain from his or her education in medicine.

Regardless of whether one chooses osteopathic or allopathic medicine it is important to note that either way, the future doctor will have the choice of applying to any residency program in any specialty.4

For references, see page 27.

The important thing is to make a

m.d. vs d.o. schools: A comparison M.D.

Schools

D.O.

Schools

Degree Requirements

Medical Training

Treatment Philosophy

Specialties

4 years of medical school

1 year internship, 2+ years residency

symptomfocused

all traditional specialties

4 years of medical school

1 year internship, 2+ years residency

holistic & natural focus

all traditional & neuromusculoskeletal medicine

22 • The Medical Decoder • Fall 2015

The Increase, Causes, Prevention, and Misconceptions of Skin Cancer

BY RICH APRAMIAN

Human Interest • Volume 6 • 23

M

any people know that spending a summer day outdoors can lead to a painful sunburn. However, fewer people know about the less obvious, but serious dangers that can arise from sun exposure year-round.1,2 Understanding both the mechanism by which UV light can damage unprotected skin and the proper ways to protect skin from damage are important to increasing sunscreen use and combating the rising incidence of skin cancer.3 Recent studies conducted by the Centers for Disease Control and Prevention (CDC) indicate that many people do not take the necessary precautions to protect their skin from harmful UV rays.1,4,5 This can result in damage that may cause cancer.6,7 The skin is the body’s largest organ and it serves several major physiological functions.

These functions include temperature regulation, vitamin D synthesis, and the prevention of fluid loss from the body.3 The skin consists of three layers: the epidermis (the top layer), the dermis (the middle layer), and the hypodermis (the bottom layer) (Figs.

1 and 2).7,9 The epidermis consists largely of cells called keratinocytes.9 These are cells that produce keratin, a protein that, among other functions, strengthens the skin.9

The epidermis can be further divided into sublayers, composed of other types of cells. These include a layer of squamous cells (found at the top of the epidermis), basal cells (found below the squamous cells), and melanocytes (found at the bottom of the epidermis).7,8,9 Melanocytes are cells that produce melanin, the

pigment that protects the skin from the sun’s UV rays by absorbing them.7,911 The cells in these layers are most severely damaged by UV rays. That damage, if severe enough, can then lead to skin cancer.12,13

Figure 1: Anatomy of the Skin

Note: Figure shows some of the key anatomy of the skin and some of its layers.7

Figure 2: The Epidermis and Dermis of the Skin

Note: Figure shows a general image of the two uppermost layers of the skin.9

Skin cancer is one of the most common forms of cancer in the United States.7 There are three common types: basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and melanoma, the most fatal type.7 The nonmelanoma skin cancers, BCC and SCC, account for 96% of all skin cancer incidence.14 Nonmelanoma skin cancers affect cells other than melanocytes. Both BCC and SCC, while disfiguring, are

24 • The Medical Decoder • Fall 2015

“highly curable” according to the CDC.7 Because they are often curable, nonmelanoma skin cancer statistics often do not appear in overall cancer studies. In fact, it is estimated that only 0.1% of nonmelanoma skin cancer cases are fatal.15

Melanoma, on the other hand, poses a greater threat to one’s health, as related growths are far more likely to spread to the rest of the body than growths from either BCC or SCC.16 Melanoma’s aggressive growth makes it harder to treat.16 Nonetheless, the American Cancer Society states that melanoma, BCC, and SCC are all usually curable when caught in early stages.16

Skin cancer is caused by DNA damage in skin cells.17 Although UV light has the potential to cause DNA damage, according to the Mayo Clinic, UV light-induced DNA damage does not explain skin cancer found in areas of the body not exposed to UV light.8 This suggests that there are other possible environmental and genetic risk factors for developing skin cancer.8 Nevertheless, the prevailing view is that most skin cancers arise from UV-induced DNA damage.1,6,8,12,13 This DNA damage can shut off genes that normally protect cells from mutating into cancer.

There are three types of UV rays that are emitted from the sun: UVA, UVB, and UVC. UVC rays are absorbed by the ozone layer and do not come in contact with people’s skin. However, when the UVA and UVB rays come in contact with bare, unprotected skin, damage to skin cells can occur.7,12 Several studies conclude that skin cancer is dramatically increasing in

the United States each year.4,18 Data analyzed by the CDC indicates that from 2002-2011, the incidence of melanoma increased in men by 1.5% per year and in women by 1.1% per year.4 Similarly, the American Cancer Society estimates that there will be 73,870 new diagnoses of melanoma in the U.S. in 2015.19 Another 2012 study indicates that there has been up to a 200% increase in the incidence of SCC in the United States over the past thirty years.20 Because the sun is believed to cause 86% of melanoma cases and 90% of nonmelanoma cases, it is no surprise that the sunscreen industry is worth $382.4 million dollars per year.1,21 This industry experiences seasonal sales, most of which are during the late winter through mid-summer 21 months. The problem, skin experts say, is that the skin needs to be protected year-round, as skin damage from UV rays is not seasonal. In fact, 80% of UV rays pierce through clouds, so clouds are not a substitute for sunscreen.1 Additionally, there is unseen danger caused by snow. Snow reflects up to 80% of UV rays, causing high levels of exposure.1 Dr. Perry Robins, the president of the Skin Cancer Foundation, explains that the sun’s rays can be just as harmful while skiing as they can be while at the beach.1

The study’s results pointed out that less than 15% of men and less than 30% of women use sunscreen on all exposed areas of the skin.5 The study also indicated that when sunscreen is used, 42.6% of women and 18.6% of men only apply sunscreen to their face.5 Women may be more likely than men to use sunscreen on their faces because of the of UV-resisting and anti-aging properties of cosmetics that contain sunscreen.5 It is also important to note that not all sunscreens are equal in their ability to protect the skin. To offer adequate skin protection, Dr. Elizabeth Hale, a dermatologist and professor at New

sunscreen in order to achieve the sun protection factor (SPF) advertised least two tablespoons of sunscreen should be applied to the body every two hours.2 This amount should be applied more frequently if someone is swimming or perspiring heavily.2,9

Furthermore, Dr. Hale recommends using sunscreen with an SPF of 30 or greater. The SPF specifically refers to protection against UVB rays. An SPF rating is determined by dividing the time it would take to burn with sunscreen on your skin by the time it would take to burn without sunscreen.

For example, if someone is in conditions where the skin would burn in five minutes without sunscreen, but is using an SPF 30 sunscreen, then the skin would theoretically not start to burn for 150 minutes (5 minutes x 30 SPF = 150 minutes).13 Choosing a recommended type of sunscreen and applying it liberally could be the difference between developing skin damage and keeping your skin healthy.

Understanding the causes and the measures that can be taken to prevent skin cancer are the first steps in fighting the rising incidence rate of skin cancer.

Despite the importance of covering one’s skin to prevent sun exposure, a 2013 survey performed by the CDC indicates that a majority of Americans do not use sunscreen regularly.5

York University Langone Medical Center, recommends using sunscreen with specific ingredients. Sunscreen containing zinc oxide and titanium dioxide are the most effective, as they work immediately upon application, unlike some sunscreens that take longer to be effective.2

Dr. Hale also emphasizes the necessity of using a sunscreen that offers a broad-spectrum defense, stating that “protection from both UVA and UVB is necessary, and some chemical sunscreens don’t provide comparably broad-spectrum defense.”2 She also stresses the importance of using an adequate amount of

Understanding the causes and the measures that can be taken to prevent skin cancer are the first steps in fighting the rising incidence rate of skin cancer. Shielding the skin remains one of the easiest and most effective tools to staying protected. Educating people about how UV rays can cause skin damage and what SPF means can lead to more appropriate sunscreen use and reduced skin cancer rates.

For references, see page 27.

Human Interest • Volume 6 • 25

REFERENCES

Cover Graphics: Elephant Graphic by Boudewijn Mijnlieff from Noun Project Stethoscope Graphic by Florent from Noun Project

From Bench to Bedside: Bridging the Gap Between Science and Medicine 1. Woolf, Steven H. “The Meaning of Translational Research and Why It Matters.” Journal of the American Medical Association 299.2 (2008): 211-13.

Web. 11 July 2015.

2. Kon, Alexander A. “The Clinical and Translational Science Award (CTSA) Consortium and the Translational Research Model.” American Journal of Bioethics 8.3 (2008): 58-60. Taylor and Francis. Web. 15 Oct. 2015.

3. Fontanarosa, Phil B., and Howard Bauchner. “Scientific Discovery and the Future of Medicine.” Journal of the American Medical Association 313.2 (2015): 145-46. Web. 11 July 2015.

4. Contopoulos-Ioannidis, Despina G., Evangelia E. Ntzani, and John P.A. Ioannidis. “Translation of Highly Promising Basic Science Research into Clinical Applications.” American Journal of Medicine 114.6 (2003): 477-84. Web. 11 July 2015.

5. Zerhouni, Elias. “The NIH Roadmap.” Science 302 (2003): 63+. Scopus. Web. 11 July 2015.

6. Collins, Francis S. “Reengineering Translational Science: The Time Is Right.” Science- Translational Medicine 3.90 (2011): n. pag. Web. 11 July 2015.

7. “ED-17-A.” Liaison Committee on Medical Education. American Association of Medical Colleges, n.d. Web. 12 July 2015.

8. “MD-PhD Dual Degree Training.” American Association of Medical Colleges. American Association of Medical Colleges, n.d. Web. 12 July 2015.

9. “MD/MTR.” Perelman School of Medicine. University of Pennsylvania, n.d. Web. 12 July 2015.

Graphics: Rat by Francisca Arévalo from the Noun Project Humans by Philippe Tardif from the Noun Project Clipboard by Greg Beck from the Noun Project Hospital by Creative Stall from the Noun Project

The Sustainable Development Goals 1. Nagasaki, T. (2015, October 30). The success of the SDGs depends on robust impact measurement and data collection. Retrieved November 14, 2015, from http://www.theguardian.com/sustainable-business/2015/oct/30/the-success-of-the-sdgs-depends-on-robust-impact-measurement-and-datacollection 2. Sustainable Development Goals. Retrieved November 14, 2015, from http://www.un.org/sustainabledevelopment/sustainable-development-goals/ 3. Towards a monitoring framework with targets and indicators for the health goals of the post-2015 Sustainable Development Goals. (2015). Retrieved November 14, 2015, from http://www.who.int/healthinfo/indicators/hsi_indicators_sdg_targetindicators_draft.pdf 4. The 169 Commandments. (2015, March 28). Retrieved November 14, 2015, from http://www.economist.com/news/leaders/21647286-proposedsustainable-development-goals-would-be-worse-useless-169-commandments A Guide to U.S. Health Care Policy 1. Understanding Obamacare: Politico’s Guide to the Affordable Care Act. Politico. Retrieved November 24, 2015.

2. Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally. The Commonwealth Fund. Retrieved July 17, 2015.

3. Berman, R. (2015, February 3). Why Republicans Are Voting to Repeal Obamacare—Again. Retrieved July 17, 2015.

4. ObamaCare Explained | An Explanation of ObamaCare. (n.d.). Retrieved July 17, 2015.

5. ObamaCare 2015 - Obamacare Facts. (n.d.). Retrieved July 17, 2015.

Graphics: Elephant Graphic by Boudewijn Mijnlieff from Noun Project

Standardizing Surgical Safety 1. Safe Surgery Saves Lives Frequently Asked Questions. 2014. (Accessed 16 February, 2015, 2. Haynes AB, Weiser TG, Berry WR, et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. The New England Journal of Medicine2009:491-9.

3. Organization WH. Implementation Manual: WHO Surgical Safety Checklist 2009. 2009.

4. About WHO: What we do. 2015. (Accessed 23 August 2015, at http://www.who.int/about/what-we-do/en/.)

5. Patient Safety: Global support for Safe Surgery Saves Lives. 2015. (Accessed 10/4/2015, 2015, at http://www.who.int/patientsafety/safesurgery/ endorsements_received/en/.)

6. Haynes AB, Berry WR, Gawande AA. What Do We Know About the Safe Surgery Checklist Now? Annals of Surgery 2015;00.

Medical School: Public vs. Private 1. AAMC, “Medical Schools” https://www.aamc.org/about/membership/378788/medicalschools.html 2. AAMC Website, “Private Medical Schools” https://services.aamc.org/tsfreports/report.cfm?select_control=PRI&year_of_study=2011 3. US News and World Ranking, “Best Medical Schools: Primary Care” http://grad-schools.usnews.rankingsandreviews.com/best-graduate-schools/top-medical-schools/primary-care-rankings?int=af3309&int=b3b50a&i nt=aac509 4. AAMC, Medical Student Education: Debt, Costs, and Loan Repayment Fact Card https://members.aamc.org/eweb/DynamicPage.aspx?Action=Add&ObjectKeyFrom=1A83491A-9853-4C87-86A4-F7D95601C2E2&WebCode=PubD etailAdd&DoNotSave=yes&ParentObject=CentralizedOrderEntry&ParentDataObject=Invoice%20Detail&ivd_formkey=69202792-63d7-4ba2-bf4ea0da41270555&ivd_prc_prd_key=D9B3A33A-B3B5-4F02-9A95-E19B7CECF07A 5. MSAR, “Medical School Admissions Requirements” https://www.aamc.org/students/applying/requirements/msar/

26 • The Medical Decoder • Fall 2015

REFERENCES

6. AAMC, “Public Medical Schools” https://services.aamc.org/tsfreports/report.cfm?select_control=PUB&year_of_study=2011 7. UW Medicine Official Website, “WWAMI”: http://www.uwmedicine.org/education/md-program/admissions/why-uwsom#wwami 8. UW Medicine Official Website, “Admissions Process FAQs” http://www.uwmedicine.org/education/md-program/admissions/faqs/admissions-process 9. Washington University School of Medicine in St. Louis Office of Student Financial Planning: https://finaid.med.wustl.edu/how-to-apply/doctor-ofmedicine/ 10. Duke University School of Medicine: Third Year Program https://medschool.duke.edu/education/degree-programs-and-admissions/third-year-program To D.O. or Not to D.O.?

1. What is Osteopathic Medicine? (2015) Retrieved from AACOM website. http://www.aacom.org/become-a-doctor/about-om#aboutom 2. Dolgin, Eric J., The Jones Group, (2013) Retrieved from Osteohome website. http://www.osteohome.com/page16/page28/page28.html 3. Joshi, Nirmal. (2015) Doctor, Shut Up and Listen. The New York Times. http://www.nytimes.com/2015/01/05/opinion/doctor-shut-up-and-listen.html?_r=0 4. Prep, Veritas. (2012) How to Decide Between an M.D. and a D.O. US News. http://www.usnews.com/education/blogs/medical-school-admissions-doctor/2012/04/23/how-to-decide-between-an-md-and-a-do 5. Two Kinds of Physicians: Allopathic and Osteopathic (2007) Retrieved from Indiana University Bloomington website. http://www.hpplc.indiana.edu/ medicine/med-res-twokinds.shtml 6. Should Osteopathic Medical Students Take the USMLE Step 1? (2013) MSUCOM Division of Faculty Development. http://com.msu.edu/Students/Academic_Guidance/USMLE_FAQ_12_2013%20.pdf

Cancerous Consequences: The Increase, Causes, Prevention, and Misconceptions of Skin Cancer 1. Skin Cancer Foundation. (2015, March 6). The Skin Cancer Foundation Shares Essential Sun Safety Tips for Outdoor Winter Sports. Retrieved July 12, 2015, from http://www.skincancer.org/media-and-press/press-release-2015/winter-sports 2. Hale, E. (n.d.). Ask the Expert: How Much Sunscreen Should I Be Using on My Face and Body? Retrieved July 7, 2015, from http://www.skincancer.org/ skin-cancer-information/ask-the-experts/how-much-sunscreen-should-i-be-using-on-my-face-and-body 3. U.S. National Library of Medicine. (2014, August 10). Skin Conditions. Retrieved July 1, 2015, from http://www.nlm.nih.gov/medlineplus/ skinconditions.html 4. Centers for Disease Control and Prevention. (2015, May 5). Skin Cancer Trends. Retrieved July 1, 2015, from http://www.cdc.gov/cancer/skin/ statistics/trends.htm 5. American Academy of Dermatology. (2015, May 19). Study: Most Americans Don’t Use Sunscreen. Retrieved July 2, 2015, from https://www.aad.org/ stories-and-news/news-releases/study-most-americans-don-t-use-sunscreen 6. Centers for Disease Control and Prevention. (2012, May 11). Sunburn and Sun Protective Behaviors Among Adults Aged 18–29 Years — United States, 2000–2010. Retrieved July 5, 2015, from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6118a1.htm 7. Centers for Disease Control and Prevention. (2014, January 22). What Is Skin Cancer? Retrieved July 2, 2015, from http://www.cdc.gov/cancer/skin/ basic_info/what-is-skin-cancer.htm 8. Mayo Clinic Staff. (n.d.). Diseases and Conditions: Skin Cancer. Retrieved October 10, 2015, from http://www.mayoclinic.org/diseases-conditions/ skin-cancer/basics/causes/con-20031606 9. King, D. (2014, December 3). Introduction to Skin Histology. Retrieved July 7, 2015, from http://www.siumed.edu/~dking2/intro/skin.htm 10. U.S. National Library of Medicine. (2014, October 27). Melanin. Retrieved July 1, 2015, from http://www.nlm.nih.gov/medlineplus/ency/ article/002256.htm 11. Brenner, M., & Hearing, V. (2007, November 16). The Protective Role of Melanin Against UV Damage in Human Skin. Retrieved August 15, 2015, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2671032/ 12. Erb, P., Ji, J., Kump, E., Mielgo, A., & Wernli, M. (2008). Apoptosis and Pathogenesis of Melanoma and Nonmelanoma Skin Cancer. Retrieved July 3, 2015, from http://link.springer.com/chapter/10.1007/978-0-387-77574-6_22 13. Tachibana, C. (2010, June 1). Probing Question: What Does the SPF Rating of Sunscreen Mean? Retrieved August 15, 2015, from http://news.psu. edu/story/141338/2010/06/01/research/probing-question-what-does-spf-rating-sunscreen-mean 14. U.C.S.F. Staff. (2007, May 4). Nonmelanoma Skin Cancer vs. Melanoma. Retrieved October 19, 2015, from http://dermatology.medschool.ucsf.edu/ skincancer/general/MelanomavNon.aspx 15. Cancer.net Editorial Board. (2015, June 1). Skin Cancer (Non-Melanoma): Statistics. Retrieved August 15, 2015, from http://www.cancer.net/cancertypes/skin-cancer-non-melanoma/statistics 16. American Cancer Society Staff. (2015, April 13). Skin Cancer Facts: What is the Skin? Retrieved October 10, 2015, from http://www.cancer.org/ cancer/cancercauses/sunanduvexposure/skin-cancer-facts 17. Mayo Clinic Staff. (n.d.). Diseases and Conditions: Melanoma. Retrieved October 10, 2015, from http://www.mayoclinic.org/diseases-conditions/ melanoma/basics/causes/con-20026009 18. Howlader N., Noone A.M., Krapcho M., Neyman N., Aminou R., Waldron W., Altekruse S.F., Kosary C.L., Ruhl J., Tatalovich Z., Cho H., Mariotto A., Eisner M.P., Lewis D.R., Chen H.S., Feuer E. J. (2012, April). SEER Cancer Statistics Review, 1975-2009 (Vintage 2009 Populations), National Cancer Institute.

Retrieved July 2, 2015, from http://seer.cancer.gov/csr/1975_2009_pops09/ 19. American Cancer Society. (2015). Cancer Facts and Figures 2015. Retrieved July 8, 2015, from http://www.cancer.org/acs/groups/content/@ editorial/documents/document/acspc-044552.pdf 20. Skin Cancer Foundation. (2015). Skin Cancer Facts. Retrieved July 8, 2015, from http://www.skincancer.org/skin-cancer-information/skin-cancerfacts 21-. Petrillo, N. (2014, August 22). Endless Summer: How Six Seasonal Industries Stay Warm in Winter. Retrieved July 6, 2015, from http://media. ibisworld.com/2014/08/22/endless-summer-six-seasonal-industries-stay-warm-winter/

References • Volume 6 • 27

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