The Medical Decoder Spring 2015

MD

Volume 5 • Spring 2015

THE MEDICAL DECODER

Holistic Review: Preparing a New Generation Page 23 Out With the Old, In With the New...

MCAT Page 26

The Changing Face of Medicine

IN THIS ISSUE Science & Technology

5 Could Kidney

Denervation End the Hypertension Epidemic?

Paige VonAchen

Northwestern University ‘15

8 Sound of Silence: The

Effects of Nicotine on Auditory Cells Robert Fisch

Northwestern University ‘15

12 Minimally Invasive,

Maximally Effective Dane Rucker

Northwestern University ‘16

Health Care & Policy

16 Talking Taboo: A New

Approach to Chronic Illnesses and End-ofLife Care Joanna Jaros

Northwestern University ‘14

19 Football’s Biggest

Headache

Michael Rallo Rutgers University ‘17

Human Interest

31 A Traveler’s Guide to

the Kingdom of the Ill Alex Winnett & Hannah Stowe McMurry University of Massachusetts Boston ‘16 Georgetown University ‘15

2 • The Medical Decoder

The Pre-Medical Experience

23 Holistic Review:

Preparing a New Generation Sarah Smith

Northwestern University ‘15

26 Out With the Old, in

With the New... MCAT Lukasz Jaros

Northwestern University ‘16

The Medical School Experience

37 The Impending Crisis

with Primary Care Aditya Ghosh

Northwestern University ‘15

Editors-in-Chief

Brianna Cohen Svetlana Slavin

Editing Staff

Anisha Arora Arjun Balakumar Andy Donaldson Aayush Gupta Korri Hershenhouse Sarah Laudon Nathaniel Moxon Isabel Ngan Savan Patel Alec Straughan

Creative Director Lauren Kandell

Design Team

Jacob Meshke Alexis O’Connor Zachary Woznak

Marketing Directors Aditya Ghosh Sarah Smith

40 References Volume 5 • Spring 2015 • 3

LETTER FROM THE EDITORS

Dear readers,

Welcome to the fifth edition of The Medical Decoder! This exciting issue explores the changing face of medicine. The health care field is rapidly evolving, and this transformation is all the more prominent for pre-health students who are being ushered into this advancing world.

The focus of medicine is shifting to encompass a more patient-centered model.

MD writers Alex Winnett and Hannah Stowe McMurry detail a nuanced approach to patient treatment in their article “A Traveler’s Guide to the Kingdom of the Ill”.

Doctors, they argue, must act as careful mediators between the world of the sick and the world of the healthy. Similarly, Joanna Jaros’s piece on end-of-life care explores the importance of patients’ priorities and wishes in their last moments of life. “Talking Taboo” echoes Atul Gawande’s sentiments about the important role doctors need to undertake in balancing treatment with compassion.

As pre-medical students, we have bore witness to the evolution of medical schools’ admissions standards. The new Medical College Admission Test, which is extensively outlined in Luke Jaros’s “Out With the Old, In With the New...MCAT”, reflects medical schools’ attempts to train physicians who are cognitively and emotionally competent. Now more than ever, medical schools are seeking students who demonstrate the potential of becoming well-rounded doctors. Sarah Smith’s research into the holistic approach medical schools are taking in evaluating applicants is explained in “Holistic Review: Preparing a New Generation”.

As if the changes in the field of medicine were not enough, The MD is also evolving; this edition is the first publication under our new leadership team. As the new editors-in-chief we would like to thank you for your continued readership and support. The MD would not be the growing publication it is today without the backing of its readers. We are pleased to present the fifth edition of The Medical Decoder. Enjoy!

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

4 • The Medical Decoder

Could Kidney Denervation End the Hypertension Epidemic?

By Paige VonAchen

Cardiovascular disease is the world’s leading cause of death. High blood pressure, also known as hypertension, is one of the major symptoms of cardiovascular disease. It affects approximately 30-40% of people worldwide and its prevalence only continues to increase with rising obesity and an aging population.

Science & Technology • Volume 5 • Spring 2015 • 5

Diving deeper into these mechanisms, it has been found that along with the sympathetic nervous system, the renin-angiotensin pathway in the kidney also increases blood pressure. This works through the following series of events: in response to low blood flow in the kidneys, the juxtaglomerular cells in these organs release renin, a protein. This molecule consequently helps to convert another molecule, angiotensinogen, into angiotensin I, and finally angiotensin II. Angiotensin II is a potent vasoconstrictor, which Figure 1: Medtronic’s renal denervation device called Symplicity. increases blood pressure in a similar Ten percent of adults suffer from “resistant” manner as the sympathetic nervous system.

In the 1930s, in order to reduce patients’ blood hypertension that is unresponsive to antihypertension drugs for unknown reasons.1 pressure, doctors would surgically remove the Millions of dollars have been poured into research nerves that detect blood flow in the kidneys. on the causes of and treatments for hypertension. However, these practices were high risk, and In studying factors that contribute to with the development of antihypertension drugs, the procedure high blood pressure, was eventually phased researchers have out. As hypertension observed that the rates continue to rise – sympathetic nervous likely due to an increase system (the “fight” part in sedentary lifestyles of our body’s “fightin certain populations or-flight” response) – and medical plays a major role. technologies progress, Elevated sympathetic there has been a renewed nervous system activity interest in finding results in constricted blood vessels and an increased heart rate. With the heart pumping solutions that are as direct as the original 3 more blood, and a narrower vessel for the nerve removal surgeries, albeit less invasive.

Fast-forward to today, and we find the blood to flow through, the pressure inside the circulatory system (the system that largest medical device companies racing to conducts blood through the body) increases.2 develop “renal denervation” technologies that This understanding has led to today’s safely ablate, or burn, these kidney nerves.

What is renal denervation? It is a nonantihypertension drugs which systemically decrease the activity of the sympathetic invasive catheter-based procedure that delivers nervous system. Patients who take these drugs low-level radiofrequency energy through the experience a decrease in blood pressure and renal artery wall to the surrounding nerves. It are at a lower risk for cardiovascular disease. consists of a device similar to that pictured in

Will renal denervation technology be the solution to the world’s rising cardiovascular disease problem?

6 • The Medical Decoder • Science & Technology

differences between those treated with the device and the control group.5 However, a recent post hoc analysis of the trial suggested that there were confounding factors that may have impacted the final results.6 Despite the potential possibilities of success with renal denervation, doctors and patients should not treat it as the holy grail of hypertension treatment. In addition to this procedure, doctors should also focus on preventative measures, including a healthy diet and exercise. However, not all cases of blood pressure and cardiovascular disease are due to lifestyle. People may be genetically predisposed to cardiovascular disease.

Will renal denervation technology be the solution to the world’s rising cardiovascular disease problem? Only time will tell. As Figure 2: Anatomy of the abdominal aorta, inferior vena cava, renal artery, and kidney. companies and research groups continue to hash out the kinks with this technology, patients with Figure 1. The wire-like part of the instrument is resistant hypertension wait anxiously for the inserted through a patient’s circulatory system procedure to be available to the general public. ∎ into the renal artery (Figure 2). The probe at of the end of the wire (Figure 3) effectively ablates For references, see page 40. surrounding nerves with radio frequency energy.

This inhibits the renin-angiotensin pathway that would normally increase blood pressure.

The result is a decrease in vasoconstriction and a decrease in the patient’s blood pressure.3 If medical companies can get these new renal denervation devices approved by the Food and Drug Administration, analysts estimate the hypertension-treating device market to be at about $2.8 billion dollars by 2020.4 Medtronic, the world’s largest medical device company and the leader in the renal denervation race, has gone through three clinical trials testing its “Symplicity” device. The first two trials showed that the procedure safely denervates the kidney and provides substantial, sustained reductions in blood pressure in humans.

Unfortunately, their latest and most Figure 3: Probe used to ablate renal nerves in renal extensive study has shown no significant denervation surgery.

Science & Technology • Volume 5 • Spring 2015 • 7

8 • The Medical Decoder • Science & Technology

Already associated with a host of throat, lung and mouth diseases, your afternoon cigarette break might also be hurting your hearing.

By Robert Fisch

E

ach year, an estimated 443,000 people die from exposure to either primary or secondhand tobacco smoke.

An additional 8.6 million people have serious illnesses as a result of smoking.

These illnesses come in the form of lung cancer, chronic pulmonary disease, heart disease, stroke, and various other medical complications.1 However, the side effects of exposure to tobacco smoke may be more harmful than previously thought, as smoking could also be quietly affecting people’s hearing.

Different research groups have recently found that smoking results in a decreased ability to hear high frequency sounds, and an increased degree of tinnitus, the constant ringing sound that lingers in a person’s ear, and hearing loss in adults.2,3,4,5 Research regarding the physical effect that nicotine has on the organs within the ear is sparse. However, Dr. Amel M. AbdelHafez and his team of doctors at Assiut

University in Northern Egypt have found compelling visual evidence that nicotine can severely affect the size, shape, and health of cochlear hair cells that are imperative to hearing.6 Located deep inside the ear, the cochlea, a small, coiled, snail-like structure, is the primary organ for sound detection. Within the cochlea, hair cells are responsible for neuronal propagation of a detected sound to the auditory cortex of the brain.

The auditory cortex then sends this information to other parts of the brain for processing. The cochlea’s essential hair cells have protrusions called cilia that bend upon sound detection, causing cell depolarization and adjacent neuronal firing.7 Complete hair cell ablation, or hair cell removal, fully wipes out the ability to hear, exemplifying these cells’ crucial role in hearing.8 To test how hair cells are physically affected by nicotine, Abdel-Hafez and his team took a closer look at hair cells and the surrounding cochlear support cells using modern microscopy techniques. These imaging techniques included standard light microscopy and two different types of high-magnification, high-resolution electron microscopy.

The team used cells belonging to guinea

Science & Technology • Volume 5 • Spring 2015 • 9

pigs, which share very similar auditory anatomy with humans.6 The cells that the researchers examined were exposed to different levels of nicotine and later compared.

Abdel-Hafez’s team used 15 guinea pigs to carry out their experiments. Five guinea pigs were given no nicotine as a control group, five guinea pigs were given a specific dose of nicotine every day for a month to mimic moderate tobacco users as an experimental group, and five guinea pigs were given double the dose of nicotine every day for a month to mimic heavy tobacco users as a second experimental group.

The guinea pigs were then anesthetized and euthanized, allowing the researchers to remove the cochleas and prepare samples for imaging.

While imaging these different cells, the researchers looked at cochlear cell structure, organization, and size to determine the health of these vital cells. What they found in these images did not come as a surprise.

Hair cells and surrounding support cells within the cochlea of the non-nicotine group of guinea pigs were visibly healthy.

They displayed appropriate spacing, were organized in the expected mosaic configuration, and were free from scars, growths, or any other disfigurations.

The cilia attached to the hair cells were sturdy, smooth, evenly spread out, and neatly structured. This clean cell colony is an example of healthy hearing cells that should be able to properly detect sounds at frequencies and volumes normally audible to guinea pigs.

The cells of the two experimental groups did not exhibit these healthy characteristics.

Hair cells and surrounding support cells of the low-dose nicotine guinea pigs were visibly not as healthy as their non-nicotine counterparts. Even at a moderately low dose, hair cells began to show signs of wrinkling and deterioration. The cells were organized relatively normally, but seemed to be squeezed toward the midline of the cell colony as a result of structural cells pushing in on the weakened hair cells. The nuclei within these hair cells became darker and there were large vacuoles – bubblelike membranebound organelles within a cell – that did not appear in the healthy cochlear cells.

The cilia began bundling, bending, and showing signs of deformity and weakness.

The “heavy smoking” group of guinea pig ear cells displayed even worse signs of deterioration. Organization worsened and cells wrinkled. Support cells further encroached on the weakened hair cells.

Discolored nuclei and large vacuoles were

Even at a moderately low doses [of nicotine], hair cells began to show signs of wrinkling and deterioration...The “heavy smoking” group of ear cells displayed even worse signs of deterioration.

10 • The Medical Decoder • Science & Technology

also visible. The cilia were even more bent, weak, and bundled than the low-dose nicotine cells. Growths protruded from the cells and scars were visible throughout the colony.

While this study itself did not test the hearing ability of the guinea pigs, it provides evidence that nicotine is linked to deteriorating cochlear cells. These findings reinforce previous studies by adding visual evidence of physical damage to cochlear cell health caused by nicotine. Previous research showed significant hearing loss as a result of smoking, including a 2014 study that demonstrated that factory workers who smoked cigarettes had a noticeably weaker ability to hear high frequency sounds than non-smokers at the same factory.3,4 In tandem, these studies show that auditory cells are both physically and functionally affected when exposed to nicotine.

The results from Abdel-Hafez’s research are also in accordance with an earlier finding that the presence of low doses of nicotine on any cells that display nicotinic receptors induces degradation and apoptosis, the process of programmed cell death.9 Cochlear hair cells do in fact display nicotinic receptors and are therefore at risk of degradation and apoptosis when exposed to this tobacco constituent.10 A big challenge moving forward in research is obtaining hearing ability results and imaging from the same subject. If a single study could show decreased hearing ability and decreased hair cell health in the

same subject, this would likely dispel any doubt about the negative effects of smoking on hearing. However, this is a challenge considering that live human cochlear cells cannot be harvested for research, as doing so would irreversibly damage the subject’s hearing.

Additionally, in animal-based experiments, it is difficult to mirror the exact conditions of human tobacco users, and to quantify cell health and

This study...provides evidence that nicotine is linked to deteriorating cochlear cells. These findings reinforce previous studies by adding visual evidence of physical damage. degeneration. While qualitative imaging can show signs of cell health, it cannot directly compare the function of hair cells.

Regardless, more research is necessary to uncover the direct effect that cigarette smoking can have on hearing.

For now, Abdel-Hafez and his research team have potentially quieted opposing studies, as there seems to be clear evidence of direct cochlear cell damage after exposure to nicotine. These findings may affirm tobacco as a true silent killer of hearing. ∎

For references, see page 40.

Science & Technology • Volume 5 • Spring 2015 • 11

12 • The Medical Decoder • Science & Technology

Minimally Invasive, Maximally Effective Laparoscopic surgery is a popular alternative to traditional, open surgery. It has the potential to improve recovery, decrease pain, and save money.

By Dane Rucker

Photo by Leah Gunn

Science & Technology • Volume 5 • Spring 2015 • 13

Surgery has been an essential treatment tool for as long as medicine has existed.

Consequently, as doctors’ understanding of medicine improved, so did their surgical techniques. Now, after thousands of years of innovation, doctors have the capability to relieve pain, repair organs, and improve bodily function in a quick and effective manner. Despite all of their previous advances, surgical techniques continue to improve in order to minimize any negative effects on patients.

as small as a third of an inch. For more complicated procedures, such as cardiac surgery, there can be multiple incisions as long as three or four inches.

A laparoscope attached to the end of a long tube, known as an “arm,” is inserted through the primary incision into the body cavity. Additional surgical instruments are placed inside the area of operation. As the laparoscope moves through the body, it relays images onto a screen that allows the surgeon to visualize Surgical advancements aim to improve the instruments’ movement. The surgeon recovery times, decrease pain, reduce total number of hospital visits, and lower costs; these advancements have yielded operations superior to traditional surgery under many circumstances. Currently, one of the most popular and influential innovations is the development of minimally invasive, laparoscopic surgery.

As the laparoscope moves through the body, it relays images onto a screen that allow the surgeon to visualize the instrument’s movements. The surgeon can then perform a modified version of the traditional, open, surgery.

Laparoscopic surgery relies on small cameras, no wider than a pinky finger, called laparoscopes. The now-popular procedure was introduced in the early 20th century by the Swedish surgeon Hans Christian Jacobaeus.1 Over the following decades, the procedure was further refined, and by 1990, surgeons around the world were performing the technique.2 The procedure begins with an incision, measuring as small as one tenth of an inch, close to the target area. The size and number of cuts depend on the procedure.3 For example, the removal of the gall bladder requires only one incision

can then perform a modified version of the traditional, open, surgery.4 This technique also enables the surgeon to have a magnified view of the internal organs, which often translates to a more accurate procedure.5 Laparoscopic surgery has numerous advantages over a traditional approach.

Smaller incisions allow the body to recover more quickly and with less pain, permitting a shorter hospital stay. The minimally invasive technique also lowers the risk of permanent scarring, intense blood loss, and a hefty hospital bill.6

14 • The Medical Decoder • Science & Technology

Like most advancements in technology, this innovative surgical procedure also comes with some disadvantages. Many doctors who were already trained in their respective fields must now adapt to these changing techniques. This requires that they spend time perfecting their skills in these surgeries.

Furthermore, the initial costs of implementing laparoscopic surgery are higher than continuing traditional surgical methods because it requires expensive equipment and individualized training. The burden of these costs may be unappealing to certain hospitals, preventing them from offering laparoscopic surgery as an option.12

Patients also often request laparoscopic surgeries because of the advantages that accompany this technique. Yet, under some circumstances the surgery may require an increased visual field only available with traditional surgery. For example, certain types of thoracic surgery and tumor removal operations are better-suited for a traditional approach, because it can be beneficial for surgeons to examine the surrounding physiology to completely address the problem. Patients who request laparoscopic surgery could be increasing their operating time, turning a simple procedure into a more difficult and dangerous one.11 Many other factors including age, general health, and medical history are also considered when determining the best surgical approach.

University of Cincinnati estimated that only 10% of all lung cancer operations in the United States in 2007 were performed using minimally invasive techniques. Today, up to 40% of all lung cancer patients receive minimally invasive surgery.9 With an increase in the use of laparoscopic surgery, new technologies are being implemented to further improve the quality of this technique. For instance, robotic surgery is emerging as an innovative facet of minimally invasive surgery. Similar to laparoscopic surgery, robotic surgery utilizes three or four small incisions. However, rather than controlling the instruments directly, the surgeon uses a remotely controlled robot. This enables the surgeon to make small, precise movements that he or she would not be able to manage without the use of the nimble robot.2,10 Robotic surgeries are developing as the newest technique for tumor removal because of the technology’s ability to cut out tumors with minimal damage to neighboring tissues.8

There is a growing consensus that minimally invasive surgeries have many benefits over a traditional approach.

While there are risks associated with laparoscopic surgery, the benefits of higher efficiency surgery and shorter recovery times are promising. The evolution of surgical techniques will be exciting to monitor as surgeons continue to develop more effective ways to perform procedures on their patients. ∎

The emergence of laparoscopic techniques is altering the field of surgery.

For references, see page 41.

For example, thoracic surgeons from the

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Image courtesy of National Cancer Institute

Talking Taboo

A New Approach to Chronic Illnesses and End-of-Life Care

By Joanna Jaros

A

mere century ago, physicians and scientists faced an immense challenge: limited understanding of the human body. A lack of knowledge regarding anatomical structures, biological and biochemical pathways, and mechanisms of disease pathology meant that limited treatments were available for the sick.

Consequently, the few available medications were idealized as cure-alls. A sick patient with a known illness was expected to take a single, standardized pill and become healthy nearly instantaneously.

For example, a patient with a bacterial malady such as pneumonia, gonorrhea, or rheumatic fever could rest assured knowing that several doses of penicillin would reliably alleviate his or her symptoms.1 Side effects of personalized treatments were not part of the medical

repertoire, and physicians were viewed as one-stop shops for medications. Moreover, chronically-ill and end-of-life patients who did not respond to medications died without any significant intervention.

Today, medical practice is strikingly different. Physicians undergo rigorous training in medical school and residency to master a subset of over 4,000 procedures and 6,000 medications.4 Research studies investigate 78 organs, 13 organ systems, and more than 60,000 identified ways in which they can all fail.2 Each day, our access to knowledge of diseases and their complex etiologies grows. In contrast to our predecessors, many modern procedures and medications now target chronic illnesses and end-of-life suffering. This evolution of the medical field has challenged physicians and their teachers

16 • The Medical Decoder • Health Care & Policy

to adapt their practice in an unprecedented manner. Specifically, doctors are taking a new look at end-of-life care.

As a future medical student, I felt challenged to better understand medicine’s approach toward mortality. Although I found this topic untouched by most writers, I finally stumbled upon the book Being Mortal by Dr. Atul Gawande, a respected medical writer and surgeon at Brigham & Women’s Hospital. As I read through the book, I became immersed in the picture Gawande was painting. I was especially rattled when he described a 90-year-old nursing home resident with dementia and summed up her gut-wrenching experience: “All privacy and control were gone. She was put in hospital clothes most of the time. She woke when they told her, bathed and dressed when they told her, ate when they told her…There was a succession of roommates…

She felt incarcerated, like she was in prison for being old.”3 This injustice must be restricted to only nursing homes, I thought to myself.

Unfortunately, I discovered that this was not the case. Later in the book, Gawande continued to show that a “fix-it-now-and-maybe-thingswill-get-better-later” attitude toward health care is commonplace. Whether it be a patient going in for knee surgery or a diabetic, hypertensive woman who needs to control her lipids and blood pressure, medicine has, in some ways, become about finding the most innovative science-based fixes.

Gawande continues by referencing a conversation with a palliative care colleague, Dr. Susan Block, who states, “To most doctors, the primary purpose of a discussion about terminal illness is to determine what people want – whether they want chemo or not – whether they want to be resuscitated or not – whether they want hospice or not. [They] focus on laying out the facts and options.”3 My current job at an electronic medical record vendor has given me a glimpse of advanced-care planning and the current mindset towards end-of-life care. Constrained by innate biology, the human reaction has been to mechanize, automate, and systematize health care in an effort to achieve better outcomes. If we – patients and doctors – want to accept the inevitability of death, should these be our only priorities?

I believe that the missing component in endof-life care is a fundamental understanding of patients’ priorities and values. Future physicians may need to restructure their approach to advanced care planning to include patient goals, not just their own treatment goals. If providers are able to make this leap, we can move towards a health care system that provides cutting-edge treatments with room for a higher-quality lifestyle for patients in their last months of life.

How can physicians better strike a balance between patient priorities, cutting-edge science, and health care policy? Gawande and Block propose one modification to the patient-

Future physicians may need to restructure their approach to advanced-care planning to include patient goals.

Health Care & Policy • Volume 5 • Spring 2015 • 17

doctor conversation to help even the scale.

When a physician feels that his or her patient is facing an incurable disease, Gawande and Block suggest that the physician begin any end-of-life care conversation with the a few key questions. These questions allow the physician to center the conversation around the patient’s needs and concerns:

Key Questions: What is your understanding of your condition/your health?

What are your fears and worries?

What are your goals if your health worsens?

What are the sacrifices that you are willing to make?

What outcomes are unacceptable for you?

between patient and physician goals and to emphasize the physician’s moral obligation to preserve patient autonomy during treatment.

A month after finishing Being Mortal, I had the opportunity to attend a lecture by Dr. Gawande. In his talk, Gawande highlighted a key belief of the medical practice: sacrifice time now for future gains. For example, a knee replacement will require complex surgery and months of down time. Patients can choose to trade off short-term suffering for long-term improvements in mobility. While this makes sense for younger patients, Gawande suggests this may not be the best option for chronically ill patients who already face an expected shortened lifespan. Instead, he proposes “fighting for a good day” as a better approach to best serve the patient in his or her final days.2 Having reflected on the evolution of medical thought and its relation to end-of-life care, I see a huge potential for growth. While our medical knowledge has increased significantly in the past century, we remain imperfect. Gawande aptly writes: “We’ve been wrong about what our job is in medicine. We think our job is to ensure health and survival. But really, it’s larger than that. It is to enable well-being. And well-being is one of the reasons one wishes to be alive.”3 Health care delivery has the capacity to address the quality of life concerns that Gawande has envisioned. With the right set of questions and a listening ear, doctors can provide well-balanced end-of-life care. As a future physician, I am excited to enter a field where I am able to not only contribute to scientific innovation, but also to the wellbeing of those around me. ∎

The first question allows the patient to process his or her medical condition and for the physician to fill in the gaps as needed.

Ensuring that the patient understands his or her condition is vital for a fruitful end-oflife conversation to occur. The subsequent questions are meant to gauge the patient’s values – what activities, people, or experiences do they live for? What trade-offs are they willing to make to improve their health? What freedoms are they unwilling to sacrifice?

These questions require a physician mindset that centers on listening to and prioritizing patient needs.3 The mantra of the modern medical profession is to provide the best treatments available to patients. Through his discussion, Gawande aims to expose the disconnect For references, see page 41.

18 • The Medical Decoder • Health Care & Policy

s ’ l l a b t Foo Biggest e h c a Head

By Michael Rallo

Concern surrounding concussions has sparked social reform and medical advances, pushing the issue to the forefront of America’s beloved sport.

Health Care & Policy • Volume 5 • Spring 2015 • 19

Each year during football season, athletes engage in a battle on the field.

Bodies rush towards each other with tremendous force – helmets crash and the crowd cheers. For sixty minutes, these athletes are warriors.

However, each impact that occurs has the potential to cause a concussion and leave the player with irreversible brain damage.

The effects of a concussion begin with the initial impact. The brain strikes the front of the skull, then bounces and impacts the opposite side. These collisions can result in swelling, bruising, and even bleeding from the injured brain. The collisions also initiate a cascade of intracellular events, which can leave the brain vulnerable to future injury.1 The physical injury manifests itself in symptoms such as loss of consciousness, amnesia, confusion, disorientation, headache, and emotional problems. Although they typically resolve within 7-10 days, symptoms can persist for weeks, months, and even years.

In the days following a concussion, patients are advised to rest and avoid strenuous physical and mental activity to prevent further injury.2 The “brain-rest” described above is challenging for individuals, especially athletes, who want to get back to their daily routine as fast as possible. Physicians are faced with the

difficult decision of determining the most appropriate time for a patient to rest before returning to full activity. This becomes even more complex when a physician must clear the athlete to return to an activity that could subject them to a similar injury.

The most devastating, albeit rare, consequence of an athlete returning to play too soon is Second Impact Syndrome (SIS).

In these cases, a player returns to the field, often shortly after sustaining a concussion, and suffers another hit. The second impact triggers catastrophic swelling in the already-injured brain. Inside the rigid container of the skull, the brain has no room to swell so it herniates — the brain stem pushes through an opening in the bottom of the skull. The individual typically loses consciousness and stops breathing.

Even with successful resuscitation efforts, the damage to the brain is irreversible and either leaves the individual brain dead or with a severe and permanent disability.3 The long-term effects of repeated concussion have been brought to light by the National Football League’s (NFL) emerging concussion crisis.

In 2002, medical examiner Dr. Bennet Omalu discovered the first evidence of extensive damage in the brain of a professional football player while performing an

20 • The Medical Decoder • Health Care & Policy

autopsy on retired Pittsburgh Steeler Mike Webster. This came after Webster’s accusations that injuries sustained during his seventeenyear career in the NFL contributed to his dementia.

The damage found in Webster’s brain was consistent with chronic traumatic encephalopathy (CTE), a progressive neurodegenerative disease caused by repetitive head injuries.4 CTE is associated with deposits of proteins and brain tissue tangles, which cause cellular dysfunction and eventual cell death. These structural brain changes are responsible for neurological symptoms including memory and emotional disturbances, suicidal tendencies, and motor dysfunction.5 CTE is a likely explanation for the misfortunes that plagued Webster and other retired football players.

Despite being aware of the risks that these contact sports pose, athletes continue to play.

Why? Although external factors such as money may contribute, most athletes play because they truly enjoy the activity. The sport provides entertainment to the participants themselves, as well their families and spectators. As such, these individuals play a major role in the development of “concussion culture”.

One of the most significant relationships that exists is that between an athlete and his or

her coach. The coach provides guidance, motivation, and criticism, as well as expectations of the athletes.

C o n s e q u e n t l y, athletes are driven by their desire to not let their coaches down. This is a major issue with respect to concussion diagnosis because athletes are often ashamed to admit that they have suffered an injury.6,7 Similarly, athletes may be pushed by their parents and families to participate and excel in sports. Parental motivation can be extremely important in the athletic growth of an individual.

However, when parental motivation turns into parental pressure, it can be dangerous in that players may feel that admitting to an injury, and being taken out of the game will be seen as a disappointment. This relationship can be quite complicated, as parents want to see their child succeed, but often do not realize the severity of the sustained injury.7 The relationship between player and teammate is also important, as athletes do not want to let their fellow teammates down or appear weak in front of their team. This is a major reason why athletes may ignore an injury. Lastly, the relationship between the athlete and sports spectators is also significant. This relationship can be summarized in a quote by the renowned sportscaster, Stan Savran, who said “the

Health Care & Policy • Volume 5 • Spring 2015 • 21

management of concussion, there has also been biggest cheers are for the touchdowns, but the significant research done on its underlying second biggest cheers are for a nasty hit.”4 mechanisms and potential therapies. Despite Although these sociological factors may not advances in research and education, concussions seem important to pre-health students, we must remain a major issue in the sports setting. recognize that a patient is not a set of symptoms, This past January, both Ben Roethlisberger but a person. In order to build and maintain and Heath Miller of the Pittsburgh Steelers a good rapport with a patient, healthcare returned to play within five minutes of taking workers must understand their patients’ beliefs a hard hit. Although they may not have suffered and desires. It may be hard to understand why concussions, both players rejoined the game athletes continue to put themselves at risk, too quickly for a thorough assessment to have knowing that their next injury could be lifebeen performed.10 This raises the question of changing. But if the relationship between an whether sideline physicians are truly unbiased individual and his or her sport is considered, in their decisions. the patient is given an opportunity to find trust Many football players, coaches, and fans feel in his or her physician. threatened by the rise of a concussion-conscious In recent years, the public. They worry efforts of physicians It may be hard for us to that concern over and scientists have understand why athletes concussion will lead to led to a change in how continue to put themselves at the demise of football. concussions are handled Concussion does not in the sports setting. The risk... But if the relationship have to be the end between an individual and of sports. However, NFL’s Head, Neck, and Spine Committee is co- his or her sport is considered, players, coaches, chaired by two renowned the patient is given an and their families neurosurgeons, Drs. opportunity to find trust in must become more Hunt Batjer and Richard educated to realize his or her physician.

Ellenbogen, who oversee the gravity of this type the management of of injury. Concussion concussions in professional football. The should not be thought of as an injury that can committee has developed sideline assessments be walked off. It must be considered an injury to increase the accuracy of concussion diagnosis that requires professional assessment and and to ensure that players who have suffered management. a concussion are not immediately allowed to As the public becomes increasingly aware return to play. of this injury, parents are going to ask a Additionally, it has become a standard in both fundamental question: “Is it safe for my child to professional and college football for physicians participate in a certain sport?” The public will to be present on the sideline, constantly look to doctors as authority figures on these observing players for signs and symptoms of issues. As such, physicians must be proficient concussion. Players that are showing symptoms in their science. But above all else, a physician consistent with a concussion are not allowed to should remember to understand the emotions, return to play until they are cleared by the team goals, and values of a patient, football player or physician. This guideline is in place to prevent not. ∎ an athlete returning to play and suffering an additional injury.8, 9 For references, see page 42.

As progress has been made in the clinical

22 • The Medical Decoder • Health Care & Policy

Holistic Review: Preparing a New Generation

Medical schools across the country are revamping standards and demanding more well-rounded applicants.

By Sarah Smith Ask any pre-med undergraduate student what the two most important defining factors in the medical school application process are, and their answer will likely be GPA and Medical College Admission Test (MCAT) score. This assessment holds some validity. Admissions committees at medical schools have focused heavily on these hard and fast numbers in the selection of applicants.1 While other factors such as extracurricular involvement, philanthropy, and research experience undoubtedly play a role in the admissions process, most medical school admissions committees acknowledge that GPA and MCAT scores are “cut-off points to whittle down the initial applicant pool.”2 As a result, “top” medical schools boast the highest average GPAs and MCAT scores.

The Pre-Medical Experience • Volume 5 • Spring 2015 • 23

In recent years, critics have begun to question the heavy prioritization of these two parameters in the medical school admissions process. While GPA and MCAT scores may reveal an aptitude for science, they cannot predict “key aspects of behavior, character, and performance [that] are essential for the practice of medicine.”2 Furthermore, studies have shown that the broader context of an applicant’s life, including socioeconomic status, race, and gender can significantly influence GPA and MCAT scores.

For example, MCAT preparation through test prep companies has developed into a lucrative industry, which critics have noted creates a significant disadvantage for those who cannot afford these services.2 These concerns reflect larger trends in the world of medical education. Discussions about diversity and admissions policies are

taking place within most institutions of higher education, and universities and medical schools are working to build a more diverse range of classes. Additionally, a call for more personable, empathetic doctors has resonated over the past few years. With unsatisfactory patientphysician communication often acknowledged as the dominant cause of malpractice lawsuits, the need for doctors with good communication skills is increasingly apparent.3 In 2007, the Association of American Medical Colleges (AAMC) created the Advancing Holistic Review Initiative, designed to develop “missioncentered, admissions-related tools and resources that medical schools can use to create and sustain diversity.”4 Through this project, the AAMC lends support to medical schools that want to adjust their admissions process to be more comprehensive and integrative by considering factors beyond grades and test scores. Holistic review allows for the assessment of an applicant’s abilities as a balanced combination of life experiences, academic metrics, and personal attributes.1 The transition to holistic review is few or no carried out through workshops offered extracurriculars by the AAMC. These workshops are geared toward helping medical school admissions committee members and key administrators develop assessment parameters that reflect their school’s diverse interests and mission statements.4 poor bedside manner In practice, the transition to holistic review varies across medical schools because each school’s mission statement also varies. For example, the Icahn School very high GPA of Medicine at Mount Sinai adopted & perfect test a radical version of holistic review, scores only offering an early acceptance program for undergraduate sophomores studying humanities or social sciences. These rigid & more goal-oriented students are exempt from taking the MCAT and typical pre-med classes. One

the old

oriented toward specialization

exclusively interested in science uninvolved in campus social life a lot of lab research

24 • The Medical Decoder • The Pre-Medical Experience

of the aims of this program is to train physicians who have a “strong appreciation of human rights and social justice,” which aligns with the school’s mission statement of providing “high quality patient care…in an atmosphere of social concern and scholarly inquiry into nature, causation, prevention, and therapy of human disease.”5 Since the founding of the holistic review program, 54 institutions have held AAMC workshops. 4 While holistic review considers a broader view of each applicant, it does not ignore the importance of GPA or MCAT scores. Holistic review is designed to analyze these factors within the context of an applicant’s life experiences and background.1 While this concept is relatively new, schools that have chosen to shift towards holistic review have seen positive results. For example, Boston University School of Medicine transitioned to a holistic review process with intense training of admissions staff.1 Since this transition, the entering classes have included students who are “culturally, linguistically, racially, ethnically, and demographically more diverse than previous classes,” and the school’s undergraduate GPAs and MCAT scores have not fallen below its usual averages.1 Holistic review is designed to increase diversity and place a heavier emphasis on experiences that reflect an applicant’s character. Despite these advantages, its implementation is no small task. On top of giving more weight to a candidate’s application outside of his or her academic scores, medical school selection boards that utilize this holistic review program must also weigh how compatible each applicant is with the school’s mission statement. This requires administrators to have a clear, cohesive, and universal understanding of the mission statement of their given school. Furthermore, because the establishment of holistic

review is expensive and time-consuming, it requires a strong commitment by the school.4 Holistic review challenges admissions boards to reconsider their selection processes and to think critically about what parameters will best predict a student’s success as a physician in the changing world of medicine.

The widespread adoption of holistic review demonstrates the “imperative for a diverse physician workforce in an increasingly diverse society.”1 Furthermore, it shows the importance of behavioral factors and personality traits in shaping successful doctors. For undergraduates who face the upcoming application process, getting a grasp of the shift towards holistic review is key in understanding the world of medicine that they are joining. ∎ For references, see page 42.

the new involved in campus life empathetic

varied interests

friendly & personable

strong test scores

involved in non-science organizations good communicator

connects science to real world

The Pre-Medical Experience • Volume 5 • Spring 2015 • 25

Out with the Old, In with the New...

By Lukasz Jaros

For most prospective medical students, the Medical College Admission Test (MCAT) brings with it a shudder of anguish. The comprehensive exam is a grueling test of general science knowledge and critical thinking skills that can make or break a medical school application. Proper preparation takes months of intensive studying before the test itself, which takes several hours to complete. Then after all of this, admission is not guaranteed. With such great pressure to succeed, the introduction of the new MCAT sent many students scurrying to take the old version of the exam. However, the transition to the new MCAT is now complete and understanding its changes will lead examinees to greater success.

26 • The Medical Decoder • The Pre-Medical Experience

The Pre-Medical Experience • Volume 5 • Spring 2015 • 27

What’s different?

The most profound change students will notice is the exam’s length. Prior to 2015, the exam took three hours and twenty minutes to complete, including twenty minutes for breaks. Now the sitting time is seven and a half hours, six hours and fifteen minutes of which will be spent completing the exam. This timespan corresponds to twice the length of the old exam. The extended time will likely prove taxing on many examinees.

The new MCAT is longer due to the expansion of sections from the older exam and the addition of one new section. The new exam is comprised of four parts: Biological and Biochemical Foundations of Living Systems (formerly Biological Sciences), Chemical and Physical Foundations of Biological Systems (formerly Physical Sciences); Critical Analysis and Reasoning Skills (formerly Verbal Reasoning); and Psychological, Social and Biological Foundations of Behavior.

Some of the changes in these sections appear minute. For instance, the natural sciences sections will frame problems in a manner that demonstrates the medical applications of natural sciences. 2 For example, examinees might now be asked to calculate the flow rate through a blood vessel rather than a pipe.

Another small change appears in the Critical Analysis & Reasoning Skills section.

This section will drop natural sciences as a topic in its passages and exclusively use topics from the humanities and social sciences. 2,3 Other modifications are more noticeable. For instance, introductorylevel biochemistry will make its debut and account for roughly 25% of questions in the Biological and Biochemical Foundations of Living Systems section. 2,3 Furthermore, the Psychological, Social, and Biological Foundations of Behavior section represent perhaps the most significant addition to the new MCAT and consists of 59 questions. 1,2 As the name implies, this section tests students’ knowledge of sociology and psychology. Because an understanding of behavioral and environmental factors in patients’ lives substantially improves patient outcomes, scores in this section are of great value to medical schools’ admissions boards. Students should be aware that the addition of this section increases the number of recommended preparatory courses for the MCAT. The nature of questions has also been restructured in order to test a variety of skills. The new MCAT will not only assess critical thinking skills and general knowledge as before, but also

The new MCAT will not only test critical thinking skills and general knowledge as before, but also the fundamentals of research design and analytical interpretation of results.

28 • The Medical Decoder • The Pre-Medical Experience

the fundamentals of research design and analytical interpretation of results. The exam now asks test-takers to demonstrate their ability to design experiments free of bias and to recognize faulty logic.

Furthermore, students are asked to draw conclusions and make inferences based on varying forms of data (figures, tables, graphs, etc.). 6 Such skills are crucial to all medical fields, as physicians apply the results of new research to contemporary therapies and treatments.

In order to complement the new exam, the Association of American Medical Colleges (AAMC), which creates and administers the MCAT, has restructured the scoring system.

The previous test scored each section on a scale of 1 to 15 for a total scoring range from 1 to 45 points across the three sections. The new exam scores each section on a scale of 118 to 132, resulting in a total range of 472 to 528. 1,2 Perhaps more importantly, the new Section

Time

scoring is accompanied by revamped scoring profiles, which highlight the strengths and weaknesses of each applicant. The innovative inclusion of confidence intervals in these scoring profiles shows that exam scores are not fixed but can be somewhat fluid due to factors such as fatigue or the specific question set used in the exam. 1,2,7 This will prevent admissions committees from over-analyzing minute differences in applicants’ scores by reminding committee members of the imperfections of the exam. 7 An exam is only perfect if a person would get the exact same score each time he or she took the exam. However, this is not the case, as many people’s scores fluctuate depending on various factors.

Percentile scores now appear alongside the exam scores rather than being tucked away on the AAMC website, further allowing examinees to demonstrate to admissions officers how they fared compared others who took the same exam.

Number of Questions

Discipline (% of section)

Biological and Biochemical Foundations of Living Systems

95 min.

59

Biology (65%) Biochemistry (25%) Organic Chemistry (5%) Inorganic Chemistry (5%)

Chemical and Physical Foundations of Biological Systems

95 min.

59

Inorganic Chemistry (30%) Biochemistry (25%) Physics (25%) Organic Chemistry (15%) Biology (5%)

Psychological, Social, and Biological Foundations of Behavior

95 min.

59

Psychology (65%) Sociology (30%) Biology (5%)

Critical Analysis and Reasoning 90 min.

Skills

53

Foundations of Comprehension (30%) Reasoning Within the Text (30%) Reasoning Beyond the Text (40%)

Total

230

6 hours, 15 min.

The Pre-Medical Experience • Volume 5 • Spring 2015 • 29

Why all the change?

medication prescribed, but also on improving other factors in the patient’s life that contribute to the illness. In response to these types of developments, many medical schools have overhauled their curricula and admissions criteria to emphasize teamwork and holistic education.

Improvements in the MCAT have finally brought this assessment in line with the challenges present in modern medical practice. Whereas the old format focused on traditional scientific knowledge and basic comprehension skills, the new design primarily evaluates knowledge of biology and higher order analytic skills in the context of holistic medicine.

This restructuring should provide a boost in morale to the pre-medical students for whom the knowledge and skills gained in pre-med classes often seem irrelevant to their future careers. The revised scoring profile should also benefit the examinees and the medical schools’ admissions committees by providing more accurate and in-depth feedback.

The development of the new MCAT reflects the evolution of the medical field.

Before medical school even begins, students are forced to shift their focuses to adapt to the changing phase of medicine. ∎

Over the past two decades, rapid advances in medicine have necessitated collaboration amongst highly specialized physicians in order to provide effective patient care. For example, care in the last two years of a patient’s life once took two or three medical professionals. Now it requires, on average, a team of fifteen doctors and specialists due to the vast amount of available procedures.

These doctors must work in concert to prevent mistakes and provide efficient care.

Failures in communication often result in unnecessary procedures and can negatively impact patient health. 8 At the same time, the medical community has realized that the impact of a patient’s behavior and environment is vital to successful treatment. 9 Consider a case where two patients are suffering from high cholesterol and hypertension. Both receive the same medication. However, the first patient leads a sedentary lifestyle and must increase his level of exercise to reap the full benefits of the medication. The second patient leads an active lifestyle but maintains a poor diet due to his cravings for sweets and their abundance at his workplace. Here, the patient must overcome these temptations in his work environment to obtain the best health outcome.

In each case, improving the treatment outcome does not rely solely on the For references, see page 43.

The improvements in the MCAT have finally brought this assessment in line with the challenges present in modern medical practice.

30 • The Medical Decoder • The Pre-Medical Experience

A Traveler’s Guide to

The Kingdom of the Ill Chronic Illness and the Patient Experience

By Alex Winnett and Hannah Stowe McMurry

The Pre-Medical Experience • Volume 5 • Spring 2015 • 31

E

ach year, millions of individuals leave the life that they are familiar with and move to a new region, bringing very little, if anything, with them. Their arrival also brings a myriad of difficulties regarding how the change will be handled by both the individuals and by the inhabitants of the receiving country.

These travelers struggle to rebuild their lives, navigate the new terrain, and understand what is necessary for survival in this new land. For many, this is the ultimate test. There are pitfalls with every step, and survival demands maximal resourcefulness.

One hundred and thirty-three million people worldwide experience a similar displacement, though not a physical, geographic one.1 These people experience a nuanced movement from what Susan Sontag describes as the “kingdom of the well” to the “kingdom of the ill,” the journey taken by those adjusting to a new chronic disease diagnosis; it is the path of reconfiguring not only day-to-day tasks and habits, but also one’s own self-identity.2 The transition between the kingdoms and survival in the new “land” poses challenges.

These challenges and the skills needed to tackle them are specific to each individual and each illness terrain. As an example, for patients with chronic rheumatoid arthritis, doorknobs become obstacles to safety and freedom.

When caring for chronically ill individuals, it is important for caregivers to understand the meaning and nuances of these psychological frameworks in order to guide patients through the complexities of a chronic illness experience.

In the kingdom of the ill, adaptability is

vital. In many cases, the key component of this adaptability – on the side of patients and caregivers alike – is positivity. However, within the kingdom of the ill, achieving and maintaining positivity is a difficult task. Positivity is dependent on factors including personalized omens or signs, here termed Illness Directives, as well as on the heightened importance of day-to-day victories or losses, here termed Challenge Amplification.

Illness Directives

In many cases of chronic illness, navigating the day-to-day experience of a disease is a process that patients must undergo with little direction or preparation, given the difficulty of predicting the trajectory of an illness.

This lack of clear signage or foresight leads the weary travelers to look closely for personal symbolism, or Illness Directives.

Minute details stand out and often have significant meaning for the patient.

When there is no roadmap, gut instincts – based off symbolic extrapolations – become one of the only available directives for one’s illness trajectory. Ideally, these symbols can help enhance positivity and boost patient morale. For example, if a purple hospital gown was worn when it was discovered that one’s cancer was responding to treatment, parking next to a purple car in the parking lot of the hospital before an appointment can leave the patient feeling more hopeful and in control.

However, such symbols can also irrationally serve as negative omens that erode positivity.

For example, a woman who struggled with scoliosis as an adolescent remembers “every time I visited a new hospital, I was highly

In the kingdom of the ill, adaptability is vital.

And in many cases, the key component of this adaptability – on the side of patients and caregivers alike – is positivity.

32 • The Medical Decoder • Human Interest

conscious of the walkway leading to the hospital doors - if the path entering the hospital was straight, I was hopeful that the treatment I would receive there might help straighten my spine - but if the path was windy or curvy, I became convinced that the new doctors would not be able to help me.”21 The development of these symbols is unique to each patient and is a significant phenomenon that affects the psychology of chronic illness.

Challenge Amplification

For most people, putting on shoes takes 15 seconds. With speed and finesse, habitants of the kingdom of the well are able to thrust their feet into shoes and, if necessary, bend down to adjust the shoe for comfort or tighten the laces.

They do this every day, sometimes multiple times a day – nothing more than a small activity of daily life. However, for individuals with chronic illnesses such as ALS, Parkinson’s disease, or rheumatoid arthritis, it is little things – little battles, little victories, or even little losses – that translate to enormous psychological effects. This phenomenon is termed Challenge Amplification. For healthcare professionals and caregivers, recognizing this principle and maximizing the impact of victories, minimizing the sorrow of losses, and appreciating the “little battles” is crucial. By doing so, caregivers can truly assist, comfort, and encourage individuals to remain positive throughout their illness.

Just as self-conceived omens and signs can serve as potent indicators or destroyers of positivity, seemingly trivial challenges are amplified or augmented such that their outcomes can have a significant impact on the psychology of the chronically ill. Interestingly, a recent debate on “NPR” regarding physicianassisted suicide (PAS) brought up a similar theme. The debate presented a situation in which a patient facing a

terminal cancer diagnosis was firmly in favor of ending her life. Her concerned physician asked her what the worst thing about her current life status was. The patient said it was the hairs on her chin that she was unable to remove. The doctor removed them for her, and her demeanor took a great turnaround – she stated that she “felt like a woman again” and opted to not follow through with the suicide.6 Although an isolated example, this story shows that the woman’s ability to control her appearance in a rather simple way became a major victory that restored a measure of her previous quality of life and bolstered her ability to face the challenges of her illness.

Another pertinent example of the psychology of a chronically ill patient was described in an interview with a staff member at Massachusetts General Hospital: “During one of my first overnight shifts, I transcribed a feeding tube order into the patient’s chart. The patient was an 84-yearold male with a slew of illnesses that led to the decision to admit him to hospice care. As I stood outside the room writing in the order, I looked up to see a hand slowly waving me in. He lay there, mustering the energy and will to speak.

His mouth looked dry, and his body was nothing

Human Interest • Volume 5 • Spring 2015 • 33

more than a heavy appendage weighing him down. I expected he wanted water, but waited patiently for his request. ‘Kill me,’ he said.

I was shocked, but did my best to not show it. ‘Please, kill me. Pull these tubes and cords out,’ he whispered, his eyes staring fervently at me with the hope that I’d fulfill his request. ‘I used to be you. Now I’m nothing,’ he continued dejectedly. I became painfully aware of my ablebodied privilege and physical independence in juxtaposition to his total powerlessness.

And though I was certainly shaken, I sat down, and told him that his time will come, that he will soon be at peace, and that if there is anything I can do in the meantime to make him more comfortable, I will gladly do so. He closed his eyes for a minute. I waited, not wanting to leave him in the dark isolation of his room.

Eventually the man opened his eyes, again taking a moment to muster the energy to speak.

‘I’d like a lollipop’ – one of the few items he could still eat by mouth. After asking what color, I placed a green lollipop in his mouth. He closed his eyes again. Though it paled in comparison to his wish to be physically independent and in control of his body, he was able to eat whatever color lollipop he desired, which was, sadly, one of the few things he could still do. When he finished, I showed him how to use the call bell to reach me, wished him a good night, and left the room – still shaken at his first request.

34 • The Medical Decoder • Human Interest

Upon reflection, I realized a simple piece of candy in the kingdom of the well is an important victory for a patient living in the kingdom of the ill. A victory so large in fact, that it may have changed this patient’s will to live.”21 We often assume that chronic illness and unalterably poor quality of life are synonymous, and that only sweeping policies on major issues such as PAS will be able to solve the problem.

But taking the “little battles” approach and understanding the phenomenon of Challenge Amplification can allow caregivers to improve patient comfort and positivity even when the disease highly limits function. In fact, the American Medical Association’s (AMA) stance on PAS, reflects this patient-centered care model; the AMA states that rather than encouraging or performing PAS, physicians should work hard to meet the needs of their patients – especially when those needs can be as simple as giving a terminally ill woman a facial treatment or a hospice patient a green lollipop.8 The phenomenon of Challenge Amplification is also observed in mentally ill patients. As Moriah Cummings observed while working as a social worker at the YWCA transitional facility for the homeless and mentally-ill, the effect of seemingly small, everyday challenges are intensified for chronically ill individuals.

Cummings recounts a facility resident who, on most days “floated around the room socializing with the other women effortlessly,” was later plunged into a “complete state of paranoia” where she had isolated herself and “began frantically shutting all her closet drawers and window shades” and contemplated suicide because she had lost her wallet.12 Oftentimes, mentally ill patients are more stigmatized because their symptoms are not easily apparent.

For that reason, this patient “beg[ed]

[Cummings] not to think she was crazy because” her missing wallet had caused an explosion of disorganized emotion and chaos.12,13 For caregivers attempting to treat recent immigrants to the kingdom of the ill, the importance of exploring small solutions for individual scenarios cannot be overemphasized.

This method of care becomes as much about helping patients maintain the positivity and victories that are vital for survival as it is about technical, biomedical interventions.

While it is easy to get swept up in the fanfare of major pharmaceutical or technological solutions, the translation from one test group to the whole population and expectations of miracle-like success often leads to a path of disappointment as many chronic diseases are “without fanfare” – they present slowly, and vary from individual to individual.14 In this sense, large-scale attempts to treat all patients at once often overlook important, individual aspects of disease progression and the psychological and psychosocial experience of chronic illness.

For caregivers, the ability to develop personalized disease management strategies is necessary not only for the well-being of the patient, but also for the caregiver themselves.

Caregivers act as guides through the kingdom of illness. Commuting back and forth with their ill-fated travelers can shake their senses of positivity. The ability to create personalized, individual solutions for patient needs can help caregivers strengthen their own sense of helpfulness. This positivity is crucial, because it allows for patients and caregivers to open channels of support between one another,

without which patients and caregivers alike can become disoriented and lost in the kingdom of the ill.

As one veteran nurse explained, “it’s important to keep your own head and be confident in what you know should be done and has happened. Keeping that in mind is how I’ve stayed strong.”15 Her strength is an alternate expression of positivity for her patients. She goes on to explain that perseverance is necessary to accept the often problematic outcomes of diseases. Positivity and perseverance allow both the caregiver and the patient to be at peace with the difficulties that they face. For the caregiver, “it’s a double edged sword – you want to invest in your patients, but you never know what’s going to happen … The most dangerous thing you can do is take your patients home with you.”15 In other words, the difficulties of the kingdom of the ill can easily pollute the kingdom of the well and poison the caregiver who must travel between the two. Many other caregivers have described the dangerous double-edged nature of caring for the seriously ill, speaking of “the blade of self-protection and compassion”, one that “we pick up before a shift and lay down afterwards, but we all know it’s never far from us.”15,16 If peace cannot be maintained by positivity, a toxic occupational health exposure occurs.

Chronically ill individuals require personalized caregiving because it is typically the chronically ill who give the most attention to the ebbs and flows of life, and who place the most significance upon interactions with their caregivers. In the kingdom of the well,

For individuals with chronic illness...it is little things – little battles, little victories, or even little losses – that translate to enormous psychological effects.

Human Interest • Volume 5 • Spring 2015 • 35

minute details are often only remembered in the most intense situations. However, for individuals living with serious chronic illness, many more everyday details acquire this level of significance.

The disorientation and intensification of experience that causes individuals with chronic illnesses to seek and be susceptible to omens and the amplification of challenges are indispensable principles for healthcare professionals and caregivers to recognize and monitor. Because “cognitive challenges can have physiological effects,” in order to comprehensively and holistically care for the psychology, as well as the pathophysiological disease presentation of the chronically ill, it is imperative that caregivers are attuned to more than the purely physiological presentation of illness.4 Additionally, caregiver recognition of Illness Directives and Challenge Amplification is likely to facilitate improved compliance on the part of the patient.

feeling beautiful or valuable are the smaller, but equally important, goals.

For the guides from the kingdom of the well who travel to the kingdom of the ill to provide assistance, this change in scale must be acknowledged so that solutions that fit the size of these patient goals – such as providing a shoehorn, giving a facial, or finding a green lollipop - can be individually engineered and applied to make living conditions in the kingdom of the ill tolerable, or possibly even comfortable.19 The principles of Illness Directives and Challenge Amplification pose opportunities for innovative, patientcentered medical intervention that can lead to comprehensive care. This will yield better health attitudes and improved management and compliance in the treatment of chronic illness.

Chronically ill individuals require personalized caregiving because it is typically the chronically ill who give the most attention to the ebbs and flows of life.

Conclusion

In the kingdom of the well, the skies are clear and travelers can look out over the landscape and see what lies ahead. In the kingdom of the ill, the only certainty is often uncertainty, and it is difficult to see far enough ahead in order to make plans. The focus is shifted to the here, the now, and the smaller challenges of the dayto-day. While in the kingdom of the well, the goals are to graduate college, make an impact on the world, and live happily and eventfully. In the kingdom of the ill, getting your shoes on and

36 • The Medical Decoder • Human Interest

Acknowledgments The authors wish to acknowledge several individuals whose support and insight was invaluable to the formulation of the principles in this paper. Many thanks to Professor Kathryn Kogan, PhD of the University of Massachusetts, Boston Psychology Department, Moriah Cummings, and the nurse who wished to remain anonymous. ∎

For references, see page 44.

The Impending Crisis With

Primary Care

A

By Aditya Ghosh

medical crisis is looming on the horizon.

The American population is getting older, and the Baby Boomer generation is beginning to reach an age at which it requires more healthcare services than ever before.1 The American medical system has attempted to evolve in order to provide the appropriate supply of medical services to meet this increasing demand.1 While there have been efforts on behalf of medical schools to expand the number of medical students that are trained each year, it is important to pay specific attention to the type of doctors that the schools need to be training.2 Unfortunately, there is a disproportionate number of doctors entering each specialty.

This discrepancy has adversely affected the number of practicing primary care physicians.

Unlike other specialties, where physicians

develop expertise in the treatment of a specific physiological system, primary care physicians provide comprehensive, general, and preventive healthcare, thereby addressing the overall needs of a patient.

It is essential to gain an understanding of the significance of primary care as well as the impending crisis that lies ahead for the field, because primary care is important to current and future healthcare providers, as well as the patients they will treat.

According to the American College of Physicians, “internal medicine physicians are specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment, and compassionate care of adults across the spectrum from health to complex illness.”3 This field is as expansive as it sounds. Internists are

The Medical School Experience • Volume 5 • Spring 2015 • 37

expected to have knowledge about every organ system and disease a patient could possibly present with. They must be able to diagnose, treat, and prevent illnesses. In more complex situations, they must know when to refer an ill patient and whom to refer him or her to. Many internists serve as primary care providers for patients and are the first doctor that a patient sees during a routine clinical visit.3 Effective distribution of primary care physicians within a population has been shown to produce positive benefits in that community.

Dr. Barbara Starfield of Johns Hopkins University observed in a Milbank Quarterly article that regions with more primary care physicians had lower total health care costs.4 Dr. Starfield also noted that these regions had better success rates in preventative interventions such as wearing seat belts, lower smoking rates, and reduced obesity levels than regions with fewer primary care physicians.4 She explains that “The literature is consistent in showing that lower rates of hospitalization . . . are strongly associated with the receipt of primary care,” she wrote.4 In an age when doctors are calling for better preventative medicine and more doctors to help impede the incoming medical crisis, it is apparent that there should be a call to train more primary care physicians.4 Why, then, are we seeing the emergence of another crisis: the decline of the primary care specialty?

One of the reasons why the effective implementation of primary care is being compromised is that incoming medical residents are avoiding entering internal medicine and primary care as a speciality.1 Dr. Thomas Bodenheimer of the University of California

San Francisco wrote a New England Journal of Medicine article titled, “Primary Care – Will It Survive?” in which he discussed the dilemma that primary care faces.

Bodenheimer claimed that “fewer U.S. medical students are choosing careers in primary care...In 1998, half of internal medicine residents chose primary care; currently, about 80 percent become subspecialists or hospitalists.”1 Bodenheimer went on to describe the poor timing of this trend; it is occurring at the same time as an aging population requires more frequent medical services by primary care specialists.1 He also pointed out that “the prevalence of chronic conditions – most of which are handled in primary care settings – is increasing, as are requirements for their proper management”.1 The imbalance between the rising pool of potential new patients and the decreasing pool of primary care physicians is disconcerting. In order to create solutions to 4 tackle this issue, one must first understand why these trends are occurring.

Why are fewer American medical residents interested in joining general internal medicine practices? The source of the problem can be better understood by identifying the characteristics of the primary care practice.

Bodenheimer’s article provides some insight into these matters: “many primary care physicians...are unhappy with their jobs, as they face a seemingly insurmountable task… the knowledge and skills they are expected to master exceed the limits of human capability, making it impossible to provide the best care to every patient.”1 Bodenheimer also cites the inadequate

In an age when doctors are calling for better preventative medicine... it is apparent that there should be a call to train more primary care physicians.

38 • The Medical Decoder • The Medical School Experience

reimbursement rate for services as reasons why primary care as a specialty is encountering difficulties.1 Such sentiments from doctors are dangerous, not only to the quality of patient care, but also to the sustainability of primary care.

Bodenheimer also highlights how reimbursements that focus on the total number of patients that a doctor sees incentivizes these doctors to see a larger number of patients.1 With this increase in the quantity of patients comes an unfortunate but unavoidable decrease in the amount of time that the physician can spend with each patient.5 This results in a decrease of the overall quality of the patient’s visit.

Bodenheimer explains how this decrease in quality creates a cycle of frustration as patients become unhappy with their physicians, which in turn leads to increased exasperation on the part of the physicians.1 The fact that primary care physicians receive among the lowest annual salaries as compared to other specialties creates even less of an incentive to pursue primary care or internal medicine. Medical students and residents are disinclined to join internal medicine when they become aware of this trend.1 As the personal finance website NerdWallet points out, “in 2012, 79% of medical school graduates reported education debt of more than $100,000 – no surprise considering the median cost of medical school attendance is more than $200,000 for both public and private schools.”6 Many medical school graduates have decided to enter higher-paying specialties in order to try to and pay off their debts. In doing so, they avoid the lower-paying specialties like primary care.6 The number of issues that the primary care specialty currently faces is daunting, and

decisive action must be taken to prevent a perpetual downward spiral for the field.

It is time for leaders, both in medical and political spheres, to take note of the impending crisis that primary care faces. If the downward spiral is allowed to continue, the medical field as a whole will suffer. At a time when The Doctors Company, a national insurer for medical liability, published a 2012 survey indicating that nine out of ten physicians would not recommend medicine as a profession, it is important to determine the reason for medical providers’ dissatisfaction.7 Now is the time to create strategies that address the issues plaguing primary care, whether through improving reimbursements, providing resources to facilitate and ease practice demands, or increasing salaries of primary care physicians. These efforts to support primary care providers will be necessary in order to fulfill the ultimate goal of medicine: giving patients and their families the best possible care. ∎ For references, see page 45.

The Medical School Experience • Volume 5 • Spring 2015 • 39

REFERENCES

Could Kidney Denervation End the Hypertension Epidemic?

1. Hypertension. (n.d.). Web. April 29, 2015, from http://www.world-heart-federation.org/ cardiovascular-health/cardiovascular-disease-risk-factors/hypertension/ 2. Guyenet, P. (n.d.). The Sympathetic Control Of Blood Pressure. Nature Reviews Neuroscience, 335-346.

3. Renal sympathetic denervation for treatment of resistant hypertension. (n.d.). Web. April 29, 2015, http://www.mayoclinic.org/medical-professionals/clinical-updates/generalmedical/renal-sympathetic-denervation-treatment-resistant-hypertension 4. Renal Denervation - The Next Big Thing in Medical Devices. (n.d.). Web. April 29, 2015, from http://www.fiercemedicaldevices.com/special-reports/renal-denervation-next-bigthing-medical-devices 5. Bhatt, D., Kandzari, D., O’Neill, W., D’Agostino, R., Flack, J., Katzen, B., . . . Bakris, G. (n.d.). A Controlled Trial of Renal Denervation for Resistant Hypertension. New England Journal of Medicine, 140329050012001-140329050012001.

6. Kandzari, David E., Bhatt, Deepak L, Brar, Sandeep, Devireddy, Chandan M., Bakris., George L (n.d.) Predictors of blood pressure response in the Symplicity HTN-3 Trial. European Heart Journal., 2015 Jan 21;36(4):219-27

Sound of Silence: The Effects of Nicotine on Auditory Cells

1. CDC. (2011). Targeting the Nation’s Leading Killer at a Glance 2. Nondahl, D. M., Cruickshank, K. J., Dalton, D. S., Schubert C. R., Klein, B. E. K., Klein, R., Tweed, T. S. (2004). Serum Cotinine Level and Incident Hearing Loss. Arch Otolaryngol Head Neck Surg. 130:1260-1264 3. Vinay. (2010). Effect of smoking on transient evoked otoacoustic emissions and contralateral suppression. Auris Nasus Larynx 37:299-302.

4. Mehrparvar, A.M., Mirmohammadi S. J., Hashemi, S.H., Davari, M. H., Mostaghaci, M., Mollasadeghi, A., Zare, Z. (2014). Concurrent effect of noise exposure and smoking on extended high-frequency pure-tone thresholds. International Journal of Audiology.

5. Paschoal CP, Azevedo MF. (2009) Cigarette smoking as a risk factor for auditory problems.

Braz J Otorhinolaryngol 75:893-902 6. Abdel-Hafez, A. M. M., Elgayar, S. A. A., Husain, O. A., Thabet, H. S. A. (2014). Effect of nicotine on the structure of cochlea of guinea pigs. Anatomy and Cell Biology. 47:162-170 7. Gilroy, A. M., MacPherson, B. R., Ross, L. M. (2008). Atlas of Anatomy. Thieme Medical Publishers Inc. pp. 536-539 8. Jones, J. E., Corwin, J. T. (1996). Regeneration of Sensory Cells after Laser Ablation in the Lateral Line System: Hair Cell Lineage and Macrophage Behavior Revealed by Time-Lapse Video Microscopy. The Journal of Neuroscience. 16(2):649-662.

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9. Berger, F., Gage F.H., Vijayaraghavan, S. (1998) Nicotinic receptor-induced apoptotic cell death of hippocampal progenitor cells. J Neuroscience. 18:6871-81.

10. Matsunobu, T., Chung, J.W., Schacht, J. (2001). Acetylcholine-evoked calcium increases in Deiters’ cells of the guinea pig cochlea suggest alpha9-like receptors. Journal of Neuroscience Research. 63:252-6.

Minimally Invasive, Maximally Effective

1. Mandal, Ananya. “Laparoscopic Surgery History.” News-Medical.net. N.p., 19 May 2010.

Web. 05 Mar. 2015.

2. Litynksi GS.(1999, August 23). Endoscopic surgery: the history, the pioneers. World J Surg. pp 745-53.

3. Vinocur, Charles D. “What Is “Minimally Invasive” Surgery?” Kids Health. N.p., 01 May 2012.

4. Agha, Riaz, and Gordon Muir. “Does Laparoscopic Surgery Spell the End of the Open Surgeon?” Journal of the Royal Society of Medicine. The Royal Society of Medicine, 5. The University of Chicago Medical Center. (n.d.). Benefits of minimally invasive procedures.

6. Green, M. (2014, February 4). Drexel Medicine: Benefits of minimally-invasive gynecologic surgery [Video file].

7. ”Laparoscopic vs. Open Approach.” Valley Health.

8. Griffin, R. M. (2008, August 12). Surgery lite: Understanding endoscopic surgery.

9. University of Cincinnati. (2007, July 2). Surgeons Say Minimally Invasive Lung Surgery Should Be Standard Care. ScienceDaily.

10. Liou, Louis. “Robotic Surgery: MedlinePlus Medical Encyclopedia.” U.S National Library of Medicine. U.S. National Library of Medicine, 7 May 2013.

11. The University of Chicago Medicine. (n.d.). Minimally invasive surgery for lung, mediastinal and pleural diseases.

12. Allaf, Mohamad. “Robotic Surgery: Minimally Invasive, Better Than Ever.” Hopkins Medicine. JHM Publications, 16 Oct. 2014.

Talking Taboo: A New Approach to Chronic Illnesses and End-of-Life Care

1. “Alexander Fleming Discovery and Development of Penicillin - Landmark - American Chemical Society.” Alexander Fleming Discovery and Development of Penicillin - Landmark - American Chemical Society.American Chemical Society, n.d. Web. 11 Feb. 2015. <http:// www.acs.org/content/acs/en/education/whatischemistry/landmarks/flemingpenicillin. html#alexander-fleming-penicillin>.

2. Gawande, Atul. All Epic - Speaker. Epic Systems, Verona, WI. 24 Oct. 2014. Lecture.

3. Gawande, Atul. Being Mortal: Medicine and What Matters in the End. New York: References • Volume 5 • Spring 2015 • 41

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Metropolitan, 2014. N. pag. Print.

4. Gawande, Atul. “Why Doctors Fail.” The Guardian. N.p., 2 Dec. 2014. Web. 9 Feb. 2015.<http%3A%2F%2Fwww.theguardian.com%2Fnews%2F2014%2Fdec%2F02%2Fsp-why-doctors-fail-reith-lecture-atul-gawande>.

5. “NHPCO Facts and Figures on Hospice Care in America.” Hospice Care in America: National Hospice and Palliative Care (2012): 3-7. NHPCO.org. National Health Organization, 2012.

Web. 11 Feb. 2015.

Football’s Biggest Headache

1. Signoretti, Stefano, Giuseppe Lazzarino, Barbara Tavazzi, and Roberto Vagnozzi. “The Pathophysiology of Concussion.” Physical Medicine and Rehabilitation 3.10 (2011): S359368.

2. Mccrory, Paul, Willem Meeuwisse, Karen Johnston, Jiri Dvorak, Mark Aubry, Mick Molloy, and Robert Cantu. “Consensus Statement on Concussion in Sport 3rd International Conference on Concussion in Sport Held in Zurich, November 2008.” Clinical Journal of Sport Medicine 19.3 (2009): 185-200.

3. Bey, Tareg, and Brian Ostick. “Second Impact Syndrome.” Western Journal of Emergency Medicine. Department of Emergency Medicine, University of California, Irvine School of Medicine, (n.d.) Web. 04 Apr. 2015.

4. “League of Denial: The NFL’s Concussion Crisis.” Frontline. PBS, 8 Oct. 2013. Web. 06 Mar. 2015.

5. McKee, Ann C., et al. “Chronic Traumatic Encephalopathy in Athletes: Progressive Tauopathy following Repetitive Head Injury.” Journal of Neuropathology and Experimental Neurology. U.S. National Library of Medicine, (n.d.) Web. 04 Apr. 2015.

6. Angela, M., and C. Kate. “Coaching Our Kids to Fewer Injuries: Youth Sports Safety Research.”

Injury Prevention 18.Supplement 1 (2012): A130-131. Web. 7. Gould, Daniel, Bill Prentice, Linda M. Petlichkoff, and Fred Tedeschi. Sports Science Exchange Roundtable 11.2 (2000): (n.p).

8. “Concussion Protocol.” NFL Evolution - Health & Safety. NFL, n.d. Web. 04 Apr. 2015.

9. “Concussion Guidelines.” NCAA Home Page. (n.p.), 08 July 2014. Web. 04 Apr. 2015.

10. Kilgore, Adam. “Ben Roethlisberger, Heath Miller Returned ‘too Quick’ to Properly Check for a Concussion.” Washington Post. The Washington Post, (n.d.) Web. 04 Apr. 2015.

Holistic Review: Preparing a New Generation

1. Witzburg, Robert A., and Henry M. Sondheimer. “Holistic Review — Shaping the Medical Profession One Applicant at a Time.” The New England Journal of Medicine 368 (2013): 1565-567.

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2. Chen, Pauline W. “The Changing Face of Medical School Admissions.” Well The Changing Face of Medical School Admissions Comments. New York Times, 02 May 2013.

3. Huntington, Beth, and Nettie Kuhn. “Communication Gaffes: A Root Cause of Malpractice Claims.” Baylor University Medical Center Proceedings 16.2 (2003): 157-61.

4. Uscher, Jen. “Reporter Archive New Medical Schools Use Holistic Admissions to Create Diverse Classes That Will Fulfill Diversity-Related Missions, Goals.” Association of American Medical College. (n.p.), Feb. 2014.

Out with the Old, In With the New...MCAT

1. What Do I Need to Know for the New MCAT 2015? (n.d.). Published by Kaplan test prep.

Retrieved February 21, 2015, from www.kaptest.com 2. MCAT 2015 Changes: Longer, Broader and Harder. (n.d.). Published by RuveneCo, Inc. Retrieved February 21, 2015, from www.mcat-prep.com 3. About the MCAT Exam. (n.d.). Published by Association of American Medical Colleges. Retrieved February 21, 2015, from www.aamc.org/students/applying/mcat/ about/ 4. What’s on the MCAT2015 Exam- Psychological, Social, and Biological Foundations of Behavior: Overview. (n.d.). Published by Association of American Medical Colleges. Retrieved February 21, 2015, from www.aamc.org 5. What’s on the MCAT2015 Exam- Psychological, Social, and Biological Foundations of Behavior: Overview. (n.d.). Published by Association of American Medical Colleges. Retrieved February 21, 2015, from www.aamc.org 6. What’s on the MCAT2015 Exam- Scientific Inquiry and Reasoning Skills: Overview. (n.d.).

Published by Association of American Medical Colleges. Retrieved February 21, 2015, from www.aamc.org 7. Understanding Your MCAT Score Report. (n.d.). Published by Association of American Medical Colleges. Retrieved February 21, 2015, from www.aamc.org 8. Gawande, A. (Speaker) (April 2013). The Checklist Manifesto. 2013 National Council Conference. Lecture conducted from Caesar’s Palace in Las Vegas, Nevada. Sponsored by HInext.

Retrieved February 22, 2015, from https://www.youtube.com/watch?v=3dCk44YyB3E 9. Why Is The MCAT Changing? (n.d.). Published by Kaplan test prep. Retrieved February 22, 2015, from www.kaptest.com 10. Donnon, T., Paolucci, E. O., & Violato, C. (2007). The predictive validity of the MCAT for medical school performance and medical board licensing examinations: A meta-analysis of the published research. Academic Medicine, 82, 100–106.

11. Julian, E. (2005). Validity of the Medical College Admission Test for Predicting Medical School Performance. Academic Medicine, 80(10), 910-917.

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A Traveler’s Guide to the Kingdom of the Ill

1. Lubkin and Larsen. Chronic Illness: Impact and Intervention (2013). Jones and Bartlett: Burlington MA. 2. Sontag, S. Illness as a Metaphor (1978). McGraw-Hill: Print.

3. Sheff, Nic. Tweak: Growing Up on Methamphetamines (2008). Atheneum Books for Young Readers: New York.

4. Boston Medical Reserve Corps. Promoting Resiliency in an Emergency: Psychological First Aid (2015). Boston Public Health Commission, DeValle Institute for Emergency Preparedness. 22 January 2015. Seminar.

5. Bradley, W. Gib’s Odyssey (2011). Lyons Press.

6. Singer P, Solomon A, Finlay I, Sulmasy D. Debate: Legalize Physician Assisted Suicide (13 November 2014). National Public Radio. Transcript. http://intelligencesquaredus.org/ images/debates/past/transcripts/111314%20Assisted%20Suicide.pdf 7. Reid, Joanna. JoannaCare – Joanna’s Story (10 October 2010). Youtube.com. Film. http:// youtu.be/3PfBAn11JGY 8. Endnotes (1999). reFrame Films. Video Media. Accessed 16 December 2014. http://www. reframe-films.com/endnotes.html 9. Cadigan, K. Out of My Mind (1996). Filmmakers Library: New York, NY. Video Media.

Accessed 16 December 2015. http://search.alexanderstreet.com.ezproxy.lib.umb.edu/ flon/view/work/1785096 10. Winnett, Alex. Interview of Alex Winnett by Stowe McMurry (12 January 2015).

11. Opinion 2.21. American Medical Association. Issued June 1994 based on the report “Decisions Near the End of Life,” adopted June 1991 (JAMA. 1992; 267: 2229-2233); Updated June 1996. Accessed online http://www.ama-assn.org//ama/pub/physician-resources/ medical-ethics/code-medical-ethics/opinion221.page 12. Cummings, Moriah. Interview of a Social Worker by Alex Winnett (13 January 2015).

13. Navasky, M and O’Connor, K. Facing Death (2010). Public Broadcast System, Frontline.

Video Media. Accessed 15 December 2014. http://www.pbs.org/wgbh/pages/frontline/ facing-death/ 14. Iverson, D. My Father, My Brother, and Me (2009). Public Broadcast System, Frontline.

Video Media. http://video.pbs.org/video/1082086931/ 15. Nurse, Anonymous. Interview of a 10+ Year Registered Nurse by Alex Winnett (11 November 2014).

16. Natalie. The Double-Edged Sword (2014). ThreeEightyFive.com (Nursing Blog). 23 June 2014. Accessed 16 December 2014. http://thirtyeightfive.com/2014/06/23/the-doubleedged-sword/ 17. Cicero – Translation by Peabody, A. Tusculanae Disputationes – Book V (400/1886).

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Little, Brown and Company: Boston, MA. Accessed 16 December 2014. https://archive.org/ details/cicerostusculand00ciceiala 18. Kleinman, A. The Illness Narratives (1988). Basic Books.

19. Fox, M. Always Looking Up (2009).

20. Fedigan, J. Healing the Angry Heart; Stories of Racism Health and Healing (2002). Boston Public Health Commission: Boston, MA. Video Media. http://www.theangryheart.com/ 21. McMurry, Hannah Interview of Hannah McMurray by Alex Winnett (5 April 2015).

The Impending Crisis with Primary Care

1. Bodenheimer, T. (2006). Primary Care - Will It Survive? The New England Journal of Medicine: 355, 861-863.

2. Whitcomb, M.E. & Cohen, J.J. (2004). The Future of Primary Care Medicine, The New England Journal of Medicine: 351, 710-712.

3. About Internal Medicine. ACP Online. <http://www.acponline.org/patients_families /about_internal_medicine/>.

4. Starfield, B.; Shi, L; & Macinko, J. (2005). Contributions of Primary Care to Health Systems and Health. The Milbank Quarterly: 83, 457-502.

5. Drake, D. (2014). How Being A Doctor Became The Most Miserable Profession. The Daily Beast. <http://www.thedailybeast.com/articles/2014/04/14/how-being-a-doctor -became-the-most-miserable-profession.html>.

6. Pratini, N. (2014). NerdWallet: Primary Care Shortage Worsens with Obamacare as Medical Students Specialize. NerdWallet. <http://www.nerdwallet.com/blog/health/ 2014/01/17/primary-care-shortage-obamacare-physician-salary-specialty/>.

7. Nine Out of 10 Physicians Unwilling to Recommend Health Care as a Profession, Exacerbating Anticipated Physician Shortage. The Doctors Company. <http://www.thedoctors.com/TDC/PressRoom/PressContent/CON_ID_004671>.

References • Volume 5 • Spring 2015 • 45

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