The Medical Decoder Spring 2014

MD THE MEDICAL DECODER

Mind the Gap Year: A Guide to Taking a Year Off

Innovations to In-Home Medical Care The Residency Work Hours Debate

Destination Immortality: A Glimpse into the Future of Anti-Aging Technology

Produced by Phi Delta Epsilon IL Gamma

Volume 3

IN THIS ISSUE Photo courtesy of Varsha Venkatakrishna

Human Interest

6 Myth vs. Fact: The

Gluten-Free Weight Loss Trend Marta Turowski

Northwestern University ‘15

9 Expediting Healing:

Improving Treatment of Injured Athletes

The Pre-Medical Experience

Elbert Mets

Cornell University ‘17

14 Mind the Gap Year

Science and Technology

Asia Jaros

Northwestern University ‘14

19 Medicine as a Career,

26 Destination: Immortality Lukasz Jaros

Philanthropy for a Lifetime

Photo courtesy of Vicky Castro

Northwestern University ‘16

Varsha Venkatakrishna Northwestern University ‘16

22 Exploring the Physician

2 ■ The Medical Decoder ■ Phi Delta Epsilon IL Gamma

Assistant Profession Cynthia Stamelos Northwestern University ‘15

Health Care and Policy

34 Innovations to In-

Home Medical Care Nickey Jafari Drake University ‘14

38 Global Perspectives

on Health: Nutritional, Dietary, and Health-Related Issues in Mexico Angie Castillo

Universidad de Monterrey ‘16

The Medical School Experience

43 The Road to

Residency: A Time for Advocacy Kriti Goel

Northwestern University ‘16

46 The Residency Work

Hours Debate Alex Pezeshki

Northwestern University ‘13

Editors-in-Chief:

Aditya Ghosh Sarah Smith

Editing Staff:

Arjun Balakumar Julie Bloom Brianna Cohen Tricia Cruz Andy Donaldson Robert Fisch Aayush Gupta Devora Isseroff Jenna Stoehr Alec Straughan Krish Suresh Charlotte ter Haar Jane Wang

Creative Director: Svetlana Slavin

Design Team: Nicholas Giancola Lauren Kandell Lan Nguyen Carlos Mucharraz

Photographers:

Bryan Huebner Jordan Fleming Alexis O’Connor

Online PR Director:

Cynthia Stamelos

Volume 3 ■ Spring 2014 ■ 3

Dear readers,

LETTER FROM THE EDITORS

Welcome to the third edition of The Medical Decoder (MD). This journal was founded last year and is produced by Phi Delta Epsilon IL Gamma, Northwestern University’s chapter of the international medical fraternity. Since the time of the MD’s founding, the previous editions of the journal have been read by thousands worldwide, and we are proud to say that the journal is now officially an intercampus and international publication. This journal is tailored to be a lucid and comprehensive guide in the world of science and health care, and it is designed for anyone interested in staying actively engaged with current medical trends.

Students’ lives are hectic, and busy schedules can make it challenging to stay engaged with changes occurring in the fields of medicine and health care. The journal is meant to aid people, especially students, in learning more about these fields without having to sort through all of the esoteric material regarding these subjects. By providing students with a reader-friendly option that helps them stay up-to-date and “decode” health care-related information, the MD presents an innovative way to facilitate the development and empowerment of students with the goal of making them better leaders and doctors in the future.

The MD is divided into five central pillars: Human Interest, The Pre-Medical Experience, Science and Technology, Health Care and Policy, and The Medical School Experience. By featuring articles relating to these pillars, the MD covers a vast array of themes that educate students on topics ranging from health care reform and the medical school interview process to health representation in the media and new technological advances in the medical field.

The topics presented within this journal come from the viewpoints of pre-medical and medical students, but given that changes in health care and medicine will affect each of us, the topics discussed are relevant to anyone.

The MD team is proud of everything that the journal has already offered to students.

This third edition marks the first time that the journal has incorporated articles from other campuses, including those outside of the United States. As the publication grows, our MD team is growing with it. We would love your support in helping spread the word about the journal, and we are always looking for exciting articles and ideas from new campuses. If you are interested in becoming part of the MD team and submitting an article, please feel free to contact either one of us.

On behalf of Phi Delta Epsilon IL Gamma and the MD team, we would like to welcome you to the third edition of The Medical Decoder.

Sincerely, Aditya Ghosh & Sarah Smith

Editors-in-Chief

(AdityaGhosh2011@u.northwestern.edu, SarahSmith2015@u.northwestern.edu) 4 ■ The Medical Decoder ■ Phi Delta Epsilon IL Gamma

human interest

:

Human Interest ■ Volume 3 ■ Spring 2014 ■ 5

Myth vs. Fact: The Gluten-Free Weight Loss Trend

By Marta Turowski

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I

n the United States alone, the glutenfree market is expected to become a 6.6 billion dollar industry by 2017.1 However, only about 0.5-1% of Americans have celiac disease, a condition that prevents the small intestine from properly absorbing food in the presence of gluten.2 What accounts for this discrepancy?

The answer lies in the marketing. Time and time again, Americans are seduced into new dietary schemes, spending large amounts of money to partake in the latest fad. One study claims red wine boosts health, and another asserts that it is poison. Carbs are evil, or they are your best friend. While for some, gluten-free living is a way to treat a serious medical condition; for most of the 15-25% of people eating gluten-free it may not be necessary.2 A majority of the gluten-free craze can be attributed to websites like Wheat Belly, which blame gluten as a major cause of obesity, diabetes, heart disease, dementia, arthritis, and acne.3 While websites like Wheat Belly exaggerate, their claims do have some scientific basis. It is true that eating many wheat products can lead to weight gain and diabetes. Wheat products are usually found in processed foods, containing simple refined carbohydrates.3 These foods contain many calories and can lead to weight gain.

Furthermore, the wheat we consume has been genetically modified, and is therefore different than the wheat consumed a gen-

eration ago.3 These new strains of wheat are known as high-gluten.4 Studies suggest that this genetically modified form of gluten affects digestion in ways that can cause weight gain. Since wheat is being added to so many foods, it is theorized that overexposure to gluten is causing people to develop intolerances.4 But before you go running from the bread aisle to the gluten-free section of your local market, take a second to examine the contents of gluten-free products. Unfortunately, eating gluten-free is not a guaranteed way to avoid over-processed ingredients. Gluten-free products are often made with corn flour. Corn is sometimes more processed and genetically modified than wheat. Furthermore, gluten-free products can be completely stripped of nutrients and pumped full of fat and sugar in order to improve taste.2,3,4,5 The products that are being advertised as weight loss items can be more likely to make you gain weight than lose it. The gluten-free trend often focuses on selling new gluten-free products that are heavily processed rather than encouraging consumers to replace gluten naturally.

Evidence does show, however, that replacing wheat products with naturally gluten-free alternatives such as quinoa, amaranth, and millet is nutritious and can lead to weight loss.2 Unfortunately, people do not always understand the difference between replacing Human Interest ■ Volume 3 ■ Spring 2014 ■ 7

gluten products with natural options versus processed ones. Many major food companies want to keep it that way. Gluten-free products are substantially marked up because they are specialty items.5 The opportunity to mark up products with gluten-free labels has caused the number of gluten-free products on the market to skyrocket.2,5 In fact, the power of this trend is so strong that products that have never even contained gluten are now petitioning to be labeled as gluten-free.1 However, customers are not oblivious to these steep prices. Consequently, the gluten-free buying spree is expected to decline in coming years.1 When any dieting trend becomes popular, it is essential to do your research. Being a smart consumer is always important, especially when food companies opt to prioritize profit over product transparency. So, when

shopping gluten-free, check labels for natural alternatives to gluten. These products are nutritious, easier to digest, and could even help you lose a little weight! ÌMD References

1.Schultz, E.J. “Gluten-Free Food Fad Growing Momentum Among Marketers” Advertising Age 16 Sept. 2013: 0015. Academic OneFile. Web. 22 Jan. 2014. http://go.galegroup.com/ps/i.do?id=GALE%7CA343336943&v=2.1&u=north western&it=r&p=AONE&sw=w&asid=d078a0c1a979f60163a1629b9758a352 2.Voiland, Adam. “Gluten-Free Diet: A Cure for Some, a Fad for Most.”

U.S. News & World Report. EBSCO Host, 1 Dec. 2008. Web. 22 Jan. 2014. <http://web.ebscohost.com.turing.library.northwestern.edu/ehost/ detail?sid=22a1d0ae-f5e5-4a44-939f-d0edc10199c1@sessionmgr114&vid=1& hid=114&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ==#db=mth&AN=35407819>.

3. The Diet Detective: The Gluten-Free Fad.” UWIRE Text 7 Oct. 2013: 1. Academic OneFile. Web. 22 Jan. 2014. http://go.galegroup.com/ps/i.do?id=GALE %7CA344966244&v=2.1&u=northwestern&it=r&p=AONE&sw=w&asid=b45 6214c513254cf9763fd2978b6dd9d 4. Fast, Yvona. “Kicking the Gluten habit: going gluten-free is the latest diet fad--but is it healthy?” E July-Aug. 011: 36+. Academic OneFile. Web. 2 Jan. 2014. http://go.galegroup.com/ps/i.do?id=GALE%7CA261870077&v=2.1&u =northwestern&it=r&p=AONE&sw=w&asid=ce2121f92efc5fb99161f983e6 1e5868 5. Gulli, Cathy. “Gone gluten-free.” Maclean’s 16 Sept. 2013: 54+. Academic OneFile. Web. 22 Jan. 2014. http://go.galegroup.com/ps/i.do?id=GALE%7CA 342766073&v=2.1&u=northwestern&it=r&p=AONE&sw=w&asid=25aafa9ff8 1ec863f97da1153d458dc5 6. Pietzak, Michelle. “Celiac Disease, Wheat Allergy, and Gluten Sensitivity When Gluten Free Is Not a Fad.” The American Society for Parenteral and Enteral Nutrition. SAGE Journals, Jan. 2012. Web. 22 Jan. 2014. <http://pen. sagepub.com.turing.library.northwestern.edu/content/36/1_suppl/68S.full>.

7. Caution Bread. N.d. Photograph. MindyBodyGreen. 22 Jan. 2013. Web. 22 Jan. 2014. <http://www.mindbodygreen.com/0-7482/10-signs-youre-glutenintolerant.html>.

8. Savinon, Amy. Gluten Free Green. N.d. Photograph. Why Am I Eating Gluten Free?Thedailyhiit. Web. 22 Jan. 2014. <http://www.dailyhiit.com/hiitblog/hiit-diet/nutrition/eating-gluten-free/>.

9. Carlos Augusto Monteiro, Renata Bertazzi Levy, Rafael Moreira Claro, Inês Rugani Ribeiro de Castro and Geoffrey Cannon (2011). Increasing consumption of ultra-processed foods and likely impact on human health: evidence from Brazil. Public Health Nutrition, 14, pp 5-13.

Who Should

Gluten-Free?

While many who eat gluten-free are following a health fad, more and more people are getting advised to eliminate or limit the amount of gluten in their diet.

In the past, only celiac disease patients were advised to eliminate gluten from their diets because of their inability to process it. Today, people with a variety of diseases are given the same instructions. Patients who experience abdominal discomfort, bloating, diarrhea, joint pain, and even depression have seen improvement in their symptoms when gluten was eliminated from their diets.2,4 People with a gluten intolerance usually experience other intestinal issues such as lactose mal-absorption and irritable bowel syndrome.2,6 Although eliminating gluten has been proven to aid people with a variety of ailments, it is crucial that people do not eliminate gluten from their diet without consulting a doctor first.

Eliminating it without a proper consultation could mask the symptoms of a more severe problem.2 It is highly encouraged that people consult a physician before pursuing a gluten-free diet because if misunderstood, it could actually lead to malnutrition, weight gain, or masking of a more severe illness.

8 ■ The Medical Decoder ■ Phi Delta Epsilon IL Gamma

Expediting Healing Improving Treatment of Injured Athletes

By Elbert Mets

P

op, snap, click. These are the sounds of an athlete’s worst nightmare. Seriously injured athletes are required to spend time away from their sport, undergoing physical therapy regimens and even reconstructive operations.

Sports-related injuries can have long-term effects, and physicians who treat these injuries are constantly searching for ways to expedite rehabilitation without sacrificing the quality of their patients’ care. Recently, sports medicine has seen promising advances in treatment of knee and shoulder injuries that could improve and accelerate recovery.1,4,6

Each year in the United States alone, there are over 120,000 cases involving tears in the anterior cruciate ligament (ACL) of the knee.1 The ACL plays an important role in knee stability, connecting two bones, the tibia and the femur.1,2 Unlike many of the other tendons in the body, after being torn, the ACL is unable to heal on its own.4 While some individuals who have sustained this injury choose to live without surgery, many athletes opt for reconstructive surgery.1

At present, the primary means of surgical intervention for ACL damage is a procedure called ACL reconstruction. 1,3,4 This surgery is performed arthroscopically and involves removing damaged ACL tissue and replacing it Human Interest ■ Volume 3 ■ Spring 2014 ■ 9

with another tendon.1,3 Arthroscopic surgery is performed through a small surgical incision with a telescopic device, which allows imaging within the joint in question. This is in contrast to “open” surgery, where a larger surgical incision allows direct, nontelescopic vision and surgery. The replacement tendon can be obtained either from the patient, by grafting a resected segment of the hamstring or of the patellar tendon, or, alternatively, the tendon can be from a cadaver.1,3

While this procedure has a high success rate, ACL reconstruction is still an imperfect science and may have marked consequences for patients.3 One year after reconstruction, 80% of knees exhibit signs of post-traumatic osteoarthritis. 1 Osteoarthritis following ACL reconstruction manifests as degradation of knee cartilage, resulting in pain and loss of motion.1,5 In addition, patients are at increased risk of reinjuring their knees following an initial ACL tear.1,4 Heightened risk of a recurring injury may hamper an athlete’s performance when they return to their sport.

Recent advances in ACL reconstruction may improve prognosis for injured athletes. Orthopedic sur-

geon-scientist Dr. Martha Murray of Harvard Medical School and Boston Children’s Hospital recently analyzed the composition of synovial fluid, which bathes the knee and the ACL.4 Through her team’s analysis, they isolated an enzymatic anticoagulant, an agent that prevents the formation of blood clots in synovial fluid.1,4 This enzyme hinders ACL repair, as coagulation is necessary in repairing a tendon.4 To counteract anticoagulation in synovial fluid, Dr. Murray devised a “biologic-based-scaffold” composed of collagen and platelets that can be used with current ACL reconstruction surgery. 1,4 Dr. Murray’s scaffold attaches to the recovering ACL and stimulates clotting on the ligament itself, facilitating more effective healing.1,4 While this therapy has only

Adrian Peterson of the Minnesota Vikings underwent ACL reconstruction surgery and returned to the field eight months later.

Photo courtesy of StarTribune

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been used in trials with pigs, pigs treated single dislocation, the risk for that underwent this treatment fared repeated dislocation is greater than better postoperatively than control 70%.6 pigs, who either had no surgery or

Typical approaches to addressreceived surgery without the collagen ing shoulder instability include physscaffold. 1,4 ical therapy regimens and surgery.

This recent advance in ACL reWhile surgery has seen a recent push construction seems promising as a vi- towards arthroscopic procedures able treatment for injured athletes. If rather than open procedures, there the surgical approach is shown to be is now increasing evidence that athsuccessful in letes under the If the surgical approach age of 20 who human clinical trials, athletes is shown to be successful have suffered could face a detraumatic in human clinical trials, cidedly better shoulder disathletes could face a prognosis postlocation may operatively. benefit from decidedly better prognosis

Knee inopen surgipostoperatively. jury isn’t the cal intervenonly field that has seen advancetion.6 Open procedures involve an ment in surgical outcomes; surgery initial arthroscopic investigation of for sports-related shoulder injuries the patient’s shoulder anatomy, folis also moving in a promising direclowed by an opening of the shoulder tion. Shoulder injury and instability and realignment and reattachment of are frequent occurrences in young appropriate structures.6 If successful, athletes, particularly those engaged open shoulder surgery can reduce the in contact sports.6 If left untreated, risk of recurring instability, giving it anterior shoulder instability can an edge over arthroscopic and nonresult in recurrent dislocations. surgical approaches.6 Repeated wear on the shoulder or

In some cases, it may be more traumatic impact can cause the ball difficult for physicians to perform of the humerus (the upper arm) to open procedures in order to fix shoulbecome detached from the socket in der instability.9 To remedy this, sevthe shoulder blade.7 Following an un- eral open stabilization procedures

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Human Interest ■ Volume 3 ■ Spring 2014 ■ 11

have been adapted and advanced so that they can actually be performed arthroscopically. 9 Arthroscopic adaptations may be preferred in instances where patients, such as young athletes, have particularly muscular shoulders that inhibit access by way of large incisions.9 In addition, surgeons may select arthroscopic procedures when patients have particularly severe muscle or ligament tears.9 These procedures benefit from the decreased risk of recurrent instability associated with open surgery, as well as from the lower opportunity for infection characteristic of smaller incisions used in arthroscopic procedures.9 Several of these arthroscopic renditions have been successful when compared with their open counterparts. 9

A physician’s choice to perform an open or arthroscopic procedure is largely dependent on the severity of shoulder instability and the type of sport the athlete plays. Open stabilization procedures are recommended largely in patients with severe dislocation or bone damage. 6 According to Dr. Evan Flatow of Mount Sinai Hospital in Manhattan, the body of evidence supporting either option is unfortunately rather limited.8 In addition to either procedure, physical

therapy is frequently recommended for patient-athletes’ rehabilitation.

Recent advancements in the treatment of both ACL tears and shoulder instability aim to return athletes to their sports with the lowest chances of recurrent injury. With the medical field constantly advancing, athletes today face increasingly better odds of returning to their sport after sustaining an injury. ÌMD References 1. Kiapour, A., & Murray, M. (2014). Basic science of anterior cruciate ligament injury and repair. Bone & Joint Research, 3(2), 20-31.

2. Petterborg, L. J., Beasley, J., & Gooch, A. (2012, November 29). Anterior Cruciate Ligament. Virtual Health Care Team. Retrieved February 16, 2014, from http://shp.missouri. edu/vhct/case3505/index.htm 3. Vorvick, L. J., & Ma, C. B. (2011, June 4).

ACL reconstruction. MedlinePlus Medical Encyclopedia. Retrieved February 13, 2014, from http://www.nlm.nih.gov/medlineplus/ency/ article/007208.htm 4. Reynolds, G. (2013, August 28). Why A.C.L. Injuries Sideline So Many Athletes. Well. Retrieved February 16, 2014, from http://well. blogs.nytimes.com/2013/08/28/why-a-c-linjuries-sideline-so-many-athletes/ 5. Handout on Health: Osteoarthritis. (n.d.).

National Institute of Arthritis and Musculoskeletal and Skin Diseases. Retrieved February 16, 2014, from http://www.niams.nih. gov/Health_Info/Osteoarthritis/ 6. Delos, D., Moran, C., & Warren, R. F. (2013). Open Bankart Repair in Contact Athletes: Why and How. Operative Techniques in Sports Medicine, 21(4), 200-224.

7. Chronic Shoulder Instability. (n.d.). OrthoInfo. Retrieved February 16, 2014, from http://orthoinfo.aaos.org/topic. cfm?topic=a00529

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the

: experience pre-medical

The Pre-Medical Experience ■ Volume 3 ■ Spring 2014 ■ 13

o

MIND THE GAP YEAR

A Guide to Planning a Year Off

By Asia Jaros

W

hen my biochemistry professor first suggested a gap year to me during my junior year of college, I could not have been more against the idea.

Me? A GAP YEAR? I’m ready for medical school now. I can’t pause this late in the game. What would my parents think? I had just stumbled through the MCAT, written an admittedly questionable draft of my personal statement, and attempted to compile application materials, all while juggling two jobs and four classes. As much as I was eager to jump into the medical school application process, I could not shake the feeling that, as an applicant, I was not representing myself to the best of my ability.

In May, at the last minute, I finally accepted the challenge to step back and reevaluate my priorities in terms of medicine and my career development. If you’re anything like the typical type-A premedical student that I am, you’ve likely spent the last couple of years stretching yourself thin between academics, coursework, community service, jobs, friends,

and a myriad of extracurricular activities.

At some point during our pre-medical coursework, we’ve all heard a physics professor recite Newton’s first law: “An object in motion stays in motion unless compelled by an external force.” Similarly, it seems intuitive for us as motivated, determined, and passionate individuals to run towards the medical field without taking any pit stops along the way. We may be unhappy with certain components of our applications: our resumes, our professional relationships, our GPAs, etc.

Yet, we continue to run; we stay in motion. After all, it’s what we’ve been taught and rewarded for doing all our lives.

I encourage you to pause and honestly consider your motivations for working in the medical profession. There can be great value in seeking that external force that compels you to alter your trajectory, be it for a year or indefinitely. For me, taking a gap year means taking the time to refresh my mind and become a more engaged and aware member of my community. It means promoting a body-mind-

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soul harmony and recharging mentally from my undergraduate career for the upcoming years in medical school and residency. It means taking the time to read, to expand my knowledge in non-medical fields, to cook new dishes, and to travel and meet new people.

What could it mean for you?

Ultimately, the best advice I can give is: Don’t be afraid to take the leap. A lack of inherent structure and the uncertainty of a gap year is daunting at first, but a gap year is a key opportunity to develop yourself outside of medicine and to budget your time autonomously. It could be a chance to re-evaluate your motivations for medicine, to supplement your application with meaningful experiences, and put your best foot forward as an applicant.

I know that I’ll be working on all three in the following year as I work as a project manager at a company that creates software for medical groups. While evaluating myself as a potential medical school candidate last year, I became increasingly aware that my experience with the business and administrative realms of health care was lacking. I believe that by implementing electronic medical software in various hospitals across the country as a project manager, I will gain a valuable skillset that will help me throughout medical school and my career.

The Pre-Medical Experience ■ Volume 3 ■ Spring 2014 ■ 15

Six Steps to a Successful Gap Year: 1. Explore your options Start with your career advisor or pre-medical counselor. They’ll provide you with information on gap year opportunities, such as scholarships abroad, Fulbright research, and potential job opportunities. Begin planning for these scholarships or job applications during the end of your junior year and summer preceding senior year. If you plan on continuing with research, you can prepare by developing your relationship with your PI, who could later refer you for a lab technician or research coordinator position.

2. Learn by example Meet with professionals in your future field and ask them how they began their careers. Make a list of advocates, mentors, and teachers who could provide you with useful job opportunities and connections. Think outside of the box by bridging your extracurricular talents and goals with your academic pursuits. Begin relationships with possible recommenders and continue networking. Plan on maintaining them beyond your undergraduate career.

3. Identify areas where you would like to improve Create realistic, well-defined goals and work towards them. One of my goals for my upcoming gap year is to become more independent and self-sufficient prior to entering medical school. I hope to improve my time-management skills, to observe patient interviewing techniques from compassionate and caring physicians, and to gain confidence and knowledge through hands-on experience as a volunteer medical translator at a community health clinic.

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4. Be strategic Take the time to align your goals with your projected gap year activities. For example, if you enjoy service, you could get involved with a nonprofit organization such as Teach for America or Match Teaching Corps. If you want to become more familiar with various drugs and medications, you could work at a local pharmacy as a technician.

Working as an EMT or medical scribe are also great options for developing self-confidence and getting clinical exposure. In fact, some of these programs may even cover medical school expenses if you commit to working for several years (Check out: https:// www.scribeamerica.com). For research and academia aficionados, you can choose to apply for a position as a research coordinator in early spring of your senior year. Your premed advisor will be particularly useful to you in this area.

5. Start now!

Plan ahead. Internships with medical offices and job openings will be filling up quickly during the fall of your senior year. Make the time to apply for them, perhaps by cutting back on your extracurricular responsibilities or taking fewer classes. Many positions are competitive and applications can be reviewed on a rolling basis, so preparing for application due dates is crucial.

6. Have faith If you put in the work, your gap year plan will turn out better than you expected! A year ago, I remember saying the words “You see, a gap year just isn’t my thing. I can’t do that.” Today, because I opened myself up to a new opportunities and a new career trajectory, I am extremely enthusiastic about starting my gap year, and I encourage everyone to give taking time off before medical school some serious thought. It never hurts to keep your options open; you may find something great waiting for you after graduation – medical school or otherwise.

The Pre-Medical Experience ■ Volume 3 ■ Spring 2014 ■ 17

Gap Year Ideas

1. Fulbright and Rhodes Scholarships for teaching or research in the country of your choice 2. Teach for America 3. Peace Corps 4. Medical scribing 5. Medical internship at a clinic 6. Pharmacy technician 7. Medical software representative 8. Volunteering at a local hospital 9. Research coordinator position 10. Lab technician 11. Emergency medical technician (EMT) 12. That extracurricular you’ve always dreamed of pursuing i.e. Anything from becoming a ski instructor to attending culinary school ÌMD 18 ■ The Medical Decoder ■ Phi Delta Epsilon IL Gamma

Medicine as a Career, Philanthropy for a Lifetime T

By Varsha Venkatakrishna

his past winter break, I had the opportunity to go to India through All India Movement for Seva, a charity designed to provide education and health care to people in rural India. On the trip, I toured villages in northern India and observed mobile dental clinics, women’s health clinics, and residences for students who couldn’t afford transportation fees to and from school.

I had the opportunity to observe a mobile health clinic firsthand in the rural village of Dandoori. This clinic had no rooms or sophisticated technology. However, there was a large expanse on a hill with a large tent-like fixture, a dental van for teeth

cleanings, and a man with a megaphone announcing the clinic’s arrival.

I was impressed by how efficiently the health care providers were able to treat villagers in such an informal space. There were specialized sections for women’s health, tooth extractions, and prescriptions.

As hundreds flocked to be treated, the staff briskly worked and treated each patient with equal care, as if

Photo courtesy of Varsha Venkatakrishna

The Pre-Medical Experience ■ Volume 3 ■ Spring 2014 ■ 19

they were in a traditional hospital single physician would be involved setting. The clinic mostly treated with treating up to 300 people and tooth decay, reproductive health is- giving health education lessons in sues in women, malnutrition, and nearby schools. anemia. Many of the patients I saw Dr. Dhirawani then spoke seeking treatment were jaundiced about how important he felt his due to a lack of proper nutrition. work was and how he felt an obliga This kind of clinic is held about tion to give free care to those who once a month. Volunteer physicians truly needed it. He said that clinics and dental students arrive, and vil- like his were making a direct impact lagers soon on people’s

With the skills to save follow. Trust lives, and lives and provide care to develops behe between the peo- those in need, doctors who lieved ple of the village are willing to donate their that time and low-cost or free and the doctors, there and as the word of care to the less privileged are were free care spreads to few valuable assets to society. nearby regions, the proclinic’s popularity grows. By the time fessions where one could make such I visited, the clinic was seeing up to a direct impact. I was taken aback by 650 people every day. how much he valued and genuinely

Beyond the clinic’s ability to enjoyed giving back to his country treat villagers, I was impressed even through medical care. While I had more so by the physicians’ genuine volunteered in the past, I had never philanthropic drive. After we toured considered continuing to serve the clinic, my group and I were able through my professional career like to sit down with Dr. Rajesh Dhirawa- Dr. Dhirawani. But my thoughts ni, a reputable oral and maxillofacial have changed since returning from surgeon working in the nearby city India. of Jabalpur. He began by explaining My experiences with the mohis usual experience at the camp: a bile clinic also led me to think about

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the way in which students on the prehealth track understand and approach philanthropy. Premed students volunteer in hospitals and clinics both locally and around the world during their undergraduate years. While philanthropy can offer an opportunity to gain worldly experiences by helping the under-privileged, the philanthropic mindset may end when students return home.

That disconnect, for some, can be an issue. As future doctors, premed students have the potential to make a world of difference through philanthropy. With the skills to save lives and provide care to those in need, doctors who are willing to donate their time and low-cost or free care to the less privileged are valuable assets to society.

Being a doctor is an esteemed profession with many benefits. Physicians have the tools to improve the health of many people at home or abroad who cannot afford proper

Photo courtesy of Varsha Venkatakrishna

care. There is great value in approaching volunteering as more than just an undergraduate requirement and making philanthropic involvement a part of one’s career. While getting involved in philanthropy as an undergraduate is important, continuing the practice into adulthood can be even more rewarding.

After all, as Dr. Dhirawani explained, it can be an incredibly gratifying way to use the education pre-health students work so hard for. It is empowering to know that after years of challenging pre-med courses, medical school, residency, and fellowships, you can continue to make a substantial difference where it is needed most. ÌMD

The Pre-Medical Experience ■ Volume 3 ■ Spring 2014 ■ 21

Exploring the Physician Assistant Profession S

By Cynthia Stamelos

ince the beginning of my college career, I knew I wanted to explore the realm of medicine, but I was not interested in following the traditional doctor route: going from college to medical school and then onto a residency. The physican-route requires a rather independent individual, and after some soul-searching, I realized I would prefer to work under the guidance of a well-versed expert. It was then that I discovered the physician assistant (PA) profession. I was intro-

duced to the profession through patients I currently work with as a physical therapy aide. I enjoyed talking to patients about my prospective career paths, and a couple of them suggested that I look into the PA profession based on my disposition and concerns about the future. They understood my passion for medicine, but at the same time respected my hesitation to stick to a specific specialty.

Several aspects of the profession initially attracted me. As a PA,

22 ■ The Medical Decoder ■ Phi Delta Epsilon IL Gamma

I would be able to work semi-autonference is that a physician has more omously with a physician, providindependence and is fully responsible ing patients with similar high-qualfor their patient, whereas a PA works ity care, while having the ability to under physician supervision.3 The change my specialty with ease.1 Being degree to which a PA is supervised a PA seemed like a flexible profession. depends on state law. Although a PA I also realized that working under the is expected to develop an expertise supervision of a physician would be within the supervising physician’s the perfect fit for me, so that I could specific scope of practice, the physiease into cian addresses the As a PA, I would be able to more complicated the process, rework semi-autonomously cases that a PA quiring may not have the with a physician, providing training to hanless physician conpatients with similar high- dle.4 However, sultation the majority of quality care, while having PAs still have as my experience in the ability to change my the ability to the hospital prescribe medi1 specialty with ease. grew. cations to pa What exactly separates a PA tients.4 from a traditional physician? A PA

The physician assistant profesworks with a physician to provide sion is a recent addition to the medimedical care, diagnoses, and health cal field. It was founded in the 1960s maintenance services.2 One of the

by Dr. Eugene Stead, Jr. of Duke biggest differences between a PA and University as a way of increasing the a physician is the amount of schooloutput of quality health care after ing required. A PA usually attends the World War II.5 The war brought three to four years of graduate school a large influx of patients, and as a with an emphasis on primary care, result, Dr. Stead believed that it was whereas a physician attends four possible to “meet many patient needs years of medical school followed by without a traditional medical educaresidency.3 Another noteworthy diftion.”6 As the Chairman of the De-

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The Pre-Medical Experience ■ Volume 3 ■ Spring 2014 ■ 23

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The physician assistant field is a profession that many students explore extensively and ultimately choose because it coincides with their ideal method of practicing medicine.

partment of Medicine at Duke University, Dr. Stead installed the first Physician Assistant Program at the university in 1965.6

Since then, the field of PAs has risen to new heights and has taken on a more collaborative nature with medicine. In fact, “employment of physician assistants is projected to grow 38% from 2012 to 2022.”7 In addition, with the Affordable Care Act, more people have access to health care and preventative care, resulting in a large influx of patients. PAs aid doctors by treating patients after their primary doctors have examined them.3 I have worked as an aide in a physical therapy clinic for over a year now, and many of my patients tell me that they see a PA more frequently than they see their physician.

There are many appealing factors that draw students to the PA career path. First, the salary of a PA is stable. According to the Bureau of Labor Statistics, a physician assistant

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earns an average of $90,930 a year.7 Another attractive aspect to being a PA is the fewer number of years required in graduate school. In addition, the PA profession can provide a more flexible schedule.1 Due to the focus on general primary care in graduate school, it is relatively simple for a PA to switch medical specialties within the profession, assuming that he or she has met the qualifications for the specialty desired.8 On the other hand, nurse practitioners, who are commonly compared to PAs, are generally trained in a single specialty.1

The physician assistant field is a profession that many students explore extensively and ultimately choose because it coincides with their ideal method of practicing medicine.

PA schools are becoming increasingly selective due the increase in demand for PAs.2 There is a large emphasis on having prior medical experience before entering graduate school; many PA schools require high levels of pa-

24 ■ The Medical Decoder ■ Phi Delta Epsilon IL Gamma

tient contact hours prior to applying, about 1,000 hours on average.8 Additionally, to maintain PA certification, 100 hours of continuing medical education every two years is required, and the PA must recertify every 10 years.8

I encourage students interested in medicine to explore alternative career paths related to health care.

College is a great time to assess where your interests truly lie. Because the PA profession requires many hours of patient contact, many students take a gap year or two after college to decide if the PA route is truly the correct path for them.3 In fact, according to U.S. News, “the average age of people entering PA programs nationwide is 27”.9

Thus, it is worth taking that time to link your lifestyle preferences to your career path. My decision to follow the PA route was based on a realistic evaluation of the demands of training to become a physician versus a PA, and the fact that they have a similar expected workload and interaction with health care. Both PAs and physicians are crucial components of the health care team. The PA profession provides its own unique, attractive opportunities, and I am excited

to start my journey down this path at the conclusion of my undergraduate career. ÌMD References 1. Mittman, D., Cawley, J., & Cawley, J. (2002, August 31).Physician assistants in the United States. Retrieved from http:// www.ncbi.nlm.nih.gov/pmc/articles/ PMC1124003/ 2. California Physician Assistant Board, Department of Consumer Affairs. (2014).

Publication: What is a physician assistant?.

Retrieved from website: http://www.pac. ca.gov/forms_pubs/what_is.shtml 3. Stamelos, J. (2014, January 3). Interview

by C.K. Stamelos. An orthopedic surgeon’s take on physician assistants.

4. Colby college health services: Physician assistants. (n.d.). Retrieved from http:// www.colby.edu/administration_cs/ healthservices/staff/pa.cfm 5. Medelita honors physician assistants and Dr. Eugene Stead during national pa week.

(11, October 2011). Retrieved from http://www.usnews.com/education/ articles/2010/08/06/why-physicianassistant-school-may-be-right-for-you 6. Medelita honors Physician Assistants and Dr. Eugene Stead during national pa week. (2011, October 11). Retrieved from http://www.prweb.com/releases/2011/10/ prweb8867456.htm 7. Bureau of Labor Statistics, U.S. Department of Labor. (2014). Occupational outlook handbook, 2014-15 edition: Physician Assistants. Retrieved from website: http://www.bls.gov/ooh/healthcare/ physician-assistants.htm 8. Frequently asked questions about the physician assistant profession. (2011).

Retrieved from http://www.pace.edu/ physician-assistant/frequently-askedquestions 9. Burnsed, B. (6, August 2010). Why physician assistant school may be right for you. Retrieved from http://www.usnews. com/education/articles/2010/08/06/whyphysician-assistant-school-may-be-right-foryou

The Pre-Medical Experience ■ Volume 3 ■ Spring 2014 ■ 25

Destination:

26 ■ The Medical Decoder ■ Phi Delta Epsilon IL Gamma

:Immortality

By Lukasz Jaros

O

ver the past century, the average human lifespan has increased from 45 years to almost 80 years. In large part, this is the direct result of the invention of vaccines, antivirals, and antibiotics.1 The threat of outside agents to health has decreased significantly. Now, scientists have turned to the human body to tackle the remaining barriers to extending human life. As it turns out, the very essence of life, DNA, can also facilitate illness and death, as damage to DNA can occur as an individual ages. The new treatment that is being developed to address this issue is gene therapy. However, to prove its worth, gene therapy cannot simply treat against the progress of degradation in the human body; it must also reverse it. If humans attain immortality, the inevitable questions becomes, “Should we live forever?”

Science and Technology ■ Volume 3 ■ Spring 2014 ■ 27

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o understand how scientists are undertaking the monumental task of extending life, one must first understand the mechanism of aging and death. Dr. Valter Longo and his team at the University of South California are making steady progress in this direction. In 1996, Dr. Longo described how, much like the combustion reaction damages the engine of a car over time, mitochondria (which supply every cell in our body with energy) wear down due to the energy-releasing reactions occurring within them.2 These chemical processes can cause similar damage to DNA, whether inside the mitochondria or elsewhere in the cell. This corruption of cellular structures represents the main cause of bodily decay and aging. Throughout the past decade, Dr. Longo and his team have isolated 2 genes (RAS2 and SCH9) and two genetic pathways (IGF-1 and PKA) responsible for aging.3 By excising these genes and restricting caloric intake, they have increased the lifespan of yeast tenfold and doubled the lifespan of mice.4

In 2008, Dr. Longo explained in The Journal of Cell Biology how “the deletion of SCH9 [and RAS2]…protects against age-dependent defects…by inhibiting error-prone recombination and preventing DNA damage and dediffer-

entiation, [which is a specialized cell’s regression to a more embryonic, unspecialized form].”3 In effect, the deletion reduced the risk of harmful DNA mutations by keeping the cell in the G0 phase, a specialized, non-dividing, resting state that resists environmental stresses and reduces risk of cancer. Meanwhile, the low calorie diet enhanced the effect by favoring these non-dividing cells and acting on the natural inhibitory pathways that prevent cellular division under unfavorable conditions. Finally, the absence of IGF-1 and PKA pathways repress metabolic activity in mitochondria, further decreasing their degradation.5

In 2011, Dr. Longo collaborated with a team of endocrinologists from Ecuador to demonstrate that human populations with deficiencies in expression of the genes IGF-1, RAS, PKA, and SCH9 displayed a delayed onset of aging in addition to a very low incidence of cancer and diabetes.6 Theoretically, scientists could significantly delay aging in humans by excising these genes. However, these deficiencies are also associated with stunted growth.6 Scientists must first develop techniques to turn the genetic expression on and off before moving on with developmental issues.

Currently, Dr. Christopher Voigt

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and his research team at the Massachusetts Institute of Technology are attempting to solve this very issue. In 2005, the team developed techniques to bestow bacteria with new abilities to sense their environment.7 As proof of their concept, they inserted genes into E. coli (which normally live in the lightdeficient environment of the large intestine) in order to allow the bacterium to react to light stimulus. This experiment demonstrated the ability to genetically engineer a desired genetic response to a designated stimulus.

In the past five years, the team has further expanded this genetic control to operate in more complex functions.8 By placing different promoters (regions of DNA that initiate transcription of specific genes) and repressors (DNAbinding proteins that prevent transcription of a particular gene) on select sites in the bacterial DNA and then spatially arranging them in a particular fashion, Dr. Voigt’s team programmed the bacteria to give certain outputs in the presence of a series of specific environmental triggers. Consequently, these extensively modified bacteria could sense and react to changes in light, tempera-

ture, acidity, and the concentration of specific compounds in a carefully designed manner.2 In fact, Dr. Voigt’s team has already modified E. coli to invade cancer cells (in vitro) and release cytotoxic chemicals while leaving normalfunctioning cells alone.9 This success suggests that programmed bacteria may be used in the future to deliver anything from cancer treatments to genetic modifiers. The diversity of treatments that could be delivered in this manner provides an important advantage in extending the human lifespan. Nonetheless, further research on the effectiveness and potential side effects is still required before programmable bacterium can be utilized as a vector in human patients.

Dr. Aubrey de Grey, a theorist and geneticist, has proposed an additional approach to the problem of ag-

Photo courtesy of Vicky Castro

Science and Technology ■ Volume 3 ■ Spring 2014 ■ 29

ing. He alleges that the accumulation of compounds, then perhaps they can forcompounds in the body that cannot be mulate the rejuvenating medicine that broken down by enzymatic activity can Dr. de Grey envisions.2 generate the aging effect.10 This “junk”

While the hunt for specific comexists both within the cell and in the pounds and genes continues, the mere extracellular matrix. Several other con- prospect of viable rejuvenation has exditions associated with aging, such as cited many scientists. While other treatmacular degeneration, atherosclerosis, ments must be utilized while a patient and Alzheimer’s, arise from a buildup of is relatively young, an injection of Dr. de harmGrey’s miPerhaps the biggest obstacle ful procrobial enteins in zymes could standing in the way of or near remove the gene therapies becoming cells, harmful comclutter and commonplace in the medical promispermit the market is that they can be ing their body to viewed as incursions against structural repair damintegrity the philosophy of human life. age indeand proper pendent function.11 of age.2 Consequently, the aging process

Dr. de Grey’s pursuit of a treatcould be halted, allowing humans to ment has led his team to the most remain 25 years old forever. unlikely of places: the graveyard. As it

Despite these promising projects, turns out, the solution to aging may be gene therapy must overcome several found in the processes occurring postobstacles before it can become a viable mortem.2 After an individual dies, inanti-aging treatment. Current delivery sects, bacteria, and other decomposers systems consist of other viruses or bacbreak down cells and tissue, including teria.12 However, these often incite an the compounds that the body was inca- immune response that destroys them pable of digesting. If scientists can dis- and the designed genes that they carry. cover exactly which enzymes and genes Thus, even if the initial dose achieves a are employed in the digestion of those certain degree of success, the triggered

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tion of tumors increases when more genes are involved.12 Unfortunately, the anti-aging medicines devised by scientists such as Dr. Voigt and Dr. Longo do involve several genes and genetic pathways. Nonetheless, medicines that will help us achieve immortality are still in the early stages, and it is possible that Photo courtesy of Vicky Castro multiple research teams are working on immune response could diminish the effectiveness of subsequent treatment.12 gene therapy projects will aid in resolving its problems.

This presents a major predicament beIf immortality crosses over into cause current gene therapies are short- the realm of reality, humans will have to lived and require multiple applications to affect the scores of cells in the body.12 answer the question, “Should people live forever?” After all, many areas around The only other options, injecting eithe world already struggle with overther naked DNA or DNA protected by a protein complex, are even more likely population and the problems with pollution that accompany it. Consequently, to trigger an immune response, as the body has evolved highly specialized de- immortality may necessitate laws barfenses to destroy foreign genetic mate- ring conception in an effort to curb a rising population. Also, the technology rial.12 may be expensive at first, further di Even if scientists do overcome these setbacks, another hurdle lies with- viding society according to wealth and promoting inequality. in the cell. Gene therapy is ideal when

Perhaps the biggest obstacle only one gene is involved. However, inserting multiple genes simultaneously standing in the way of gene therapies becoming commonplace in the medican have serious consequences. For cal market is that they can be viewed example, the probability of inserting a as incursions against the philosophy promoter or repressor into the wrong section of DNA and inducing the forma- of human life. The ethical dilemmas Science and Technology ■ Volume 3 ■ Spring 2014 ■ 31

surrounding the introduction of antigeneral public, their implications for aging technologies are largely centered humanity will be unprecedented. ÌMD upon the potential progression towards References achieving immortality in humans. Hu- 1. Sonnega, A. (2006). The Future of Human Life Expectancy.

Retrieved from Population Reference Bureau man societies operate under the belief website: http://www.prb.org/pdf06/NIA_FutureofLifeExpectancy.pdf that life has value because it is finite.

2. Through the Wormhole: Can We Live Forever? : Videos : Science Channel [Video file]. (2011, July 27). Retrieved People are motivated to work hard to from http://www.sciencechannel.com/tv-shows/throughfulfill both personal and professional the-wormhole/videos/can-we-live-forever.html 3. Madia, F., Gattazzo, C., Wei, M., Fabrizio, P., Burhans, goals before their time runs out. RelaW. C., Weinberger, M., . . . Longo, V. D. (2008). Longevity mutation in SCH9 prevents recombination errors and pretionships matter more as people know mature genomic instability in a Werner/Bloom model sysJournal of Cell Biology, 180(1), 67-81. doi:10.1083/ that time with one another is relatively tem. jcb.200707154 4. Kaczor, T., & Longo, V. (2012, April 3). Caloric Restriclimited. However, immortality could tion and Fasting in Disease Prevention and Treatment - Natural Medicine Journal: The Official Journal of the radically alter such a belief system. As American Association of Naturopathic Physicians. Reextended families could come to include trieved March 14, 2013, from http://www.naturalmedicinejournal.com/article_content.asp?article=312 many more generations, the traditional 5. Yorimitsu, T., Zaman, S., Broach, J. R., & Klionsky, D. J. (2007). Protein Kinase A and Sch9 Cooperatively Regufamily structure might be threatened late Induction of Autophagy in Saccharomyces cereviMolecular Biology of The Cell, 18(10), 4180-4189. by a lifespan extension. The job market siae. doi:10.1091/mbc.E07-05-0485 could be drastically changed by a much 6. Taubes, G. (2013, March 27). Rare Form of Dwarfism May Protect Against Diabetes Cancer. Discover. Retrieved higher retirement age, which would in- from http://http://discovermagazine.com/2013/april/19double-edged-genes#.Ux4NM1xS_nY evitably require governments to restruc- 7. Anderson, J. C., Clarke, E. J., Arkin, A. P., & Voigt, C. A. (2006). Environmentally Controlled Invasion of Cancer ture their methods for allocating limited Cells by Engineered Bacteria. Journal of Molecular Biology, 355(4), 619-627. doi:10.1016/j.jmb.2005.10.076 resources. The possible outcomes are 8. Tamsir, A., Tabor, J. J., & Voigt, C. A. (2011). Robust multicellular computing using genetically encoded NOR endless and largely unpredictable. gates and chemical `wires’. Nature, 469(7329), 212-215. doi:10.1038/nature09565

All of these ethical and social is9. Voigt, C. A., & Clancy, K. (2010). Programming cells: sues present a substantial barrier to in- towards an automated ‘Genetic Compiler’. Current Opinion in Biotechnology, 21(4), 572-581. doi: 10.1016/j. troducing immortality drugs. However, copbio.2010.07.005 10. Nuland, S. (2005, February 1). Do You Want to Live the issue of whether or not immortality Forever? | MIT Technology Review. Retrieved March 14, 2013, from http://www.technologyreview.com/featuredtherapies should ever be utilized will story/403654/do-you-want-to-live-forever/ 11. SENS Research Foundation (2013). Aging as We’ve not be so easily decided. After all, the Known It | SENS Research Foundation. Retrieved March human instinct causes us to desire pro- 14, 2013, from http://sens.org/research/aging-as-weveknown-it longed life and the prospect of conquer- 12. University of Utah Health Sciences (n.d.). Challenges in Gene Therapy? Retrieved March 10, 2013, from http:// ing death seems irresistible. If these learn.genetics.utah.edu/content/genetherapy/gtchallenges/ therapies are indeed introduced to the 32 ■ The Medical Decoder ■ Phi Delta Epsilon IL Gamma

health care & policy

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Health Care & Policy ■ Volume 3 ■ Spring 2014 ■ 33

By Nic

key Ja f

ari

Innovations to In-Home Medical Care

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he general perception of in-home medical care revolves around thoughts of nursing homes, assisted living centers, and hospice care for terminally ill patients. Home health care encompasses any type of professional health care service provided within a patient’s home. Because the average hospital stay in the United States is $18,000, much higher than any other Organization for Economic Co-operation and Development (OECD) nation, being creative and focusing on preventive care will be crucial aspects of reform.1

In 2012, it was estimated that the U.S. spends over $8,000 per person per year on health care, or about 17% of gross domestic product.1 This amount of spending is not sustainable and calls for innovation and change. Our technological capabilities are rapidly advancing, our standards of what constitutes “good health” are changing, and the baby-boomer population is retiring in large numbers, increasing the amount of pres-

sure on our health care system. In-home medical care has responded to these issues and is quickly changing the face of medicine in our country. Concierge medicine, patient-centered health models, and video-conferencing therapies are examples of how innovation will help improve health care delivery in the future.

The Agency for Healthcare Research and Quality (AHRQ) describes the patient-centered medical home (PCMH) as the model that ensures the highest quality health care for all Americans.

The PCMH provides comprehensive, patient-centered, coordinated care, that is easily accessible and ensures quality and safety.2 The state of Idaho is adopting an outcomes-based system or ‘medical home’ care model. The medical home model “seeks to coordinate care and better engage patients and families, using health coaches, care transition pathways and other interventions to reduce expensive re-hospitalizations.”1 This model is patient-centered and “links provid-

34 ■ The Medical Decoder ■ Phi Delta Epsilon IL Gamma

ers, hospitals and health and social service agencies.”3 The intent is to reduce test duplication thereby reducing costs.3 Idaho lawmakers wish to start rewarding the value of medical services by evaluating outcomes rather than the pure volume of services.3 With the current pressure to reduce spending on health care, it is important that providers understand the value of preventative care and target this care at the right populations.4

Compared to other OECD nations,

fective health care for our population.

Another recent trend in the U.S. health care system involves experimenting with different ways to approach inhome care. As the baby-boomers grow older, there has been an increasing demand for geriatric medicine, and demand is beginning to exceed available resources. While increasing numbers of elderly patients require treatment for depression and other mental health issues, the U.S. currently “lacks enough geriat-

“Being creative and focusing on preventive care will be crucial aspects of reform.1” the U.S. performs an extraordinary amount of diagnostic testing, and our rate of MRI tests and CT tests is “more than twice the average.”1 Focusing on outcomes will help ensure that physicians only recommend tests that are absolutely necessary. However, some providers have voiced concerns over the new system that Idaho is adopting, because providers will be assessed on patient outcomes without control over whether or not patients follow through with their advice and treatments. Going forward, ongoing efforts should continue to utilize best practices and innovations to achieve the highest quality and cost ef-

ric mental health professionals to match the population.”5 According to Professor Namkee Choi of the University of Texas, anti-depressant medications can be ineffective with certain elderly patients because these treatments are unable to alleviate many psychosocial stressors such as financial concerns and lack of transportation.5 Thus, different options are being explored to aid patients experiencing depression. For example, a six week study in Texas used video-conferencing technologies, such as Skype, to provide psychotherapy to seniors. This study found that “94 percent of the participants praised the experience.”5 This Health Care & Policy ■ Volume 3 ■ Spring 2014 ■ 35

strategy allows elderly patients to receive the attention they need at a relatively low cost and from the convenience of their own residence. Video-conferencing treatment for mental illnesses is just one example of how innovation enables delivery of valuable therapies to patients in a timely, convenient, safe, and easily accessible manner.

Another important trend to follow is concierge medicine, which requires physicians to be available twenty-four hours a day to provide care for their patients. Family physicians are increasingly turning to concierge medicine when they are “fed up with traditional medical practices that they say have grown complicated and impersonal.”6 This system is based on monthly or annual cash fees instead of insurance reimbursements.6 Concierge medicine can increase doctors’ overall incomes while lowering the number of patients they see. In turn, most doctors who switch to concierge medicine end up working fewer hours, which can improve the quality of care they provide. Another advantage that concierge medicine provides to patients is that it reduces waiting time at a doctor’s office. It is important to note that the U.S. already has among the lowest waiting times for its patients.1 While an attractive option, “once employed by a hospital

system, employment contracts and noncompete clauses make it difficult for physicians to start independent practices, whether concierge or traditional.”1

There is also fear that if an increasing number of wealthy Americans will start using concierge services. This shift would only further fragment our pub-

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lic health care system. “It’s an attempt to formalize two-class medicine,” said Wharton School of the University of Pennsylvania professor of health care management Mark V. Pauly. “Those who can pay will get better treatment with a smile, and those who can’t will have to wait.”5 Therefore, it will be some time before anyone can conclusively determine how concierge medicine has affected health care overall, and whether this trend is a health care fad or if it will catch on and become widely used by those who can afford it.

Outcomes-based health models, video-conferencing, and concierge medicine are just three examples of the way modern medicine is changing. While finding creative ways of using new technologies to aid senior citizens is a step in the right direction for health care, the aforementioned developments cannot currently be considered definitive solutions to many of the problems within our system. While this surge for creating better preventative medical protocols is encouraging, new challenges lie ahead as health care providers will need to find ways of holding patients accountable for their own personal health. Thus, with new approaches to health care, doctors will have the option of using these alternatives to treat their patients. As para-

digms in health care are shifting, it is critical that doctors begin helping their patients develop individualized plans of action to cater to patients’ unique needs.

The challenge will be to find ways to increase the quality of care while concurrently cutting costs to an overburdened health care system. ÌMD References 1. Kane, J. (2012) Health Costs: How the U.S. Compares With Other Countries <http://www.pbs.org/newshour/rundown/ health-costs-how-the-us-compares-withother-countries/>.

2. Agency for Healthcare Research and Quality. (2014) Defining the PCMH. U.S. Department of Health and Human Services. <http:// pcmh.ahrq.gov/page/defining-pcmh>.

3. Spence, W. (2014) Idaho pursues ‘medical home’ care model. January 15, 2 0 1 4 . < h t t p : / / w w w. i d a h o s t a t e s m a n . com/2014/01/15/2974462/idaho-pursuesmedical-home-care.html>.

4. Goozner, M. (2014) When an ounce of prevention is worth an ounce of cure. February 15, 2014. <http://www.modernhealthcare.com/article/20140215/MAGAZINE/302159984> 5. Zaragovia, V. (2014) Eldercare Experts Find Skype Can Beat Depression Better Than Meds. January 15, 2014. <.http://washingtoninformer.com/news/2014/jan/15/ eldercare-experts-skype-better-depressionmeds/>.

6. Nixon, A. (2014) Doctors flock to concierge practices. February 1, 2014. <http://triblive. com/business/headlines/5437721-74/concierge-doctors-patients#axzz2sCRI59hc>.

7. Concierge Medicine: The Doctor Is (Always) In, If You Pay Enough. Nov. 22, 2011. <http://knowledge.wharton.upenn.edu/ article/concierge-medicine-the-doctor-is-always-in-if-you-pay-enough/> Health Care & Policy ■ Volume 3 ■ Spring 2014 ■ 37

Global Perspectives on Health: Nutritional, Dietary, and Health-Related Issues in Mexico

By Angie Castillo

A

na and Mario are six years old and both live in Mexico. When Ana finally arrives at her house after a long walk, her mother gives her a plate with rice and beans and a cup of water to share with her younger sister. Elsewhere, when Mario arrives home after riding the school bus, his mother gives him a plateful of meat, rice, potatoes, tortillas, and a cup of Coca-Cola. Why are the diets of the children different even though they live within the same country? The reason is geographical location; Ana lives in southern Mexico while Mario lives in northern Mexico.

These children are examples of how diet and nutrition in Mexico are influenced by social factors that go beyond personal preference.

Diet and nutrition vary dramatically among Mexicans due to their different habits, geographic locations, and socioeconomic statuses. However, across the board it remains true that the typical Mexican diet lacks certain important nutrients. As a third-year medical student at La Universidad de

Monterrey who has grown up in Mexico, I have witnessed this country’s issues with diet and nutrition first-hand. These problems can be considered major reasons why obesity and malnutrition are prominent health-related risks in Mexico. While obesity is a common problem in the northern states of Mexico, malnutrition is more prevalent in the southern states where the poorest families reside.1,2 Four out of ten children suffer from malnutrition and fourteen out of one hundred kindergartners are shorter than the international average height for children of their age.1 This is a major problem, as seven million Mexicans are affected by nutrition deficiency.

Chronic malnutrition has been increasing over the past few decades, but very little has been done to address its causes and effects. Efforts must be initiated by the Mexican government to focus on ensuring that all children have access to nutritious meals. When assessing problems with the Mexican health care system, one of the most important issues to consider is that children who

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suffer from malnutrition during their affordable option for many families. In childhood are at a higher risk for devel- addition, junk food is more accessible to oping other illnesses later in life, such Mexican citizens than is healthy, nutrias cardiovascular and other chronic tious food. This fact is reinforced by the diseases.3,4 thousands of candy stores that line the

An unfortunate reality in Mexico streets of northern Mexican neighboris that many families cannot afford to hoods, whereas the grocery stores sellpurchase sufficient food with nutritious ing healthy foods in those same neighcontents. Accessibility to healthy food borhoods are few and far between. The can radically

Accessibility to healthy Mexican diet is affect people’s jokingly called food can radically affect health, an issue the “T-diet” bepeople’s health, an issue cause it is largely that influences Mexican citizens that influences Mexican based on tacos, regardless of their tortillas, tamacitizens regardless of their les, tortas, and geographic locageographic location. tostadas.5 The tion. Even though Mexico’s GDP increased from 1999 to dishes mentioned in the T-diet are not 2006, around 1.5 million children unpart of a well-balanced diet, as they conder 5 years of age still suffered from tain high levels of fat and carbohydrates malnutrition. Fortunately, this number with limited amounts of protein.5 has gone down since that period, which Analysis of how a typical Mexican indicates that positive changes are befamily spends its food budget can grant ing made for the betterment of Mexiinsight into the nutritional disparities can citizens.5 Nevertheless, there is still that exist between Mexican citizens’ much work to be done to improve the diets. On average, a Mexican family current situation. will use about 36% of its budget to buy

Obesity has recently become a foods with high levels of fat and carbosignificant health concern in Mexico hydrates.6 In fact, studies have shown that has received attention from the that Mexicans buy more sugared drinks Mexican government. Healthy foods than they buy eggs and vegetables.3 are becoming increasingly expensive,

It is important to recognize that while junk food is becoming the only both malnutrition and obesity in Mex-

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Health Care & Policy ■ Volume 3 ■ Spring 2014 ■ 39

ico are affected by the ready availability of cheap junk food. While issues regarding nutrition in Mexico are alarming, initiatives are underway to rectify these problems. Congress recently approved a new health care law that will raise taxes on all sugared drinks and other junk foods, with the sole purpose of combating the problems of obesity and malnutrition.7 This tax money will be spent on full-time preschool, elementary, and middle school programs which promote physical activity. Furthermore, there

has been a recent increase in the number of parks available where people can run, walk, or do various other exercises to stay in shape. The federal government has worked on these parks over many years expecting them to provide a safe and adequate space specifically for exercising and resting. While these programs are a great start changing these alarming health care issues in Mexico, they are not enough. Without adequate family education on how to establish well-balanced diets, these problems will

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persist. It is equally important that efforts are made to make healthy foods more affordable for the average Mexican citizen.7

There are also other courses of action that can be taken. According to the National Nutrition and Health Survey, strengthening health care and social development programs may lead to improvements in the health of Mexico’s citizens.5 Some changes that can be made include developing primary health assistance services that can more readily offer health services to the lower socioeconomic class, as well as implementing programs that would improve the training of health care personnel in Mexico.

Advancements in social development programs are also necessary in order to improve education for mothers regarding how they can maintain adequate nutrition during pregnancy or lactation.

Obesity and malnutrition in Mexico are pressing health problems that must continue to be addressed by the Mexican government and international health organizations. Many Mexican families, in both the northern and southern states, are predisposed to these conditions due to geographic location and socioeconomic class. Even though the government has started providing assistance to try and amelio-

rate some of these issues, there is still a long way to go. An emphasis must be placed on educating families, especially parents, on how to make adequate nutrition choices. With enough effort from both the people and the government, Mexico can reach its goals and promote new nutritional standards that will ultimately enhance the wellness of the future generations of Mexicans. ÌMD References 1. Ramirez, E. (2013). México, de la desnutrición a la obesidad: el fracaso en alimentación. October 16, 2013. <http:// contralinea.info/archivo-revista/index. php/2013/10/16/mexico-de-la-desnutricion-la-obesidad-el-fracaso-en-alimentacion/>.

2. UNICEF (2014). Salud y nutrición. September 20, 2013. <http://www.unicef.org/ mexico/spanish/17047.htm/>.

3. Dominguez, A. (2013). La dieta del mexicano. September 29, 2013 <http:// www.milenio.com/tendencias/dieta-mexicano_0_162583786.html/>.

4. Ensanut (2012). Encuesta Nacional de salud y nutrición 2012. <http://ensanut. insp.mx//>.

5. Hernández, M. (2012). La famosa dieta “T”. <http://lossaboresdemexico.com/lafamosa-dieta-t//>.

6. INEGI (2013). Encuesta nacional de ingresos y gastos de los hogares (ENIGH) 2012. <http://www.inegi.org.mx/inegi/ contenidos/espanol/prensa/boletines/ boletin/Comunicados/Especiales/2013/ Julio/comunica5.pdf>.

7. Sanders, N. (2013). El precio del pan de dulce aumentará 8% en México a partir de 2014. <http://mexico.cnn.com/ nacional/2013/12/30/el-precio-del-pande-dulce-aumentara-8-en-mexico-a-partirde-2014/>.

Health Care & Policy ■ Volume 3 ■ Spring 2014 ■ 41

the

:

medical school

experience 42 ■ The Medical Decoder ■ Phi Delta Epsilon IL Gamma

The Road to Residency: A Time for Advocacy

By Kriti Goel

M

ost aspiring doctors are well-aware of the limited number of medical school spots available and that admission into medical schools is not guaranteed on the first or even second try. The journey continues to be competitive even after one has gained entrance into medical school. A medical school graduate must still be matched with a residency program, and resident training positions are becoming more competitive each year.

In the past few years, while the number of graduating medical students has continued to increase, the number of residency spots, also known as graduate medical education (GME), available to medical students has remained stagnant. Years of rotations, competitive exam scores, and research experience do not guarantee a match into a residency program. In 2013, 6% of graduates in United States allopathic medical schools were unmatched. Although the majority of applicants did match, this disconnect in numbers is unsettling.1 Fortunately, we have the potential to change these numbers.

A few years ago, in order to address the large demand of physicians in the U.S., medical schools increased enrollment, and new medical schools were opened. In fact, in the last decade, 16 new medical schools have either opened or are in the process of opening to address this growing need.2 Studies conducted by the Association of American Medical Colleges’ Center for Workforce Studies show that first year medical school enrollment by 2017 is projected to be 30% higher than it was in 2003.3 This expected rise in the number of physicians trained in the U.S. is crucial for our health care system.

However, this rise necessitates an increase in residency training positions.

Atul Nakhasi, National Chair for the Student Section of the American Medical Association, describes this phenomenon as a “bottleneck effect”. He explains that the federal government funds the majority of GME programs, but this funding has Medical School ■ Volume 3 ■ Spring 2014 ■ 43

“With a growing population, the U.S. needs a cadre of welltrained physicians to serve the surging demand for health care.” been capped since the 1997 Balanced Budget Act. This act limited the number of residency training spots that hospitals can offer. With a growing population, the U.S. needs a cadre of well-trained physicians to serve the surging demand for health care.

So, what can be done? Becoming involved in this issue by joining a representative group of students will establish a strong platform from which to voice opinions. Nakhasi states “the more people that engage with that voice, the louder the voice is.” State governments are another level of authority through which advocates can implement change. Although the U.S. government funds the majority of GME, state governments also fund a portion, and have increasingly become an important player in the rise in funding for GME. Just last year, both New Jersey and Florida committed extra funds to GME. Florida now commits a total of eighty million dollars towards its GME programs, while New Jersey has increased its funding by ten million dollars.4 Bills and funding are currently being debated – the time to make a difference is now. For example, California’s state legislature is currently working to pass a three million dollar bill to fund primary care residency programs.5 Writing to a government representative is an important step students can take to ensure a bill like this passes, and similar efforts are needed across the country.

It is important to take action now to ensure that today’s aspiring doctors have the ability to care for tomorrow’s patients. Pre-medical and medical students alike must become aware of the discrepancy between rising medical school positions and stagnant residency spots. While it may seem distant to undergraduate students, beginning to address and anticipate this issue now is paramount for substantial changes to occur in the number of residency positions available. ÌMD 44 ■ The Medical Decoder ■ Phi Delta Epsilon IL Gamma

PICTURE

References 1. National Resident Matching Program, Results and Data: 2013 Main Residency Match®. National Resident Matching Program, Washington, DC. 2013. <http://b83c73bcf0e7ca356c80-e8 560f466940e4ec38ed51af32994bc6.r6.cf1.rackcdn. com/wp-content/uploads/2013/08/resultsanddata2013.pdf>.

2. Association of American Medical College, A Snapshot of the New and Developing Medical Schools in the U.S. and Canada. 2012. <https://members.aamc.org/eweb/upload/A %20Snapshot%20of%20the%20New%20and%20Developing%20Medical%20Schools%20in%20the%20 US%20and%20Canada.pdf>.

3. Association of American Medical Colleges. “Medical School Enrollment on Pace to Reach 30 Percent Increase by 2017.” 2 May 2013. <https://www.aamc.org/newsroom/ newsreleases/335244/050213.html>.

4. Association of American Medical Colleges.“Florida, New Jersey Pledge Increased Funding for GME.” AMA Wire. 13 Mar. 2013. <http://www.ama-assn.org/ams/pub/amawire/ 2013-march-13/2013-march-13-medical_student.shtml>.

5. California Academy of Family Physicians. “CAFP GME Funding Bill.” Family Doctors. <http://www.familydocs.org/health-care-workforce/policy-bills/gme-bill>.

For more information, check out the Save GME campaign at www.savegme.com

Medical School ■ Volume 3 ■ Spring 2014 ■ 45

The Residency Work Hours

Debate

by Alex Pezeshki

46 ■ The Medical Decoder ■ Phi Delta Epsilon IL Gamma

Introduction

P

ursuing a career in medicine is standards because the “practice of a long and stressful path. What medicine is a 24-hour, seven-day unites many individuals who choose commitment.”1 In recent years, howthis path is their passion for learnever, many have pointed to growing ing. Even over two thousand years evidence for the negative effects of ago, during the time of Hippocrates, fatigue on the provision of care. the acquisition of knowledge was

One case that served as a cataat the heart of what it meant to lyst for reform in medical education be an aspiring physician. During involved the death of Libby Zion. training, physiShe was an eighteen-year-old girl Interestingly, these admitted to New cians engage in work under the students of medicine York Hospital mentorship of under the care of were so engrossed more experienced both an intern in their training that and a resident physicians.1 Over time, the interacthey lived in hospitals who had been tion that fostered and became known as on call for eigha deep sense of teen hours.2 1 “residents.” learning developed Zion unforinto what we now know as teaching tunately passed away under the hospitals, learning laboratories, and care of these doctors. While other simulation labs used by faculty to confounding variables made it untrain medical students. Interestingly, clear whether the resident’s fatigue these students of medicine were so contributed to the malpractice that engrossed in their training that they ultimately lead to Zion’s death, the lived in hospitals and became known case brought to light the need to reas “residents.”1 Even when residents form resident work hours. By 1987, leave the hospital setting, they are residents trained in New York were obligated to uphold a certain set of no longer expected to work more

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Medical School ■ Volume 3 ■ Spring 2014 ■ 47

than eighty hours per week or more than twenty-four hours in a row.2 By 2003, these changes were adopted by all residency-training programs in the United States. The Accreditation Council for Graduate Medical Education (ACGME) formally created duty hour standards, which included an eighty hour weekly work limit, an adequate rest period of ten hours between duty periods, a twenty-four hour work limit per day, and limitations on the number of inhouse calls per month. After a year of implementing these restrictions,

almost all of the 7,873 accredited specialty and subspecialty programs also increased the role that faculty physicians play in overseeing residents.3

Despite the application of duty hour limits across the country in 2003, many still believe that the medical education system needs further reforms.4 Critics of the current system reference the fact that residents who train in Europe only work forty-eight hours per week.4 Meanwhile, there is resistance from American residents and physicians who oppose further restrictions for legitimate reasons. There must be an optimal balance between the provision of patient care, the education of resident physicians, and the well-being of both residents and patients.

48 ■ The Medical Decoder ■ Phi Delta Epsilon IL Gamma

Favoring the Reduction of Resident Work Hours

I

n an attempt to develop a bal In another study conducted ance between providing optimal at Brigham and Women’s Hospital, patient care and reasonable work researchers found that resident phyhours, many have proposed further sicians with chronic sleep deficiency reduction of resident work hours. exhibited deterioration in neurobeThose who favor the reduction of havioral performance.6 These resiresident work hours argue that when dents worked twenty-four to thirtyresidents hour work

Cognitive performance for are fatigued, shifts every those individuals who maintained they are more third day for a sustained level of wakefulness susceptible three weeks. for twenty-four hours was to commitBy the end equivalent to that of an individual of the third ting errors who had a blood alcohol when treating week, their concentration...higher than the perforpatients. A recent study took a mance legal intoxication limit...5 closer look at what resident fatigue weakened both within an exentails, focusing on the relationship tended twenty-four hour shift and between fatigue, alcohol, and perafter each successive extended shift.6 formance impairment.5 The results Another study done in the same of this study indicated that cognihospital concluded that resident tive performance for individuals physicians are susceptible to makwho maintained a sustained level of ing significantly more errors when wakefulness for twenty-four hours frequently working extended shifts.7 was equivalent to that of an indiIn fact, researchers quantitatively vidual who had a blood alcohol con- showed that residents made 35.9% centration of approximately 0.10%, more medical errors when they a concentration higher than the legal were working a traditional schedule intoxication limit of .08% for most (twenty-four hour shift every third states in the U.S.5 day) than when they worked an in-

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Medical School ■ Volume 3 ■ Spring 2014 ■ 49

tervention schedule which removed the extended shift.7

Research has also indicated that lack of sleep can have negative effects on personal relationships, mood, and motivation.8 These deteriorations can lead to a weakened sense of empathy and ability to clearly communicate. Without these essential qualities, patient care can suffer. Furthermore, it has been demonstrated that shift workers exhibit a 40% increased risk for cardiovascular disease.9 It is known that lack of sleep is linked to biological changes in the body such as increased stress and cholesterol levels.9

The negative effects of resident fatigue also have serious social and ethical implications. Researchers have shown that resident physicians working their extended on-call shifts are much more likely to experience sharps injuries or even car crashes on the way home from work.10, 11 By increasing the incidence of injuries both at work and on the road, sleep deficient physicians can put the general public at an elevated risk of harm.

Disputing the Reduction of Resident Work Hours

O

thers have proposed equally valid arguments that oppose the suggested reduction in resident work hours. Interestingly enough, proponents of maintaining the current eighty-hour work week in the U.S. come primarily from residents and current physicians. Their reasoning takes into account educational and age-related implications while recognizing the importance of continuity of care.

One of the most salient reasons against the reduction of residency work hours lies in the realm of education. By making significant changes to the length of time that residents learn, those who oppose further reduction of resident work hours feel that “we are on the verge of producing a generation of ill-equipped physicians that, through no fault of their own, will be product of the system that we created.”12 In response to the reduction of work hours from fifty-six to forty-eight per week in the UK in 2003, eleven surgeons at Great Ormond Street Hospital described their concerns about the future direction of surgical training in the U.K.13 They argued that the old-fashioned apprenticeship model of training was what

50 ■ The Medical Decoder ■ Phi Delta Epsilon IL Gamma

allowed for the development of highly experienced, successful surgeons. These surgeons asserted that increasing time off would further exacerbate the issue as residents would lose out on opportunities to provide adequate postoperative care and deal with complications that are common in the surgical setting.13 Ultimately, opponents of tightened resident work hours believe that the universal standard of patient care will inevitably be lowered if such reductions are made.

Dr. William Strub, a physician specializing in internal medicine, wrote an article in The Journal of the American Medical Association in which he contends that residents should not have limits placed on how many hours they work. Residency is a time to grow as a physician in training, and Dr. Strub argues that when physicians begin practicing, there are no limits placed on the amount of hours they must work.12 As Dr. Strub puts it, “being a physician requires one to master a large amount of information and to deal with a demanding style.”12 In order to attain this mastery, physicians must train in the hospital for long periods of time, a process Dr. Strub feels should not be stunted.

Resident work hours are also tied to the issue of aging. In fact, many pa-

tients are in hospitals because of agerelated problems. As a result, many physicians feel that there should be a greater focus on the continuity of patient care. At Maimonides Medical Center in Brooklyn, the average age of patients is over eighty years old, with over 20% of medical beds occupied by ventilator patients.4 As one attending physician described the environment from the eyes of elderly patients, “it’s a misery for them – they don’t know who is in charge of their case. They see an endless parade of strangers.” 4 Thus, the continuity of patient care is incredibly important. With the reduction of resident work hours, however, comes a noticeable decrease in this continuity.

“Handoffs” and “night float” residents are terms used to describe this lack of continuity as residents pass on their patients to other physicians when their shifts are over. University of California, San Francisco residents had over three hundred handoffs per patient over the course of only a month-long rotation.4 By implementing further reductions on resident work hours, a reduction in patient care continuity will inexorably ensue.

Those opposing work hour reductions have also argued that earlier generations of physicians were able to Medical School ■ Volume 3 ■ Spring 2014 ■ 51

uphold the high standards of medical excellence despite having less than ideal sleep schedules. They contend that the whole controversy surrounding resident work hours is not an issue. That being said, the expectation should still be that residents maintain high standards

B

regardless of their work schedules. Finally, the social implications of resident fatigue, specifically the concern about increased vehicular accidents, are commonly rebutted with the response that residents can sleep in the call room prior to driving home.12

Conclusion

y taking a closer look at the positives and negatives of reducing resident hours, we can see that the issue is truly not black and white. For every good reason supporting the reduction of resident hours, there may be an equally valid one against it. Therefore, it is no surprise that little agreement has been made on whether resident work-hour limits should be further tightened. Those in favor of reducing the number of resident work hours bolster their arguments by focusing on the negative effects of resident fatigue. The growing body of evidence on the psychological, biological, societal, and ethical implications of this resident fatigue lend further support to proponents of work-hour restrictions. By contrast, many residents and physicians oppose such restrictions, emphasizing the importance of continuity of care. Ultimately, it is important to find balance among the provision of patient care, the education of resident physicians, and the well-being of both resident and patient.

One proposed solution to the current issue involves the efficacy of naps to combat resident fatigue. While factors like nap duration and post-nap interval played important roles, the average effect of naps for individuals who had been awake for an extended period of time is statistically significant.14 A similar study, which examined an individual’s ability to respond to visual signals, indicated that subjects who napped for just under an hour exhibited improved alertness during the first night shift.15 Yet another way to mitigate the negative effects of resident fatigue involves the consumption of caffeine: studies have indicated that caffeine possesses alertness-enhancing effects.9 Regardless of whether these suggestions are effective solutions, we must develop a deeper understanding of each of the different perspectives on the issue before we can make an educated decision about the future of resident work hours. ÌMD

52 ■ The Medical Decoder ■ Phi Delta Epsilon IL Gamma

References 1. Howell, R. (2004). Resident duty hours: the rest of the story. Journal of the American College of Radiology, 1(2), 104-107. <http://dx.doi.org.turing.library.northwestern. edu/10.1016/j.jacr.2003.11.014>.

2. Lerner, B. H. (2011, August 14). A Life-Changing Case for Doctors in Training. New York Times. Retrieved from <http://www.nytimescom/2009/03/03/health/03zion. html?_r=1&>.

3. The ACGME’s Approach to Limit Resident Duty Hours 12 Months After Implementation. (2003). Retrieved from ACGME website. <http://www.agme.org/acgmeweb/Portals/0/PFAssets/PublicationsPapers/dh_dutyhoursummary2003-04.pdf>.

4. Okie, S. (2007). An elusive balance--residents’ work hours and the continuity of care.

New England Journal of Medicine, 356(26), 2665-2667. <http:/dx.doi.org/10.1056/ NEJMp078085>.

5. Dawson, D., & Reid, K. (1997). Fatigue, alcohol and performance impairment. Nature, 388, 235.

6. Anderson, C., Sullivan, J., Flynn-Evans, E., Cade, B., Czeisler, C., & Lockley, S. (2012).

Deterioration of neurobehavioral performance in resident physicians during repeated exposure to extended duration work shifts. Sleep, 1137-1146. <http://dx.doi.org/10.5665/ sleep.2004>.

7. Landrigan, C., Rothschild, J., Cronin, J., Kaushal, R., Burdick, E., Katz, J.,. Czeisler, C. (2004). Effect of reducing interns’ work hours on serious medical errors in intensive care units. New England Journal of Medicine, 1838-1848.

8. Owens, J. (2007). Sleep Loss and Fatigue in Healthcare Professionals. Journal of Perinatal and Neonatal Nursing, 21(2), 92-100.

9. Bøggild, H., & Knutsson, A. (1999). Shift work, risk factors and cardiovascular disease.

Scandinavian Journal of Work, Environment & Health, 85-99.

10. Lockley, S., Barger, L., Ayas, N., Rothschild, J., Czeisler, C., & Landrigan, C. (2007).

Effects of health care provider work hours and sleep deprivation on safety and performance. Joint Commission Journal on Quality and Patient Safety, 7-18.

11. Czeisler, C. (2009). Medical and Genetic Differences in the Adverse Impact of Sleep Loss on Performance: Ethical Considerations for the Medical Profession. Transactions of the American Clinical and Climatological Association, 249-285.

12. Strub, W. (2002). Current resident work hours: too many or not enough? Journal of the American Medical Association, 287(14), 1802-1803.

13. Spitz, L., Kiely, E., Peirro, A., Drake, D., & McAndrew, F. (2002). Decline in surgical training. The Lancet, 359(9300), 83. <http://dx.doi.org/10.1016/S0140-6736(02)073075>.

14. Driskell, J., & Mullen, B. (2005). The efficacy of naps as a fatigue countermeasure: a meta-analytic integration. Human Factors, 360-377.

15. Sallinen, M., Härmä, M., Akerstedt, T., Rosa, R., & Lillqvist, O. (1998).Promoting alertness with a short nap during a night shift. Journal of Sleep Research, 7(4), 240-247.

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