The Medical Decoder Fall 2013

MD THE MEDICAL DECODER

Population Health: A Call For

Value-Based

Healthcare

A Glimpse at Future Health Technologies pg. 4

Produced by Phi Delta Epsilon IL Gamma

Making the Career Choice: What are Your Options? pg. 29

Composure and Compassion: The Medical School Interview pg. 10

Volume 2

Courtesy www.northwesternu.tumblr.com

Features 29 Making the Career Choice: What are Your Options?

Varsha Venkatakrishna

04 A Glimpse at Future Medical Technologies

20 How Baby Boomers Will Change Orthopedic Care

32 Scalp Cryotherapy: Changing the Face of Cancer

07 Where Does Alternative Medicine Belong?

23 Population Health: A Call for Value-Based Healthcare

34 Primetime Prescriptions

10 Composure and Compassion: Medical School Interview

26 Emergency Contraception: A Quick Guide to the Morning After

40 References

Asia Jaros

Heather Ables

Roy Yu

Ben Fox

Devora Isseroff

Rachel Sibley

Zach Snow

Sarah Smith

Cover photo courtesy of www.skeptikai.com

2 ■ The Medical Decoder ■ Phi Delta Epsilon IL Gamma

Editors in Chief Aditya Ghosh

Writing Staff Asia Jaros

Sarah Smith

Ben Fox

WCAS ‘15 WCAS ‘15

Associate Editors Savan Patel SOC ‘13

Mahir Khan WCAS ‘15

Charlotte ter Haar MEAS ‘14

Anthony Anguiera WCAS ‘14

Kevin Zhao WCAS ‘16

Devora Isseroff WCAS ‘15

Roy Yu

WCAS ‘16

Alex Pezeshki WCAS ‘13

WCAS ‘14 WCAS ‘13

Zach Snow WCAS ‘14

Roy Yu

WCAS ‘16

Rachel Sibley WCAS ‘15

Heather Ables WCAS ‘14

Varsha Venkatakrishna WCAS ‘16

Devora Isseroff WCAS ‘15

Design Staff Brandon Caldwell WCAS ‘15

Jess Guenzl WCAS ‘16

Creative Director Svetlana Slavin WCAS ‘16

Photographer Bryan Huebner WCAS ‘16

Models Tricia Cruz WCAS ‘17

Rachel Sibley WCAS ‘15

Roy Yu

WCAS ‘16

Heather Ables WCAS ‘14

Asia Jaros WCAS ‘14

Kevin Zhao WCAS ‘16

Bethanie Willis WCAS ‘16

Left to right: Roy Yu, Arpan Patel, Charlotte ter Haar, Asia Jaros, Heather Ables, Rachel Sibley, Svetlana Slavin, Kevin Zhao, Aditya Ghosh, Bryan Huebner (not pictured: Sarah Smith, Savan Patel, Mahir Khan, Anthony Anguiera, Devora Isseroff, Alex Pezeshki, Ben Fox, Zach Snow, Varsha Venkatakrishna, Brandon Caldwell, Jess Guenzl, Trica Cruz, Bethanie Willis)

Volume 2 ■ Fall 2013 ■ 3

Color- coded Surgery and Organ Printing A Glimpse at Future Health Technologies

I

By Asia Jaros n 1990, the US Department of Ecology and technologies and therapies will undoubtedly supNational Institute of Health began its now plement, if not replace, some of the current meth-

world-renowned Human Genome Project. The ods. With the advancement of medical care and project’s mission was to identify over 20,000 genes higher levels of disease control, researchers and in human DNA, sequence over 3 billion chemical doctors have now started tackling more complex base pairs, and offer innovative treatment and di- pathology issues. agnostic tools.1 At the time, the idea of sequenc-

One such issue that Dr. Anthony Atala of Wake

ing a genome was a distant dream. Today, nearly Forest University Center of Regenerative Medicine twenty-five years after the initial undertaking of battles on a daily basis is the disparity between the project, genomic sequencing is available to the organ availability and demand.2 While the extenpublic at $3,000-5,000 per genome, and costs continue to decrease as more efficient techniques are developed.1 The medical field continues to move towards new technologies, facili-

The medical field continues to move towards new technologies, facilitation of treatments tailored to the patient, and use of less invasive medical procedures.

tation of treatments tailored to

sion of the average human lifespan is considered an achievement in the medical field, Dr. Atala reminds us of a painful reality: as human lifespan increases, the number of patients with failing organs increases. Yet,

the patient, and the use of less invasive medical the number of transplants continues to remain procedures. By the time our generation of physi- nearly the same despite the higher demand for orcian-hopefuls leaves medical school, a new slew of gans and a low supply. Today, over 116,000 patients 4 ■ The Medical Decoder ■ Phi Delta Epsilon IL Gamma

anxiously await a new organ on the national trans- several major organs including the heart and kidplant list.2,3 Dr. Atala hopes to offer an innovative ney, his project is still in the clinical trial phase and approach to the organ shortage problem with an the organs have yet to be implanted in humans. His unusual solution - organ printing.

current challenges are: the design of materials that

At his laboratory, where he performs clinical trials, are not rejected by the patient’s body, the culturing Dr. Atala uses a CT scanner to scan the patient’s fail- of stem cells outside of the patient (i.e. liver, pancreing organ. This allows him to obtain exact dimen- atic, and nerve cells which are particularly depensions and densities of the specific patient’s organ dent on a human environment), and tissue integraand customize the design. He then connects this tion once implanted into the patient.2,3 scan to a 3-D printer, similar to an ink printer. The

Printed organ implants may not be the only nov-

3-D organ printer uses cells extracted from the pa- elty on the medical horizon. Dr. Quyen Nguyen, the tient’s own tissue to recreate a copy of the scanned director of surgery at the University of San Diego, is organ.2

researching the use of a fluorescent probe to flag

In his 2011 TED talk, Dr. Atala jokingly likened or- tumors and cancers excised during surgery.4,5 A magan printing to “baking a layered cake.”2 His pecu- jor issue with current tumor removal procedures liar analogy rings true upon taking a closer look at involves ensuring complete tumor removal during the biomechanics of organ recreation. On average, surgery. This is generally based on a judgment call the process of printing a complete organ takes ap- by the surgeon about the margins of the tumor,

In an effort to reduce the number of nerve-related injuries surgeons are creating technology to tag nerves with fluorescent green molecules that can increase the visibility of these nerves drastically.

Courtesy Discover Magazine

which are not easily seen with the naked eye. Experienced surgeons judge the extent of the tumor by its size and location based on prior imaging evaluation of the area, proximity to other structures, and by feeling the tumor. This methodology is not only inconsistent, but proximately 7 hours.2 It requires a printer that can also highly inefficient and time-consuming. Oftenelevate from level to level as it builds the organ, cell times, residual portions of the tumor are left at the by cell, similar to stacking and frosting a layered margins of the excision area, and these portions recake. Although Dr. Atala has been able to recreate main undetected until the excised tumor has been Volume 2 ■ Fall 2013 ■ 5

exactly where the tumorous spots are by simply

Courtesy www.marketbot.com

observing fluorescent areas and removing them.

3D bioprinting holds tremendous potential for dealing with the rise in demand for organ transplants.

Dr. Nguyen’s idea could have a profound impact on all types of tumor removal, but especially for tumors that are located in sensitive areas such as the brain.6 The myriad of simple, yet ingenious medical technologies doesn’t stop there. In fact, organ

analyzed by a pathologist. If residual, abnormal tu- printing and color-coded surgery just scratch the mor cells are present at the margins of the removed surface of what is to come. Current research is bemass, a patient may need to undergo multiple ad- ing conducted on self-administered, high-speed ditional surgeries, chemotherapy, or radiation to voice-based tests to diagnose Parkinson’s disease, eliminate the rest of the tumor.4

new gamma-ray cameras to detect tiny tumors up

Dr. Nguyen’s approach involves using a molecular to two-fifths of an inch within dense breast tissue, marker made of fluorescently tagged-polycation, implantable, radio-frequency identification chips polyanion, and a linker.4,6 Polycationic materials for humans that would carry our medical histotend to adhere to all cells, unless they are attached ries, insurance information, and more.5,7 It is our to a polyanionic component. This polyanionic com- responsibility and challenge as future healthcare ponent restricts the polycation from binding to any professionals to educate ourselves and continue cells. The key to tagging only cancerous tissues is a this legacy of innovation. If we can expand medical linker between the polyanion and polycation por- research to incorporate non-traditional fields such tions, which contains a specifically engineered cut- as mathematics, engineering, economics, psycholting site. This site is tailored so that it can only be ogy, and other disciplines to supplement current cut by tumor-specific enzymes, for example, prote- technologies, the results will definitely exceed our ases, that are present only in cancer tissues. When current expectations and, more importantly, help this three-part molecular marker is injected into a save lives. cancer patient, enzymes within the tumor cut apart

For more information check out the online TED

the polycation from its polyanionic counterpart, Talks series: The Future of Medicine. ■ MD allowing it to bind to tissues and fluoresce. During surgery, the operating surgeon is able to see 6 ■ The Medical Decoder ■ Phi Delta Epsilon IL Gamma

For references, see page 40.

Where

Does

Alternative

Medicine

G

By Roy Yu

Belong?

rowing up in a Korean-American home meets the fingernail, and let the blood out. As she has given me a unique experience that gently pressed on my thumb, a dark maroon liquid

enables me to find valuable lessons in a variety of would ooze out. While the treatment may sound situations. My attitude toward health, for example, like it would have no effect, from personal experiis rather unorthodox because of the way my par- ence, I can testify that this works like a charm. Afents dealt with sickness. Of course, I had my regular ter about fifteen minutes, I would always feel much checkups with the pediatrician like everyone else, better. but there were several instances where my parents

As I grew older, I became fascinated and intrigued

would provide home remedies. In retrospect, I had by the therapeutic effects of these treatments. Afno idea why my parents’ methods worked.

When most people have

indigestion,

they may take an antacid or Alka-Seltzer.

My mom, however,

ter doing a bit of research, the best explanation I

About 40% of Americans are using some form of alternative medicine.

could find was based on the concept of qi in Chinese traditional medicine.

Qi

(pronounced

“chi”) is the vital force or

would use a different home remedy: acupuncture. energy responsible for controlling the human mind First, she would rub my back and arms so that the and body. It flows through the body via channels, blood would flow towards my fingers. Then she or pathways, which are called meridians. Imbalwould tie my thumb with a rubber band to constrict ances in the flow of qi cause illness; correction of blood flow, prick the part of flesh where the thumb this flow restores the body to balance. Each organ Volume 2 ■ Fall 2013 ■ 7

has its own qi, whose activity is characterized by cine” refer to health care approaches with a history the organ to which it is attached.1 In the case of an of use or origin outside of mainstream medicine.4 upset stomach, these energies have collided with They include natural products such as herbs and each other. The human hand has certain acupunc- supplements, as well as mind and body practices ture points that are assigned to each qi. Therefore, such as acupuncture and massage.4 Other examples pricking the thumb tip sends signals to manage the include homeopathy and naturopathy. Homeopaunbalanced qi.2 By now, you are likely thinking that this stuff is either really interesting or a bunch of nonsense. How can releasing a few drops of blood cure indigestion?

When I try to explain it

Over recent years, as knowledge of alternative medicine techniques have evolved, the medical field has started to understand the inherent benefits of these techniques and has begun incorporating it into medical care.

to my non-Asian friends,

thy is a system of medicine that involves

treat-

ing people with highly

diluted

substances

in

order to trigger the body’s natural system

they look at me suspiciously or even laugh. While of healing. It is based on the doctrine of “like cures it certainly may be a placebo effect of the interven- like”, which states that a substance that causes the tion, there is emerging literature that acupuncture symptoms of a disease in healthy people will cure and other forms of alternative medicine can be ef- similar symptoms in sick people.5 Naturopathy, or fective for certain conditions or ailments.3

naturopathic medicine, is a system of medicine

The National Center for Complementary and Al- based on the healing power of nature. Naturopathy ternative Medicine (NCCAM) notes that the terms is a holistic system, meaning that naturopathic doc“complementary, alternative, and integrative medi- tors attempt to find the cause of disease by understanding the body, mind, and spirit of the patient. Most naturopathic doctors use a variety

Courtesy www.flickr.com

of therapies and techniques, such as nutrition,

8 ■ The Medical Decoder ■ Phi Delta Epsilon IL Gamma

behavior change, and herbal medicine.6 Over the recent years, as knowledge of alternative medicine techniques have evolved, the medical field has started to understand the

inherent benefits of these techniques and has be- pies have not shown significant benefit but do not gun incorporating it into medical care. About 40% cause harm and the extent of relief for patients with of Americans are using some form of alternative a certain therapy may be variable. There is scientific medicine.4 Many medical schools are also starting evidence that supports the use of acupuncture for to teach these medicine techniques and theories.7 cancer related side effects such as nausea, vomiting, Several health care providers offer alternative med- hot flashes, depression and insomnia.3 In another icine in conjunction with conventional therapies, study, cancer related symptoms of pain, fatigue, which is known as “complementary medicine”. The anxiety and depression improved with massage main difference between alternative and comple- therapy.8 I am sure that some forms of CAM may mentary medicine is that while alternative medicine have shown little or no effect. However, research is often used instead of conventional techniques, has clearly shown benefits to certain patients with complementary

medi-

cine is used in addition to them. The combination of complementary and alternative medicine (CAM) with mainstream medical therapy is called “integrative

medicine.”

Integrative health care programs are rapidly being incorporated into general medical care, as there is new research demonstrating the immense benefits of this type of care for patients.

Integrative health care

use of CAM therapies.

As health care policy makers decide which types of treatment are covered by insurance, I hope that complementary

and

medicine

alternative treatments

are given more consid-

programs are rapidly being incorporated into gen- eration in the treatment of the patient. Ongoing eral medical care, as there is new research demon- research on CAM can help ensure that patients are strating the immense benefits of this type of care benefited from combining variety of treatment mofor the patients. Some cancer treatment centers of- dalities to ensure the best and sustained long-term fer services such as acupuncture and meditation to treatment success and health. help manage symptoms and side effects of conven-

■ MD

tional cancer treatments, such as chemotherapy.3,4

For references, see page 40.

The scientific basis of medical care emphasizes that treatments be utilized when they have been shown to be safe and effective. Some CAM theraVolume 2 ■ Fall 2013 ■ 9

Composure and Compassion

The Medical School Interview

By Ben Fox

‘R

efreshingly finite’ is how I’d describe my that it can help improve your own interview perfeelings as I traveled home from my medi- formance and allow you to also emerge confident

cal school interviews. Although my interviews were from your medical school interviews. While there is the challenging, final hurdles in an extended and certainly an exhaustive amount of published advice rigorous application to medical school, I walked out on interviewing, I have boiled it down to the most feeling confident I had done my best in communi- essential tips that I have learned over the course of cating why I deserved a seat in medical school. As my application process. I will begin with a short inI am now in medical school, and given my experi- troduction to the interview process and then relate ences with this process, my goal is to communicate twelve important tips that greatly improved how I the strategies I used while interviewing in hopes presented myself on interview day.

10 ■ The Medical Decoder ■ Phi Delta Epsilon IL Gamma

Simply put, interviewing is perhaps the single only three interviews after applying to thirty-plus greatest opportunity you will have to prove your- schools total! While frustrating, I made the most of self to a medical school. Admissions officers review those three interviews and realized the high dethousands of redundant sounding GPAs, MCAT cline rate was happening to most other applicants scores, and personal statements that can all blur to- as well. In reality, receiving an invitation is actually gether after a while. Fortunately, the interview pro- more difficult than gaining admission after intervides you with a great opportunity to distinguish viewing. An applicant has anywhere from a 33-50% yourself from the sea of applicants. The interview chance of gaining admission after receiving an inviis your best chance for a medical school to ascer- tation to interview. Thus, receiving an invitation is a tain your character, motivation, and determination. huge accomplishment in and of itself and a reliable The written material in your AMCAS primary appli- indication that the medical school already deems cation can only go so far in representing you as a you a worthy candidate for their program. person, unlike interviewing, which provides you a

Every school is a little different in terms of how

critical opportunity to relate to someone during the they interview, but generally, interviewing is conadmissions process. Your ability to interview can be ducted in three broad ways. The first entails the a deciding factor during the admissions process, ‘traditional’ one-on-one interview, where the appliand if approached correctly, will convince medical cant is paired with a physician, faculty member, or schools you are indeed a good fit for them.

admissions advisor for anywhere between thirty to

Upon receiving your first interview invitation, sixty minutes to discuss the applicant’s motivation feel confident you will succeed, as much of the for entering medicine. The second type consists pre-screening of applicants has already been per- of a ‘panel’ interview where two to five applicants formed. Schools sometimes review upwards of ten are paired with one or two interviewers. Usually, thousand applications and must be highly selec- a question is given to all the applicants, who then tive in who they choose to interview. Thus, a large answer in turn. The final type of interviewing is the majority of applicants to most schools don’t receive multiple mini-interviews (MMI), which is a relativeinterviews - a disappointing but almost inevitable ly new interviewing style currently used by fewer outcome for many applicants. Do not feel discour- than twenty U.S. allopathic medical schools. Broadaged if you are declined an interview by many of ly, MMIs have applicants answer eight to ten questhe schools you apply to as almost all applicants tions in separate rooms with different interviewers experience the same thing. In my case, I received over the span of an hour. For each room, the appliVolume 2 ■ Fall 2013 ■ 11

cant reads a question prompt for two minutes and formulates an answer. The applicant then enters the room and discusses the answer for six to eight minutes with the interviewer who may provide new information to the prompt. At time’s end, the interview repeats the above process until all rooms have been completed. I encourage you to research the MMI process heavily if you interview at a school that conducts them. There is definitely much more strategy and information on MMIs than can be related here. Overall, each interview style presents its own unique challenges. As such, some schools use a combination of interviewing styles or hold multiple interviews. For example, some schools have applicants complete both a traditional and panel interview, while other schools may have an applicant complete two traditional interviews with separate faculty.

Whatever the style, I am confident you will find your interview day to be really low-stress and very laid back. It may feel daunting when twenty to seventy other applicants are interviewing alongside you, but it is important to calm down either before or during the early stages of your interview. The schools know interviews are highly stressful, and as such, they take steps to calm you down throughout the day. Many schools provide a lunch, a Q-and-A session with current students, and a tour around campus. Importantly, schools do not want you to be distressed by the interview. They have spent a huge amount of time and energy screening you and thus want to judge your calm and confident self when your motivations for medicine are clearest. To help you convey your motivation clearly, I will now present the twelve most important interviewing tips that I feel will help you in developing your interviewing skills. While some tips seem obvious, you may be surprised when you find yourself making these common mistakes initially, as many applicants do. However with practice, you will target your weaknesses and eventually become a more effective and memorable interviewer.

Twelve Tips On Medical School Interviewing 1. Do Not Ramble Sometimes less is more. Rambling is one of the biggest mistakes made by novice interviewees. It conveys that you are nervous or feel unprepared to answer the question. Interviewers are constantly sizing you up to see whether you would make a competent future colleague of theirs in the medical field where communicating clearly is of utmost importance. Your goal then is to be logical, clear, and succinct when speaking. If you do have a tendency to ramble, do not be discouraged as you can easily break the habit. By 12 ■ The Medical Decoder ■ Phi Delta Epsilon IL Gamma

mock interviewing with a friend or family member, you can quickly identify if you ramble and learn how to break the habit. Importantly, your mock interviewer must be up-front and tell you if you are rambling, which brings us to a second key point of interviewing preparation.

2. Practice With Friends And Family You must practice, practice, practice for medical school interviews. You have only one opportunity with each school, so you will definitely to want prepare and make the most of it. I, along with other applicants I knew, practiced primarily with friends and family who would give honest feedback about our interviewing skills. Either I would tell them a list of questions I wanted them to ask or allow them to surprise me with their own questions. Importantly, I would explicitly ask them to tell me what they honestly thought about the interview and where I could improve, no matter how harsh their criticism might be. You NEED people to help you constructively and not try to sugar coat things.

To further simulate the interview environment, I also tried mirroring the actual conditions of the interview based on descriptions found on studentdoctor.net, a useful resource for interview preparation. This meant practicing in an unfamiliar environment (not your own living space) and mock interviewing for the appropriate duration of time (45-60 minutes usually). It was also useful when my mock interviewer and I would occasionally stop to review a question and determine how I could improve my responses.

3. Prepare For Questions Commonly Asked There are some questions you will encounter again and again while interviewing at different schools.

A list of twelve such questions will be presented in the next edition of the Medical Decoder. These are questions for which you will certainly need well thought-out answers, and while they may not all be asked in every interview, they come up on a consistent basis. You must practice what you are going to say for them or at least have a good idea of how you will answer them. I found it useful to keep a word document briefly describing my answers for each of the questions. I also wrote down my answers and took the sheet to each interview for a last minute review.

At the same time, it is extremely important that your answers do not sound rehearsed. The interviewers know that you have probably practiced for the interview, but they do not want to listen to a memorized recitation. Your goal is to communicate your predetermined answer as though you have never answered Volume 2 ■ Fall 2013 ■ 13

the question before - with passion and genuineness. I’ll stress again that you must practice. I had a friend who hoped to sound more genuine and thoughtful by not practicing. Unfortunately on his interview day, he became tongue-tied and came off as unprepared. While very intelligent and well qualified, he was rejected. This goes to show that you cannot anticipate the environment or how you’ll be feeling on the interview day. While you cannot control these factors, you can control how well you have prepared.

4. Review Your Primary Application, especially the Personal Statement Your interviews will often focus on the experiences detailed in your AMCAS primary application. Even if the interview is “closed,” meaning the interviewer has never reviewed your application, you can still answer questions based on your experiences. Your college experiences, in some way, should relate to the pursuit of your dream of becoming a doctor. Therefore, they should be easy to talk about since you are already passionate about them. In general, for my experiences, I would sum up each one into two or three important points that I could tie back to medicine and how it strengthened my resolve towards becoming a physician. For instance, I used the time I spent volunteering at a nursing home as one of the college experiences I brought up while interviewing. During my interview, I told how working with patients with dementia was initially frustrating; I first arrived to a circle of seemingly asleep residents all in wheelchairs.

I came to realize that they were, in fact, awake, and that the stimulation I provided through fun activities was important to their well-being. I managed to effectively communicate to my interviewer how each lesson I learned during that volunteering experience related back to a quality of being a competent doctor. To sum up, know your application. By re-reading your personal statement, and having two to three important points to discuss for each of your experiences, you will come across as a smoother, more collected, and an altogether more genuine and strong applicant.

5. Familiarize Yourself with Issues Confronting Healthcare Today You must show interest in the field you desire to go into, plain and simple. In medicine, this means being aware and moderately knowledgeable about larger issues facing modern healthcare. For example, I was 14 ■ The Medical Decoder ■ Phi Delta Epsilon IL Gamma

asked for my opinion about Obamacare twice, and it is very possible that depending on your major, i.e. public health or political science, you could receive more questions on this topic. In general, I recommend being aware of and retaining some general knowledge in the following healthcare issues: 1) Physician Shortage and Their Crowded Distribution; 2) The High Costs of Healthcare; 3) Increasing Prevalence of Chronic Disease; and 4) Understanding the Basic Goals of the Affordable Care Act (ACA). Interviewers do not expect a 22 year-old premed to provide a panacea to these issues, as they are often complex issues that have been around for decades now. Rather, they want to see that you are familiar with these issues and can hold an intelligent conversation about them. It may best to be non-committal with these issues, by addressing multiple sides that each issue presents and adequately demonstrating your knowledge. In the end, questions dealing with larger healthcare issues probably will not make or break your interview.

After all, they do less in answering the interview’s overall purpose of why medicine is right for you in comparison to other questions. However, I do believe that schools respect an applicant more so if they can demonstrate basic knowledge of these important health-related issues.

6. Stay Alert on Your Interview Day Interviews days are not solely for conducting interviews. They may be 7 to 8 hours long and consist of multiple presentations, a lunch, and a campus tour. While most of the material presented to you is information you could easily find on the school’s website, the schools are in the business of attracting you.

After all, medical schools have selected you to interview after sorting through thousands of secondary applications, and want to show that they offer a quality medical education. That being said, remaining energized and alert is necessary throughout the interview day.

Generally, not all applicants will interview at the same time - some will be in the morning, some after lunch, and others late in the afternoon. You have to be prepared to interview at any time of that day. I suggest bringing a bottle of water that you can refill as needed and a quick snack such as a candy or a granola bar. Another advantage of staying alert and not dozing off through the presentations is that the presenters may later be your interviewer! This is especially true in MMI interviews where at least 8-10 interviewers are needed to fill all question prompts. Overall, the goal here is for you to walk into the interview room feeling awake, confident, and ready and to give it your best shot.

Volume 2 ■ Fall 2013 ■ 15

7. Provide Memorable Examples Interviewers need something to remember you by. One of my interviewers told me she was my ‘advocate’, and it was her job to present my interview summary to the admissions office. Your advocate should be able to convey not only their general impression of you but also your memorable and meaningful answers. For example, if asked, “What has prepared you for a career in medicine?” or “What is your greatest strength?” you should avoid being vague. If you are vague, you risk sounding like another average applicant. Instead, you should focus on a few strong personal examples in some detail that work to distinguish you in a positive light. Your examples could include a value you stand by, a specific person you’ve worked with, an interesting class that stuck with you, or an experience from your primary application (that’s why having 2-3 talking points per experience can be extremely helpful!). Overall, personal examples allow you to showcase your personality, help you relate better to the interviewer if they’ve had a similar experience, and above all, give you the best chance of turning the interview into a conversation. If you can develop stretches of good conversation rather than a question-answer-repeat format, then you will have a successful interview.

8. Use Three Talking Points During interview preparation, you will often wonder if your answers are too lengthy, too short, or lacking substance. A great solution that a friend relayed to me is to divide your answer into three talking points. Her idea was that two points tends to be too short and four points brings the risk of you rambling.

Three points strikes a happy medium, giving you the best chance of being succinct yet complete. While by no means set in stone, I found using three points to be extremely helpful. For instance, my “why medicine?” answer consisted of three larger points describing my healthcare-related experiences growing up, in college, and desired ones in the future. Moreover, using three points was essential during my MMI interview as I had only two minutes to read a question, consider my answer, and formulate what I would start off presenting, which almost always consisted of three talking points. I simply could not remember much more than three main points anyway after a quick two minutes.

16 ■ The Medical Decoder ■ Phi Delta Epsilon IL Gamma

9. Answer Questions While Acknowledging All Parties Involved You will want to consider all people’s views in a complicated interview question. Doing so shows you can relate to others and identify their motivations while being the advocate for the patient, an important skill for all physicians. Though you want to apply this advice to all questions, this tip applies very well to two questions you might encounter. The first concerns a fellow medical student who you know has cheated on an exam, but no one else does. Instinctively, you might alert the professor immediately; however, doing so bypasses your classmate, risks your friendship with that person, and potentially blows the problem out of proportion. In general, you want to handle situations with the least amount of drama possible. In this case, confronting the classmate privately and encouraging them to seek out the professor on their own is the advisable action - you have considered and involved them in the decision. Put another way, what would you want your friend to do if you were the cheater: rat you out or talk to you on his or her own? The second question you may encounter concerns the hypothetical situation where an elderly patient is diagnosed with a terminal illness, but a family member does not wish for the patient to know in fear that the truth will be devastating. Here, you have to balance your patient’s needs along with the family member’s and be able to recognize what each would stand to gain or lose based on your decision.

No matter how you answer, explore and consider each party’s needs and then adequately communicate to the interviewer you have done so.

10. Ask For Time To Collect Your Thoughts “Can I take a few seconds to think about it?” I must have said this a dozen times while interviewing.

While initially practicing, there was always that urge to begin answering right away, and typically, my responses would be disjointed, as I was using too much effort to both talk and think at the same time.

After a friend suggested that I take time to formulate an answer, my response would almost always come out better and more logical, showing me that taking time to think was absolutely necessary for difficult interview questions. Many questions are geared to make you think critically and thereby require time in order to clarify your thoughts and come up with a coherent answer. Although it initially felt awkward asking for additional time, my interviewers never had a problem with it and would wait patiently for ten to fifteen seconds sometimes before I began. By asking for time, you improve your chances of avoiding long Volume 2 ■ Fall 2013 ■ 17

winded or boring answers that verge on rambling. In my opinion, asking for time is another way you show poise while interviewing - you come across as a more thoughtful interviewee.

11. Ask Genuine Follow-Up Questions Again, interview days are both for schools and applicants. Therefore, feel free to ask one to three questions at your interview’s conclusion to further familiarize yourself with the school. For example, you could ask about a unique aspect to a particular medical school such as a strong public health component in the curriculum or interesting summer research opportunities. You could also ask about the student body, the atmosphere within the school, or life outside the school. While these questions can vary greatly, your overall goal is to be genuine in your asking. Three well thought out questions can go a long way rather than tacking on three piecemeal questions at the end.

In general, I would advise preparing one to three genuine questions before arriving at your interview day. While you do not have to use them, it’s good to have these back-ups if other questions do not come to mind on the interview day. All in all, asking good questions is another important way to show interest in the school and that you’ve done your homework on the school’s specific program. This is attractive to medical schools and lets them know you have seriously considered their program.

12. COMPOSURE, COMPOSURE, COMPOSURE If I had to summarize what applying to medical school was like, I’d say it was all about maintaining composure. The application process is extensive and must be balanced with other course work and responsibilities. Through it all, you will help yourself by maintaining your composure, especially during interviews.

Some questions are just intended to be tricky and difficult. Indeed, the follow-up questions during my MMI interview seemed geared to make me second-guess or reconsider my first answer. Generally, I stood by my first answer since I believed it to be right; however, the more important goal was to maintain my poise and not appear rattled. I would rationally consider the new information and use it to support my first answer. This showed self-confidence, which is a quality your interviewer will definitely be looking for.

18 ■ The Medical Decoder ■ Phi Delta Epsilon IL Gamma

Conclusion Interviewing really is one of the only opportunities to put a face to your application. While GPAs and MCAT scores certainly weigh heavily, interviewing provides the admissions officers with a unique perspective of you as a person - one that can be a deciding factor in their decision to accept you.

On the day of, I think you will find your interview not to be too stressful. Obviously walking into the room can be daunting to anyone, but you will become comfortable after a little while. From that point, maintain your composure and be passionate about what you speak of. Try your best to prove to the interviewer that you are a worthy future colleague of theirs in medicine. Be sure to sit upright, vary the tone of your voice, answer with an appropriate level of enthusiasm, and turn your interview into a conversation. By doing these things, you give yourself the best chance of coming across as likeable yet professional.

I also encourage you to enjoy your interview day and the interviewing experience in general. For many applicants, interviewing entails traveling to new parts of the country and meeting applicants from other schools. Talk with these other applicants and have some fun with the process. Not only will you learn a lot from other applicants, but you will also calm down before your interview.

In the end, medical school interviewing is all about communicating your passion for medicine. If you can demonstrate your passion for helping others, your interview will be successful, regardless of whether or not you occasionally stumble on a question. The above tips will hopefully help you best prepare to communicate this passion in the clearest manner. From here, continue practicing your interviewing skills and asking your friends and family to critique you while doing so. These tips are meant to be a foundation for you to build upon. By utilizing these tips and maintaining your composure, you will undoubtedly succeed during your interview and end your medical school application on a resounding high note. ■ MD

Volume 2 ■ Fall 2013 ■ 19

How Baby Boomers will Change Orthopedic Care

By Heather Ables Medical advancements made during Baby Boomers’ lifetimes such as the polio and measles vaccines, as well as new surgical technologies, have allowed them to live longer and have raised their expectations of medical care.

GPA, MCAT, and the coveted MD. The lives of premed students are flooded with acronyms. At the undergraduate stage of an aspiring doctor’s life, it is easy to get caught up in the preparations necessary to gain acceptance into medical school and lose sight of the challenges that we will face when we finally have become doctors.

While I frantically refresh CAESAR during grade posting time, I also dream of becoming an orthopedic surgeon. However, it was only recently, after I had a shadowing experience with a physician that I realized I knew surprisingly little about the future of the profession and the obstacles I might face. This experience was the first time that I was challenged to look beyond just the task of becoming a doctor and consider the larger impact that I hoped to have on the medical field. After shadowing, I realized that my responsibilities as a practicing surgeon would depend largely on the patient population that I would be accountable for.

Those of us who will soon be entering medical school will be responsible for the care of a unique group of elderly patients: the Baby Boomers. According to the United States Department of Health and Human Services’ Administration on Aging, in 2009, 12.9% of the total US population was over the age of 65. By the year 2030, this percentage is expected to rapidly increase to 19% as the Boomers will begin seeking 20 ■ The Medical Decoder ■ Phi Delta Epsilon IL Gamma

more medical treatments.1 This rise would correlate number of older patients who sought medical treatwith an increase in the number of elderly individu- ment for joint pain. For many, the quick fix seems to als seeking healthcare services in order to manage chronic pain conditions and combat the woes of aging.

While the expanding number of healthcare services that Baby Boomers will require poses a challenge to medical specialists, this patient population also brings another challenge due to its unique position in history. Medical advancements made during Baby Boomers’ lifetimes such as the polio and mea-

Unfortunately, it does not appear that the increase in healthcare services needed by a growing patient population will be met with an equal increase in the number of doctors available to provide them.

sles vaccines, as well as new surgical technologies, have allowed them to live longer and have raised be a minimally invasive cortisone injection about their expectations of medical care. According to a three or four times a year. For others, whose pain 2007 report by the American Hospital Association, was more debilitating, the only option to alleviate new pain management techniques and the option their chronic conditions, like arthritis, was joint reof joint replacement surgery have allowed aging placement.

Baby Boomers to maintain a more active lifestyle

This option has only become popular within the

than their ancestors.2 As a result, these patients are last forty years, but in that time hundreds of pros-

that emphasize mobility and independence.

Unfortunately, it does not appear that the increase in healthcare services needed by a growing patient population will be met with an

Courtesy Heather Ables

anticipated to continue to seek orthopedic services thetic joints have been created, tested, and mar-

equal increase in the number of doctors available to provide them. Between 2000 and 2020 the supply of orthopedic surgeons is predicted to increase by only 2%, while the demand is expected to increase by 23%.3 During my recent shadowing experience, I was surprised by the Volume 2 ■ Fall 2013 ■ 21

Courtesy Heather Ables

keted. The rapid evolution of joint replacement and other surgical techniques will undoubtedly be an asset over the coming years as the Baby Boomers steadily age and cause an increase in the average age of patients seeking treatment. In the future, surgeons hope to use techniques that will allow for the treatment of more patients, quicker recovery times, and shorter hospital stays.2 The Baby Boomers have grown up with a focus on education, and many have been fortunate enough to pursue advanced degrees.4 Therefore, this pa-

tient population has tended to be more engaged not made to sustain intense physical activity. As in its own medical care than previous generations surgeons who operate on younger patients are alhave been.4 In fact, throughout my shadowing ex- ready seeing, these patients tend to put excessive perience, the orthopedic surgeon had to explain stress on the joint, risk wearing it out more quickly, to several adamant individuals under the age of and need follow-up operations. fifty why joint replacement should be postponed for younger

patients

like themselves.

Due to joint replacement’s

abil-

After shadowing, I realized that my responsibilities as a practicing surgeon would depend largely on the patient population that I would be accountable for.

It is undoubtedly important, as future doctors and healthcare professionals, to recognize how our patient population will change in the coming years and re-

ity to confer optimal mobility, it can be inferred spond by appropriately altering our care and delivthat this procedure will appeal to Baby Boomers ery methods. Not only in the field of orthopedics, as it can drastically reduce pain levels. Studies are but throughout medical practice, a rigorous focus showing that joint replacement surgeries are on on wellness and prevention today will be key to the rise. It is projected that nearly eight times more managing the chronic conditions of tomorrow. knee replacements will be performed in 2030 than

■ MD

take place today.5 However, prosthetic joints are

For references, see page 40.

22 ■ The Medical Decoder ■ Phi Delta Epsilon IL Gamma

P opulation H ealth A Call for Value-Based Healthcare

By Zach Snow

H

ow do YOU value good health? How much is good health worth? The average American spends more than $8,000 in medical expenses each year.

That’s nearly two and a half times more spent on healthcare than France, Sweden, or the UK.1

In terms of gross domestic product (GDP), healthcare constituted more than 17.9% of total U.S. expenditures in 2012, more than the country’s highly-controversial defense budget.2,3 With medical spending projected to reach $4.8 trillion by 2020, experts have deemed the conventional payment structure known as the “fee-for-service model” as the primary obstacle to achieving cost-effective healthcare. In feefor-service, which is the traditional model for Volume 2 ■ Fall 2013 ■ 23

payment in many hospitals and health systems health of that population. This unique approach, across the U.S., physicians are paid based on the which has recently garnered significant attennumber of medical services they provide. The tion throughout the healthcare industry, differs doctor profits directly from the sheer number of considerably from how most healthcare systems operations, procedures, and tests ordered; care is work today. based on quantity but not necessarily quality.4 In

The principal difference between population

this model, medical professionals financially ben- health and the current health care model is that efit most from ordering a multitude of services for population health is focused on caring for groups temporary fixes to the patients’ conditions, rather of patients rather than individuals; it’s more than from designing treatment plans to improve about the ‘health’ than the ‘care.’ As an alternative patient outcomes and keeping sick people out of to utilizing the traditional fee-for-service model, the hospital in the future.

Considering

the

United States’ global influence in scientific research and medical innovation, why

The doctor profits directly from the sheer number of operations, procedures, and tests ordered; care is based on quantity but not necessarily quality.

is it so difficult to cre-

hospitals

seeking

to

partake in population health employ a value rather

than

volume-

based method of care.

Value-based care means that federal health plans such as Medicare and

ate a workable, cost-effective system for keep- Medicaid as well as commercial payers such as ing our citizens healthy? Grounded in traditional Blue Cross Blue Shield fiscally incentivize hospiapproaches for treating patients, what America’s tals and health systems to limit patient volumes. medical system needs the most is an alternative In this way, both parties profit from the insurbusiness model, one that incentivizes keeping ance companies’ savings. Financially speaking, people healthy rather than solely treating those in the fee-for-service model, hospitals will try to who are already ill.

fill beds; in the population health model they will

Population health is a term used to describe try to help empty them.5 The health industry is a system of care that seeks to assess the health actively transitioning to a value-based payment needs of a target population and proactively structure that rewards those who do the best job provide services to maintain and improve the at keeping their patients healthy.

24 ■ The Medical Decoder ■ Phi Delta Epsilon IL Gamma

The health industry is actively transitioning to a value-based payment structure that rewards those who do the best job at keeping their patients healthy.

emergency hospital services in the future. As a result, medical professionals can intervene early to reduce the likelihood that these specific patients become sick, thereby reducing medical costs and improving overall population health.7 Despite the need for a hefty investment in new technologies, the most significant obstruction to transitioning from volume to value-based care is reluctance on the part of physicians and other

But how are they doing this? First, significant medical professionals to change their ways. advances in technology have enabled physicians The population health model requires physiand medical facilities to extend healthcare out- cians, particularly primary care providers, to perside of the traditional acute-care setting. Tele- form additional activities and make less money health vendors such as Bosch market products for them. According to experts in the healthcare in remote patient monitoring that can monitor industry, physicians must begin to modify much heart rate, glucose levels, blood pressure, and of what has been hardwired into their current other vitals all from within the comfort of the practices, experimenting with interventions, repatient’s home.6 IT solutions such as this, in ad- configuring office workflow, and delegating more dition to physician video-conferencing and mo- responsibility to an extended care team. bile phone health applications, are extending

Still, doctors in contention of this value-based

care outside the hospital, thereby freeing beds model ought to remind themselves of the underfor patients with more serious conditions, sav- lying principle behind good healthcare: to help ing exorbitant urgent-care costs, and maintain- their patients get healthy again. In collaboration ing a healthier environment throughout the with the innovators making America the global entire population. Furthermore, complex analyt- leader in science and industry, physicians have ics, like those offered by Explorys, a population the opportunity change the health system, rehealth corporation from the Cleveland Clinic, sift duce the national output of medical costs, and through petabytes of unstructured medical data inevitably, make patients better. That’s the value from insurance claims, labs, prescriptions, etc., to of a good healthcare system. ■ MD evaluate the risk that certain patients will utilize For references, see page 40.

Volume 2 ■ Fall 2013 ■ 25

Emergency Contraception A Quick Guide to the Morning After

U

By Sarah Smith nprotected sex happens frequently on college campuses and can have a plethora of negative consequences, from STI transmission to pregnancy. A study by the National College Health Risk

Behavior Survey found that 15% of college students have, at some point, become pregnant during their college careers.1 Studies have shown that among this high-risk group of college students, knowledge of emergency contraception is relatively low. While female college students might know of key words like Plan B or the “morning after pill”, many are unaware of the function and accessibility of an effective means of pregnancy prevention post-sex.1 Increasing awareness of emergency contraception (types, how they work, where they can be bought, regulations, etc.) among college-age women is crucial in order to prevent unintended pregnancy.

The following information comes from leading institutions and research journals focused on reproductive health and emergency contraception research: 26 ■ The Medical Decoder ■ Phi Delta Epsilon IL Gamma

What is Emergency Contraception?

Emergency contraception (EC) is a form of birth control, used after sexual intercourse to prevent pregnancy. It is both safe and effective, with no long-term or serious side effects.2 In fact, EC is even considered safe for those whose healthcare providers recommend not using hormonal birth controls out of fear of possible side effects including blood clotting and breast cancer. This is because emergency use of hormones does not carry the same risks associated with taking daily oral contraceptives.3 Depending on the type, EC can prevent pregnancy up to five days after sex. However, the longer the time elapsed between having sex and taking the drug, the less effective the drug is.

Therefore, time is of the essence when using emergency contraceptives.

What are my options?

There are three main types of emergency contraceptive pills available in the U.S.: progestinonly, ulipristal acetate, and combined progestin and estrogen pills.2 Plan B, a progestin-only pill, is likely the most easily accessible type of EC for college students. In June of 2013, after years of debate, the FDA has finally approved Plan B for over-the-counter sale with no age restrictions, meaning that Plan B is readily available in most neighborhood drug stores.4 Especially in college towns where waiting in line at the pharmacy can be a hot spot for running into peers, the ability to grab Plan B from the shelf and purchase it without having to show ID can come with the advantage of discretion. It is not uncommon to find women who keep a dose of Plan B available in their homes before any accident occurs, so that they can be preemptively prepared.

While Plan B is the most recognized brand of EC pills, it is certainly not the only one. Other brands available in the US include Next Choice One Dose, Next Choice, ella, and more. While these brands require a prescription (and a visit to a healthcare provider), they also can provide advantages depending on the circumstance. For example, while Plan B is effective for up to three days after sex, ella, an ulipristal acetate pill, is effective for up to 5 days after sex. In fact, ella has been cited as being more effective than Plan B.2 There are multiple brands of EC pills on the market, and it is wise explore those options before the need for EC arises.

Certain brands of daily birth control can be utilized for emergency contraception by taking combinations of pills. Certain brands of combined progestin and estrogen birth control pills can Volume 2 ■ Fall 2013 ■ 27

be taken in higher doses to prevent pregnancy.3 However, it is important to consult with a healthcare provider before utilizing this method as many women experience side effects like nausea and vomiting.3 EC does not come exclusively in pill form; in fact, the most effective form of emergency contraceptive is the Copper-T intrauterine device (IUD), which is also used by many women as a form of regular birth control. While a doctor or trained clinician must insert this form of EC into the uterus, he or she can do so up to 5 days after sex and this has been shown to reduce a woman’s chance of getting pregnant by more than 99%.3

How do they work?

Much of the controversy that surrounds emergency contraceptives has emerged from questions regarding their mechanism of action, i.e. the biological mechanism by which EC prevents pregnancy.

And the truth is, study of the mechanism of action of many emergency contraceptives has not been 100% conclusive. While it has been established that EC works primarily by blocking or delaying ovulation, questions remain regarding their ability to prevent an already fertilized egg from implanting.4 These questions are vital in the debate on ECs, as many believe that blocking the implantation of a fertilized egg would make emergency contraceptives abortifacients (drugs that induce abortion).

While literature exists arguing both sides of the debate (either affirmative, some kinds of EC can block implantation or negative, ECs cannot prevent implantation), there is a rising general consensus that these contraceptives do not prevent the implantation of a fertilized egg, and therefore do not act as abortifacients (note: this is less established in the case of ulipristal acetate and Copper-T IUDs). The inability of Plan B to prevent implantation and the pill’s non-abortifacient nature have been well established. However, it is important to note that emergency contraceptives do not protect against transmission of STIs.

Conclusion Mistakes happen. Emergency contraceptives can offer a simple solution to avoid unwanted pregnancy in the face of unprotected sex. While avoiding unprotected sex should obviously be a priority, it is also important to know what to do if a mistake has been made in order to prevent pregnancy. ■ MD For references, see page 41.

28 ■ The Medical Decoder ■ Phi Delta Epsilon IL Gamma

Making the Career Choice What are your Options?

S

By Varsha Venkatakrishna ince the 8th grade, I had a wildly idealistic vision for my future. It involved a crisp, white monogrammed lab coat, a shiny stethoscope, and a stack of business cards reading Dr. Venkatakrishna.

My parents, of course, were thrilled by the prospect of having a second doctor in the family and heavily supported my decision. In fact, when I entered Northwestern University as a freshman, it was with their assurances that lead me to start my collegiate journey as a premed student.

It has been quite a journey. Between finding a new passion for both creative writing and political science, to landing a compelling summer internship in a lab, I waned in and out of being premed at least fifty times during my first year. In fact, having a weekly career crisis was nothing out of the ordinary by the time spring rolled around. It was torturous living life on the fence, being too hesitant to commit to either side; however, when I realized I didn’t have to give up one passion for the sake of the other, I was relieved of my anxiety.

It is estimated that 30% of incoming freshman across the country share my story, entering as a premed, but switching to other fields as they progress through their college careers.1 While some of these students choose to switch to entirely different areas of study, others, due to their affinity for the medical field, opt for medically-related career paths that accommodate their widening interests.

Volume 2 ■ Fall 2013 ■ 29

It is understandable why students interested in the medical field would opt out of the traditional route to medicine (i.e. premed, medical school, residency, etc.). And while I attribute a few of these reasons to the highly demanding coursework of being premed, many students simply find that their passions lie in areas apart from medicine after they have been exposed to different academic fields.

Luckily, in today’s job market there are a plethora of options for cross-field careers. I have detailed only a few of these options below, in regards to job description, level of education required, the salary each path can provide, and the overall outlook for those career paths.

Education Needed •Bachelors in •Oversees vari- Healthcare Adous departments ministration for to keep up with lower tier jobs the fast-paced •MBA with a Health changes to the background Administrator medical field in science or •Coordinates healthcare pre3 quality of care ferred for upper tier jobs3 Career Path

Healthcare Attorney

Job in Bioethics

Job Description

•Oversees risk management and malpractice litigation.

•In charge of general corporate management issues in healthcare5 •Very wide range of opportunities •Positions in ethics committees • Work for nonprofit organizations •Hospital chaplaincy1

Salary

Job Outlook

•Mean annual salary of $104,0003

•Projected 22% growth from 2010 to 20203

•A bachelor’s •Mean andegree and then nual salary of completion of $102,0005 law school5

•Projected 14% growth from 2010 to 2020

•A bachelor’s degree in biology is required, but a master’s or PhD is preferable for higher tier positions13

•Average job growth of 34% from 2010 to 202013

30 ■ The Medical Decoder ■ Phi Delta Epsilon IL Gamma

•Because of the wide range of options in this field, a salary range is difficult to pinpoint13

Career Path

Patent Attorney

Scientific Consultant

Forensic Pathologist

Job Description •Plans and directs any legal issues regarding patents •Determines who owns rights to inventions7 •Conducts research in various fields of biotechnology and other life science-related disciplines to create innovations for customer projects9 •Conducts applied or academic forensic pathology •Uses scientific reasoning to help legal matters involving human remains11

Education Needed •A bachelor’s degree in a science field and completion of law school. The Patent Bar Exam is required to practice law. 7 •A bachelor’s degree is required for lower tiered jobs, a master’s degree in a science discipline is necessary for upper level jobs9

•A master’s degree or PhD in biological anthropology11

Salary

Job Outlook

•Mean annual salary of $212,0007

•Mean annual salary of $84,0009

•Mean annual salary of $66,00011

•Average job growth of 10% from 2010 to 20207

•Average job growth of 14% from 2010 to 20209

•Average job growth of 5% from 2010 to 202011

The medical field has more options than one would think. If your end goal is to attain the title of MD at the end of your name, then that is fantastic. It is also important to realize that the medical field has a much wider range of career paths though; it is flexible, integrative, and multifaceted. In short, you can find a career path in the medical field that best fits you.

I still have not decided on a career path, and by the end of the month, I may have tossed out another dozen possibilities. Though the process of choosing a career path still seems daunting as I head into my sophomore year, it is comforting to know that when I do choose one, I don’t have to sacrifice one interest for the other. There are still many career opportunities out there, and I have the ability to find a career path that combines my passions. ■ MD

For references, see page 41.

Volume 2 ■ Fall 2013 ■ 31

Scalp Cryotherapy: Changing the Face of

Cancer

By Devora Isseroff

A

patient facing cancer confronts more than psychological impact on patients. Watching your a battle with a life-threatening illness. Many own hair fall out can be a highly traumatic process

patients with cancer must face a battle with the and can cause patients to feel as if they are losing mirror. Of the 1.6 million Americans who will be di- a part of themselves. One study found that breast agnosed with cancer this year, more than half will cancer patients are more worried about losing be treated with hair loss-inducing chemotherapy.1 their hair than losing their breast.3 The loss of hair Hair has a distinct function in our society. Hair can takes the privacy out of a patient’s cancer treatsignify health, youth, sexuality, and individuality. ment. Patients have described going bald as feelIt can enhance body image, self-esteem, and self- ing as if they are wearing a sign that says, “Ask me expression. One popular British magazine esti- about my cancer.” Fear of hair loss is sometimes so mates that the average person spends almost ten severe that patients will choose not to receive or days per year styling their hair!2

prolong a recommended treatment in an effort to

Although concerns about hair loss have long keep their hair.3-5 been dismissed as purely cosmetic or superflu-

What many cancer patients and even some phy-

ous, studies show that hair loss can have a major sicians do not know is that there are options cur32 ■ The Medical Decoder ■ Phi Delta Epsilon IL Gamma

rently available that can prevent this unfortunate be approved. The FDA discontinued review of the side effect. Since the 1970s, scalp cryotherapy (lit- method in 1990 after physicians voiced concerns erally, “ice healing”) has been a standard hair loss that the treatment may allow for vagrant cancer prevention method in Europe and Canada.6-8 This cells, known as metastases, to grow unharmed in method involves strapping a bulky cap, called a the scalp. Today, a number of studies have been cold cap, to the scalp of a patient receiving che- published indicating that, at least in solid tumor motherapy. Though caps are often cooled to near patients, rates of metastases are the same as those 0˚C temperatures, they are generally well tolerat- in patients not receiving scalp cooling. ed. Major complaints are limited to headache and

However, patients wishing to use scalp cooling in

sensations of cold, but these complaints rarely the U.S. still have access to organizations like Penlead to patients discontinuing their cold cap treat- guin Cold Caps Co. or the Rapunzel Project, both ment.

of which provide cold caps to patients. A study

The very cold temperatures of the cold caps are

hypothesized

to

limit blood flow to the scalp, therefore decreasing the concentrations of cytotoxins from the chemotherapeutic drugs

The very cold temperatures of the cold caps are hypothesized to limit blood flow to the scalp, therefore decreasing the concentrations of cytotoxins from the chemotherapeutic drugs reaching and killing hair follicles.

reaching and killing hair

of

a

Swedish

cooling machine from the company Dignitana, the DigniCap, began recruiting

pa-

tients in the summer of 2013. The company hopes

follicles. Researchers also believe that the cold to gain FDA approval in the near future.7 temperatures reduce the uptake and metabolism

Cold caps provide cancer patients an effective

of the chemotherapy in hair follicles.9,10 Studies of and innovative means to avoid much of the trauscalp cooling show that a patient has about a 50% ma of a cancer diagnosis. They are an important chance of keeping all of his or her hair.11 However, victory against one of most painful and perhaps the extent of hair preservation often depends on dehumanizing effects of living with cancer. ■ MD the dose and type of chemotherapy used.

For references, see page 41.

Despite the long history of the effective use of scalp cryotherapy outside of the U.S., it has yet to Volume 2 ■ Fall 2013 ■ 33

PRIMETIME PRESCRIPTIONS by

“Y

Rachel Sibley

ou’re turning white,” Dr. House said to of nursing students and 76% of medical students the pale, sickly looking African-American tuning into House on a weekly basis, according to a

man lying in the ICU. “What does that mean?” the pa- 2008 survey conducted by researchers at the Berman tient’s mother asked in a concerned tone. Dr. House Institute of Bioethics at Johns Hopkins University.2 retorted, “It means he doesn’t need football to get a good job anymore.”

Another widely watched medical drama is Grey’s Anatomy. In the week of March 29, 2013, Grey’s

This completely inappropriate yet entertaining dialogue occurred in an episode of the acclaimed medical drama House. The show, which features the brilliant, emotionally unstable, and drug-addicted character Gregory House, was nominated 159 times for awards from American television organizations

Writers are constantly caught in a balancing act between sticking to the facts and bending the truth for the sake of entertainment.

throughout its 8 seasons, winning two Golden Globes.1 House is also very popular with students topped the Thursday rating chart with 8.8 million who are preparing for health professions with 65% viewers.3 The famous medical TV show ER was no 34 ■ The Medical Decoder ■ Phi Delta Epsilon IL Gamma

less popular, winning the People’s Choice Award for Norman Lear Center.6 However, writers are constant“Favorite Television Dramatic Series” every year from ly caught in a balancing act between sticking to the 1995 to 2002.4

facts and bending the truth for the sake of entertain-

Yet, the precedent for hospital dramas on network ment. Of course, more often than not, they choose to TV was set long before ER and Grey’s. The first medi- sacrifice medical accuracy in order to create gripping cal TV shows began in the 1960s, with Ben Casey and television. But how much do they sacrifice and why Marcus Welby, M.D., who earned the title of “Amer- is it important? ica’s family physicians”. In these past five decades,

A Plight For Nurses

not one year has gone by without a medical drama

One group that has protested against the inaccura-

gracing cable television.5 The genre’s unperturbed cies of medical dramas is nurses. Nurses argue that success stems from the lure of life and death deci- hospitals on TV seem to operate completely without sions, blood, gore, mystery, ethics and romance – all their assistance. Stating that their portrayals are rareplot components that make for irresistibly compel- ly accurate, nurses have observed that these dramas ling television.

tend to omit their roles as influential individuals in

However, medical professionals claim that these the medical setting who make decisions daily that medical dramas and others misinform audiences save lives. Nurses are often absent in medical dramas, on most aspects of real-life medicine, from specific while doctors are shown doing nurses’ jobs. Sandy procedures to the interactions between different members of the healthcare system. But who cares?

Why bother to criticize these shows when they are grossing millions of dollars and racking in Emmy after Emmy?

Television writers are the ones responsible for

Nurses have observed that these dramas tend to omit their roles as influential individuals in the medical setting who make daily decisions that save lives.

maintaining medical accuracy in their episodes. In order to create plot lines and impressive dialogue, Summers, the director of the Center for Nursing Adthe writers behind these successful shows rely on vocacy, a Baltimore-based non-profit, cites many consultations from doctors and healthcare experts, television occurrences of physicians acting in the provided by groups such as Health & Society, the role of nurses. Summers cites an episode of House in Centers for Disease Control and Prevention, the Na- which a doctor helps a postoperative patient to the tional Institutes of Health, and the USC Annenberg bathroom – a task performed by nurses in real hospiVolume 2 ■ Fall 2013 ■ 35

tal settings. In 2006, the Center for Nursing Advocacy this shortage, television has been shown to have a even included Grey’s Anatomy on its list of the “10 powerful influence on the careers that today’s young Worst Portrayals of Nursing in the Media” during the men and women choose. Annual surveys revealed Golden Lamp Awards, a ceremony which ranks the that in 2004, forensic medicine ranked 33 on the list best and worst depictions of nursing in mainstream of most popular career choices, while just one year media.7 In one episode of the show, the interns mon- later in 2005, forensic medicine jumped to 23 on the itor a premature infant through the night shift in the list, a dramatic increase in popularity that was attribneonatal intensive care unit. Summers pointed out uted to the late 2004 premiere of CSI: New York.7 that trained neonatal nurses are actually responsible

One major concern that has propelled the backlash

The Impact of Hollywood on Medical Schools

against medical dramas in the nursing community is

Unfortunately, nurses are not the only ones nega-

for this job.

the current nursing shortage in the US. According to tively impacted by Hollywood hospitals. There is a the American Nurses Association (ANA), the current growing concern among medical educators that their median age of nurses is 46 and more than fifty per- students, the young future physicians of America, cent of the nursing workforce is close to retirement. are subconsciously using medical TV shows as a type The need for more nurses will become even more of informal curriculum. Dr. Elizabeth Sinz, a professor apparent in the future. As the baby boom generation of anesthesiology at the Penn State Milton S. Hergrows older, their health needs will increase, put- shey Medical Center, said “People learn from TV, they ting a strain on the health system. Additionally, the learn from reading, they learn from what I’m teach9 new health care reforms have given millions more ing in a lecture. It all has to come together.” One of

people access to medical care, adding to the strain Sinz’s main concerns is that TV shows unrealistically on hospitals and clinics.8 Nurses partially blame this depict teamwork, especially in emergency settings shortage on the portrayal of their profession on where TV doctors often make decisions completely the small screen. Rebecca Patton, President of the on their own. In addition, these fictional TV physiAmerican Nurses Association, claimed “Young men cians never discuss the concerns that real-life docand women are choosing other professions instead tors grapple with, such as paying back student loans 9 of nursing, in part because of the negative portrayal or fighting to get Medicare claims reimbursed. Ad-

of nurses in the media”.7 While some doubt the im- ditionally, medical school professors are worried that portance medical dramas’ depiction of nurses has on their students might treat these shows as lessons in 36 ■ The Medical Decoder ■ Phi Delta Epsilon IL Gamma

medical ethics. “In a 2008 survey published in the tion that patients might have is the survival rate for April Issue of Journal of Medical Ethics, researchers cardiopulmonary resuscitation (CPR). In 1996, the catalogued 179 depictions of bioethical dilemmas New England Journal of Medicine reported that in 50 episodes of House and Grey’s Anatomy that CPR occurs successfully in 75% of cases presented aired between fall 2005 and spring 2006. Of those, on TV. However, even optimistic real-life estimates 49 involved not obtaining informed consent for suggest that CPR is successful only 15% of the time. treatment from patients or their loved ones. In some Some fear that this will give people unrealistic exinstances (43%), the characters behaved according pectations, although this has not been studied exto professional codes of conduct, but in most cases tensively.9 Medical television has also been shown to (57%) they missed the mark completely — as when influence viewers’ expectations about their chances TV doctors failed to obtain any consent at all for a of getting sick. A survey of almost 1,300 participants procedure or brazenly lied to patients to get them presented at the British Psychological Society’s conto sign off (two scenarios particularly common on ference in Bath, England revealed that participants House)”.2 Dr. Vineet Arora, the assistant dean at the who watched the most medical programs were ten University of Chicago’s Pritzker School of Medicine, percent more afraid of falling ill than others. The Brithas taken action in the classroom to combat the im- ish Heart Foundation (BHF) also realized that medical pressions that medical dramas have given medical television gives the public unrealistic expectations. students. Dr. Arora created a new class called “Medi- In 2008, BHF cautioned that “Hollywood-style” heart cal Professionalism in the 21st Century: A Real World attacks, in which actors clutch at their chests and fall Approach” in which she plays segments from “ER” to the floor, are misleading and might cause people that showcase patient-physician interactions. She to ignore some characteristic symptoms of a heart then has the class critically discuss the clips after- attack. In response, BHF produced its own short film wards, highlighting the inconsistencies that many of called “Watch Your Own Heart Attack,” combating these dramas have with the real world of medicine.9

television portrayals and publicizing the true symptoms of an attack.10

The Interference with Patient Care

Susan Morgan, associate professor in the Depart-

While medical schools can reach out to their stu- ment of Communication at Purdue University and dents using progressive new curriculums similar author of Entertainment (Mis)Education, spoke out to Dr. Arora’s, it is more difficult to reach out to the regarding what she sees as the most detrimental general population of patients. A main misconcep- effects of inaccurate medical dramas on patients.

Volume 2 ■ Fall 2013 ■ 37

Morgan was the co-author of a study published in what viewers think about donation is directly related Clinical Transplantation in 2005 that revealed that to what they see in television storylines. This is not the majority of patients who are unenthusiastic, and just about creative license. We want Hollywood writeven pessimistic, about organ donation frequently ers, producers, and executives to consider the pubcite television as evidence for their opinions. In- lic health impact of their donation storylines. That is deed, most TV episodes that feature organ dona- why we are launching Donate Life Hollywood.”11 In tion dramatize the situation by including plot lines order to pursue these goals, DLH discourages writabout black markets for organs, doctors not saving ers and producers from negatively featuring organ potential donors’ lives, or wealthy patients receiv- donation by distributing to TV networks a “top 10 ing higher priority on waiting lists.11 Morgan specifi- list of storylines that are most harmful to the pubcally recalled an episode of Grey’s Anatomy in which lic’s perception of the donation process”.11 If a film, “a patient was prematurely declared brain-dead so TV episode, or commercial contains any of these her organs could be procured”.6 Morgan fears that top 10 storylines, DLH recruits volunteers across the inaccurate portrayal of organ donation will dissuade country whose lives have been positively impacted people from becoming donors, an issue which poses by organ donation to write letters to those network as a major problem because, in the United States executives.11 On the other hand, the campaign also alone, there are roughly 118,000 people on waiting praises programs that accurately and positively fealists for life-saving transplants.12 Morgan stated: “You ture organ donation. For example, one episode of could start drawing this out to real human lives be- Extreme Makeover: Home Edition followed the story ing lost.”6

of a mother whose son had died in a car crash and

However, in 2007, hope came in the form of Do- donated his organs. DLH applauded the episode nate Life Hollywood (DLH), a campaign specifically and “after the show aired, online donor registration launched to eliminate the “stolen-kidney” story- increased 200% in California over the previous week, line and other inaccuracies in Hollywood related to a spike the campaign attributed to the show”.6 the depiction of organ, eye, and tissue donation.

In response to Morgan’s groundbreaking research,

An Accurate Medical Drama Show

Tenaya Wallace, director of DLH stated: “The organ

Thankfully, there is one popular medical drama that

and tissue donation and transplant community has has continually been praised for its accurate reprebeen upset by inaccuracies in the past but we have sentations, and it is a show that people might be least not taken action. Now we have hard evidence that likely to guess: Scrubs. Unlike the shows mentioned 38 ■ The Medical Decoder ■ Phi Delta Epsilon IL Gamma

thus far, Scrubs does not deal with life or death sce- in Scrubs episodes. For example, Doris once hid in a narios in every episode and doesn’t end with a sur- closet in order to avoid being the first doctor at the prise diagnosis – it focuses on ordinary cases. The scene when a patient was coding. “In the pilot, J.D. show’s narrator and central character is Dr. John “J.D.” performs a procedure called a paracentesis to drain Dorian (played by Zach Braff ), and it focuses on his fluid from a patient’s distended belly; he turns away progression from intern to resident to full-fledged for a moment, then looks back to discover a geyser doctor. In particular, real physicians identify most of fluid gushing into the air. It happened—just like closely with J.D.’s portrayal of the ups and downs of that—to a fellow resident at Brown.” 13 Dr. Paul Pirmedical residency. He reveals most of his feelings raglia, an internist in Providence, Rhode Island and through his internal monologues. Questions that J.D. another resident in Doris’ class explained “Being a asks in his internal monologues, such as “Am I hurt- resident is a strange place between officially being ing the patient? Am I learning what I should? Am I a doctor, which you are, but also really not knowing kissing up too much to the attending?”13 are typical it all…You get this level of authority that you don’t of the real doubts that go through a resident’s mind, think you deserve. All of a sudden you’re the doctor according to Jonathan Samuels, doctor at the NYU and people are going to listen to you.”13 Hospital for Joint Diseases.13

Even though Scrubs has been lauded for its realism,

Scrubs is able to achieve such accuracy because it remains to be the one of the only major TV producthe show’s creator, Bill Lawrence, based the show tion that has consistently stuck true to the medical on the experiences of his close friend, Dr. Jonathan facts. Next up on the agenda for medical television

It is important to remain aware of the inaccuracies that are present in medical dramas and differentiate fact from fiction.

series is Hostages, an new drama that aired on CBS in September of this year. The series stars Toni Collette, a high profile surgeon recruited to operate on the President of the United States.14 It is clear that regardless of the plot line, the actor, the location, or the negative effects of inaccurate representations: America just can’t get enough of Hollywood hospi-

Doris, throughout his internship and residency. Do- tals. Whether we like it or not, this television genre ris is now a cardiologist in LA and a medical advisor is here to stay. It is important to remain aware of the to the show, and many of his experiences from his inaccuracies that are present in medical dramas and residency at Brown University have been featured differentiate fact from fiction. ■ MD

For references, see page 42.

Volume 2 ■ Fall 2013 ■ 39

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“Where Does Alternative Medicine Belong?”

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40 ■ The Medical Decoder ■ Phi Delta Epsilon IL Gamma

com/hfmmagazine/jsp/articledisplay.jsp?dcrpath=HFMMAGAZINE/Article/data/12DEC2012/1212HFM_FEA_TrendsInterview&domain=HFMMAGAZINE>.

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“Emergency Contraception: A Quick Guide to the Morning After” 1) Hickey, MT. 2009. “Female college students’ knowledge, perception, and use of emergency contraception,” Journal of Obstetrics, Gynecology, and Neonatal Nursing, Vol 38 (4): 399-405.

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“Making the Career Choice: What are your options?”

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“Scalp Cryotherapy: Changing the Face of Cancer” 1) Cancer Facts and Figures 2013. In: Society AC, editor, 2013.

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6) Van den Hurk CJG, Coebergh JWW, Breed WPM, De Poll-Franse LVV, Nortier JWR. “Scalp cooling in cancer patients receiving chemotherapy in the Netherlands.”

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“Primetime Prescriptions” 1) “Awards for “House M.D.”” IMDb. IMDb.com, n.d. Web. 12 Sept. 2013. <http://www.imdb.com/title/tt0412142/awards>.

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3)Hibberd, James. “’Grey’s Anatomy’ Tops Thursday Ratings Chart.” Entertainment Weekly. Entertainment Weekly Inc., 29 Mar. 2013. Web. 12 Sept. 2013. <http://insidetv.ew.com/2013/03/29/greys-anatomy-tops-thursday-ratings-chart>.

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11)“Hollywood Gets It Wrong on Organ Donation.” Washington Regional Transplant Community. Donate Life, 31 July 2007. Web. 13 Sept. 2013. <http://www.beadonor. org/news-a-events/media-center/press-releases/881-hollywood-gets-it-wrong-on-organ-donation>.

12)“Statistics.” Donate Life America. Donate Life, n.d. Web. 13 Sept. 2013. <http://donatelife.net/understanding-donation/statistics/>.

13)Weiss, Joanna. “Scrubs: Goofy, Cartoonish, and the Most Accurate Portrayal of the Medical Profession on TV.” Slate Magazine. The Slate Group, 6 May 2009. Web. 13 Sept. 2013. <http://www.slate.com/articles/arts/culturebox/2009/05/scrubs.html>.

14)Mullins, Jenna. “5 Fall Shows We Love: Hostages Will Keep You Captivated.” E! Online. E! Entertainment Television, LLC., 12 Sept. 2013. Web. 13 Sept. 2013. <http:// www.eonline.com/news/457866/5-fall-shows-we-love-hostages-will-keep-you-captivated?utm_source=eonline>.

42 ■ The Medical Decoder ■ Phi Delta Epsilon IL Gamma

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