“Should international medical graduates do research?”

Medical researcher with vials of blood.

Kenneth B. Christopher, MD, SM,
November 29, 2017

Dr. Kenneth Christopher is the associate director of global education at Harvard Medical School and the course director for Introduction to Postgraduate American Medicine, an online course that prepares international medical graduates for careers in the American health system.

Dr. Christopher has written for and about international medical graduates for many years, and has agreed to share some of his blog posts with our Lean Forward audience.

The topic of today’s reblog is whether or not research has any value for international medical graduates seeking careers in the American health care system.

Internal Medicine Residency for IMGs

I get asked the “should I do research” and “where can I do research” question often. From my look at the NRMP data about half of those who match have research which means half do not.

If you are going to do two years of research and delay your application and increase the distance from your year of graduation you better produce something like this. High quality research is difficult and takes a lot of time to produce. You need to join a productive group and bring something to the table. Few IMG applicants who do any research time without previous training (MPH, MSc, PhD) have much to show for it. Performing research to get into residency is not worth the effort. Pursuing research because your passion to become an academic is a laudable act in my opinion.

If you think about it, most successful IMG applicants will match…

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Gun Violence as a Public Health Issue

By Ajay K. Singh, MBBS, FRCP, MBA
November 21, 2017

An interesting viewpoint about gun violence was recently advanced by Nicholas Kristof (with Bill Marsh) in the New York Times.

Kristoff argues that a blanket opposition to guns hasn’t worked and that an alternative approach of regulating guns should be considered. He advocates a “public health approach.”

The article cites some staggering facts:

  1. Guns per 100 people—for the US, 88.8; the next closest Switzerland at 44.7; Canada comes in at 30.8 and Japan 0.6.
  2. Murders per 100,000 people—the US 3.0; the next closest Italy at 0.7; Canada comes in at 0.5.
  3. Research on guns: from 1974 through 2012, the NIH funded just three research awards.

The Kristof article makes some sensible recommendations that seem to resonate with Americans. Here are three that caught my eye:

  1. Background Checks—93% of Americans surveyed agree and yet 1 in 5 guns are obtained without one. Nearly 90% of Americans agree that the mentally ill shouldn’t be buying guns.
  2. Safe storage—making sure guns are inaccessible to children and have trigger locks.
  3. Banning under-21-year-olds from purchasing guns—we don’t let them drink, but allowing a teenager to buy a semi-automatic gun seems sensible?

Other ideas that we could consider with a public health approach include taking a systems approach. How can the health system help reduce gun violence?

  • Could the primary care doctor ask patients about gun ownership, and perhaps even counsel them about safe gun use?
  • Does integrating educating patients about safe storage and making sure guns can’t be fired accidentally seem to make a lot of sense?
  • Could research be funded that predicts which individuals are prone to gun violence? Perhaps, high-risk individuals could be screened and then offered help by the health system?
  • Could sensible controls be built-in that, on the one hand preserve privacy, but at the same time regulate access to guns in people with mental illness? Should people with personality disorders or a history of psychotic illness be allowed to buy guns without undergoing some secondary screening? On a related note, merging databases that screen people as a part of a “background check” with databases that record diagnoses around mental health could be developed.

Whether gun violence abates in the US is a complicated question. At one level, solutions are a function of societal trends, politics, and the power of the gun lobby. Still, thinking about novel ways to frame an important problem isn’t a bad idea. Gun violence kills people, and as Kristof suggests, emphasizing and framing it as a public health issue makes sense. Has anything else worked?


Learn more about Health and Health Care Disparities from a panel of HMS experts.


Ajay Singh, MBBS, FRCP headshotDr. Ajay K. Singh is the Senior Associate Dean for Global and Continuing Education and Director, Master in Medical Sciences in Clinical Investigation (MMSCI) Program at Harvard Medical School. He is also Director, Continuing Medical Education, Department of Medicine and Renal Division at Brigham and Women’s Hospital in Boston.

Share your thoughts on solving America’s gun violence crises in the comment section below.

A Primary Care Doctor Delves into the Opioid Epidemic

November 14, 2017

[The following post by Monique Tello, MD, MPH, has been shared with us by Harvard Health Publishing, having originally appeared on their website in February 2017.]

Our nephew Christopher died of a heroin overdose in October 2013. It had started with pain pills and experimentation, and was fueled by deep grief. He was charismatic, lovable, a favorite uncle, and a hero to all the children in his life. His death too young was a huge loss to our family. I have always felt that I didn’t do enough to help prevent it, and perhaps, in a way, even contributed.

Good intentions with unintended consequences

My medical training took me through several big-city hospitals where addiction and its consequences were commonplace. Throughout all of it, great emphasis was placed on recognizing “the fifth vital sign,” i.e., pain, and treating it.

I distinctly remember as a medical student wearing a little pin with the word “PAIN” and a line across it. One was considered a bad doctor if they didn’t ask about and treat pain. And so, treat we did. This medical movement, combined with the mass marketing of OxyContin and a swelling heroin trade, has created the current opioid epidemic.

It generally starts with pain pills: Percocet, Vicodin, Oxycodone or OxyContin, either prescribed or given or bought. Quickly, a person finds that she or he needs more and more of the drug to get the same effect. Almost overnight, they need the drug just to feel normal, to stave off the horror of withdrawal. Street heroin is cheaper and easier to come by than pills, and so, people move on to the next level. Just like Christopher.

Recent data from the Centers for Disease Control (CDC) and the National Institute for Drug Abuse (NIDA) show that deaths from overdose of opioids have been rising every year since 1999. (OxyContin came to market in 1996). Deaths from heroin overdose have recently spiked: a 20% increase from 2014 to 2015. And most recently we’re seeing fentanyl, an extremely potent synthetic opioid, where even a few small grains can kill.

So, if we doctors helped everyone get into this mess, we should help them get out of it, no?

Needed: Treatment that works

As the opioid epidemic has exploded, so has the demand for treatment. But treatment is almost impossible to come by. The U.S. is short almost 1 million treatment slots for opioid addiction treatment. And not all treatments offered are that effective.

The “traditional” treatment of detoxification, followed by referrals to individual therapy or group support (think Narcotics Anonymous), may work well for some, but the data suggest that there are more effective approaches. In fact, a growing body of evidence very strongly supports medication, combined with therapy and group support, as the most effective treatment currently available.

“Detox” followed by therapy has consistently shown poor results, with more than 80% of patients relapsing, compared to treatment with medications, with only 15% relapsing. Medications, specifically methadone and buprenorphine, can help prevent withdrawal symptoms and control cravings, and can help patients to function in society. Suboxone (a combination of the drugs buprenorphine and naloxone) has many advantages over methadone. It not only prevents withdrawal and controls cravings, but also blocks the effects from any illicit drug use, making it more difficult for patients to relapse or overdose. In addition, while methadone can only be prescribed through certified clinics, any primary care provider who completes a training course can prescribe Suboxone. That means treatment for opioid use disorders could be much more widely available.

Basically, treatment with medications, and especially Suboxone, is effective, and safer than anything else we have to offer. Yes, relapses can occur, but far less frequently than with traditional treatment. And death from heroin overdose? Far, far less.

Biases against treating opioid use disorder with medications

Despite their effectiveness, there is stigma associated with treating substance use disorders with medication. I admit that I had my own doubts as well. People say, as I did, “Oh, you’re just replacing one drug with another.” But a lot of hard science has accumulated since 2002, when the FDA approved Suboxone for the treatment of opioid addiction.

Think about it. Is shooting street heroin that’s cut with God knows what, using needles infected with worse, really the same as using a well-studied, safe, and effective daily oral medication? Some may claim “Oh, you’re just creating another addiction.” Would you tell someone with diabetes who depends on insulin that they’re “addicted”? Then why say that to someone with opioid use disorder who depends on Suboxone? This is literally the reasoning that played out in my head as I have learned about treating opioid addiction, or, more correctly stated, opioid use disorder.

Stepping up

I’ve decided that it’s time to do something. There’s a great need for doctors willing and able to treat opioid use disorder. In 2016, surgeon general Vivek Murthy issued a strident call to action to all U.S. healthcare providers, asking them to get involved.

This issue has been on my mind and soul since Christopher’s death, so I started educating myself, and contacted our hospital’s substance use disorders specialist with my motivation and concerns. In the few months since then, I’ve taken the training course to become a licensed prescriber, and am working with the team to begin treating a small group of patients.

In my 16 years of clinical training and practice, I have witnessed all of this firsthand: the blatant, medically rationalized over-prescription of pain meds, the stigma and undertreatment of opioid use disorder, and the unnecessary, premature death of a really good kid. I’m just starting off on this, and I’m still learning, but my hope is to keep another family from experiencing unnecessary loss.


Register for Free Opioid Use Disorder Education

The Opioid Use Disorder Education Program (OUDEP) is an accredited, free, online medical education program from Harvard Medical School for the identification and management of opioid use disorder. This program is designed for nurses, nurse practitioners, physician assistants, physicians and other healthcare professionals collaborating to treat patients with substance use disorder and offers up to 24 CE/CME credits.


Sources

  1. Generally Medicine: Ripped from the family
  2. Generally Medicine: Drugs, Violence, and Tragedy in our Family
  3. Mularski R.A., White-Chu F., Overbay D., Miller L., Asch S.M., Ganzini L. Measuring Pain as the 5th Vital Sign Does Not Improve Quality of Pain Management. Journal of General Internal Medicine, 31 May 2006.
  4. http://www.huffingtonpost.com/kristine-scruggs-md/the-opioid-epidemic-how-d_b_9865680.html
  5. https://www.cdc.gov/drugoverdose/data/statedeaths.html
  6. https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates
  7. https://www.cdc.gov/drugoverdose/data/heroin.html
  8. Jones, C.M., Campopiano, M., Baldwin, G., and McCance-Katz, E. National and state treatment need and capacity for opioid agonist medication-assisted treatment. American Journal of Public Health, August 2015.
  9. http://www.theatlantic.com/health/archive/2015/10/why-80-percent-of-addicts-cant-get-treatment/410269/
  10. Wakeman S.E. Using Science to Battle Stigma in Addressing the Opioid Epidemic: Opioid Agonist Therapy Saves Lives. American Journal of Medicine, May 2016.
  11. Bart, G. Maintenance medication for opiate addiction: the foundation of recovery. Journal of Addictive Diseases. October 2012.
  12. Connery H.S. Medication-assisted treatment of opioid use disorder: review of the evidence and future directions. Harvard Review of Psychiatry, March/April 2015.
  13. Mattick, R.P., Breen, C., Kimber, J., and Davoli, M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database of Systematic Reviews, 6 February 2014,
  14. Mauger S., Fraser R., Gill K. Utilizing buprenorphine-naloxone to treat illicit and prescription-opioid dependence. Neuropsychiatric Disease & Treatment, 7 April 2014.
  15. Colson J., Helm S., Silverman S.M. Office-based opioid dependence treatment. Pain Physician, July 2012.
  16. Schwartz, R.P., Gryczynski, J., O’Grady, K.E. et al. Opioid agonist treatments and heroin overdose deaths in Baltimore, Maryland, 1995-2009. American Journal of Public Health, May 2013
  17. Subutex and Suboxone Approval Letter. U.S. Food and Drug Administration (October 8, 2002). fda.gov.
  18. Murthy V.H. Ending the Opioid Epidemic — A Call to Action. New England Journal of Medicine, 22 December 2016.

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Ending America’s Gun Violence

By Ajay K. Singh, MBBS, FRCP, MBA
November 7, 2017

…it is imperative, now more than ever, that we approach this public health concern in an evidence-based and apolitical manner so as to better understand the complex social, economic, and political factors associated with firearm-related injuries. – Faiz Gani

Gun violence is a leading cause of premature death in the US, killing approximately 30,000 people and causing about 60,000 injuries each year.

In the midst of writing an article about a blog post on gun violence by Faiz Gani, I heard breaking news about 26 people tragically killed in a Texas church.

Senator Chris Murphy (D-Conn) issued a statement after the Texas church mass shooting: “As my colleagues go to sleep tonight, they need to think about whether the political support of the gun industry is worth the blood that flows endlessly onto the floors of American churches, elementary schools, movie theaters, and city streets. Ask yourself—how can you claim that you respect human life while choosing fealty to weapons-makers over support for measures favored by the vast majority of your constituents.”

While the motive for the Texas mass shooting (or for that matter, the tragic mass shooting in Las Vegas) remains elusive, one factor that has been common among some earlier mass shootings is that the perpetrator(s) suffered from mental illness.

Besides the mental instability part of the problem, there is also the economic cost. The post by Faiz Gani in Health Affairs discusses the price of gun violence:

Thousands of individuals incur firearm-related injuries daily, leading to approximately 36,000 deaths each year from a firearm-related injury. The number of nonfatal injuries is estimated to be three times that number…we estimate that the annual financial burden associated with the ED and inpatient care for firearm-related injuries to be $2.8 billion in hospital charges. Taking into account the costs of rehabilitation, repeat admissions, and lost work, the CDC estimates that each year, approximately $46 billion are lost due to firearm-related injuries. This figure is comparable to the $49 billion spent to treat patients with chronic obstructive pulmonary disease, the third leading cause of death in the United States…it is imperative, now more than ever, that we approach this public health concern in an evidence-based and apolitical manner so as to better understand the complex social, economic, and political factors associated with firearm-related injuries.

Setting aside constitutional right issues around gun ownership and the huge and tragic human cost of gun violence, there is the economic cost. Isn’t it worth asking if better access to mental health services to perpetrator(s) would reduce the current rate and extent of mass shootings?

Gani’s post suggests that from a purely economic perspective, the government investing in more mental illness treatment (programs and facilities) might make the difference. Even if mental illness is not formally diagnosed, most of us would agree that this type of mindless, despicable violence has a component of mental instability.

Share your thoughts with Harvard Medical School in the comment section below.

Ajay Singh, MBBS, FRCP headshotDr. Ajay K. Singh is the Senior Associate Dean for Global and Continuing Education and Director, Master in Medical Sciences in Clinical Investigation (MMSCI) Program at Harvard Medical School. He is also Director, Continuing Medical Education, Department of Medicine and Renal Division at Brigham and Women’s Hospital in Boston.

Clinical Reasoning: Storing Stories to Narrow the Diagnosis

By Martina McGrath, MD
October 24, 2017

Accurate clinical reasoning is central to the art of medicine, and involves complex cognitive processes that most clinicians perform unconsciously. However, teaching these skills is an essential component of developing expert clinicians. In an era of rising healthcare costs, increased access to diagnostic testing and unlimited access to knowledge, the ability to sift through large amounts of data, synthesize a clinical presentation in a meaningful way and develop a logical differential diagnosis with a focused, rational plan of evaluation, is perhaps more important than ever.1

Skilled clinical reasoning follows a series of steps, beginning (as we were all taught in medical school) with history-taking and physical examination. As the clinician talks to the patient, she begins to develop an impression of the patient’s story, known as a mental abstraction.2 This mental abstraction guides further questioning and clinical examination. After acquiring the relevant data, the clinician must develop a concise one-line summary of the findings, a ‘problem representation,’ incorporating the most important features of the case, relevant negatives, and a differential diagnosis. The problem representation is an essential step in synthesizing the data to formulate a plan of diagnosis and treatment.

A specific patient presentation can trigger recall of a memory of a previous clinical encounter, along with its associated knowledge, which may include pathophysiology, treatment, complications, etc.

Helping trainees (particularly those early in their careers) to develop accurate problem representation allows them to accurately access their stored knowledge about a particular medical problem. If the presentation is not framed appropriately, the correct information cannot be accessed, leading to increased likelihood of unfocused reasoning and diagnostic errors. Teachers should encourage learners to develop a one-line summary and then explore that summary, using open questions such as “Why do you think that?” or “What features support/do not support that conclusion?” This approach informs the teaching physician of the trainees’ thinking process, and also encourages greater engagement by the trainee in clinical reasoning. It can be very instructive if the teacher then gives their own summary and reasons aloud, illustrating how the case links to their prior experience, and demonstrating effective clinical reasoning strategies.

Experienced clinicians mentally develop personal ‘illness scripts’, a repertoire of patient stories that connect prior clinical experiences with medical knowledge, and store them as accessible memories that guide diagnostic reasoning.2,3 A specific patient presentation can trigger recall of a memory of a previous clinical encounter, along with its associated knowledge, which may include pathophysiology, treatment, complications, etc. Possession of a broad range of illness scripts allows expert clinicians to rapidly formulate a diagnosis, but also recognize atypical presentations and break down complex cases into their component parts.

Encouraging the development of a trainee’s personal repertoire of illness scripts is central to clinical training. Repeated patient interactions, particularly early in a hospitalization before all testing is complete, are critical to developing this skill.4  Each experience feeds into the knowledge base behind illness scripts. Guided discussion with an experienced clinician helps to consolidate these mental connections, and provides very valuable insights. Also when rounding on admitted patients, critical reflection helps to consolidate illness scripts, and avoids cognitive errors due to failure to challenge that initial diagnostic label as more information becomes available later.

Those of us who have been fortunate enough to train with outstanding clinicians will recognize these approaches. Solving the puzzle and getting to the right treatment plan is one of the more rewarding aspects of being a medical professional, and should be a cherished skill to hand on to our future colleagues.


Learn to develop essential skills in clinical research.


References:

  1. Cooke S, Lemay JF. Transforming Medical Assessment: Integrating Uncertainty Into the Evaluation of Clinical Reasoning in Medical Education. Acad Med. 2017 Jun;92(6):746-751. doi: 10.1097/ACM.0000000000001559.
  2. Bowen JL. Educational strategies to promote clinical diagnostic reasoning. N Engl J Med. 2006 Nov 23;355(21):2217-25.
  3. Elstein AS, Schwartz A. Clinical problem solving and diagnostic decision making: selective review of the cognitive literature. BMJ 2002;324:729-32.
  4. Simpkin AL, Vyas JM, Armstrong KA. Diagnostic Reasoning: An Endangered Competency in Internal Medicine Training. Ann Intern Med 2017;167:507-8.

Head shot of Dr. Martina McGrathDr. Martina McGrath is an Instructor in Medicine at Harvard Medical School, and a member of the Renal Division, Department of Medicine, at Brigham and Women’s Hospital, both in Boston. Dr. McGrath is the Medical Editor for the Trends in Medicine blog.

 

 

 

Spirituality and Medicine

Ajay K. Singh, MBBS, FRCP, MBA
October 19, 2017

“Spiritual or compassionate care involves serving the whole person—the physical, emotional, social, and spiritual. Such service is inherently a spiritual activity.” —Christina Puchalski

An interview with Christina Puchalski on integrating spirituality into medicine in BigQuestionsOnline caught my eye. So I dug a bit more into this topic.

I came across a 2001 article by Puchalski titled, “The role of spirituality in health care” that I would strongly recommend to anyone who takes care of patients. In her article, Puchalski writes: “Spiritual or compassionate care involves serving the whole person—the physical, emotional, social, and spiritual. Such service is inherently a spiritual activity.”

According to Puchalski, physicians should incorporate spiritual practice into their interactions with patients. This could happen by physician’s being “fully present and attentive to their patients…actively listen and allow their patients to share “fears, hopes, pains and dreams.” She also recommends that physicians pay attention to “all dimensions of patients and their families: body, mind, and spirit.” Puchalski supports physician’s involving chaplains as members into the interdisciplinary health care team.

Puchalski is an advocate of “compassionate care,” which she defines as physicians walking “with people in the midst of their pain, to be partners with patients rather than experts dictating information to them.” Merriam-Webster defines compassion as “sympathetic consciousness of others’ distress together with a desire to alleviate it.”

Puchalski writes that compassion is important because:

While patients struggle with the physical aspects of their disease, they have other pain as well: pain related to mental and spiritual suffering, to an inability to engage the deepest questions of life. Patients may be asking questions such as the following: Why is this happening to me now? What will happen to me after I die? Will my family survive my loss? Will I be missed? Will I be remembered? Is there a God? If so, will he be there for me? Will I have time to finish my life’s work?

Studies support Puchalski’s contention that physicians generally underestimate patients’ spiritual needs. Ehman and colleagues performed a self-administered survey to 177 patients in a hospital-based pulmonary clinic: only 15% were asked about spiritual or religious beliefs. Nearly two-thirds of the patients said that they would welcome a question about whether they were spiritual from their doctors while they were taking the medical history. In another study, also a survey, but in primary care clinics of six academic medical centers in three states, MacLean and colleagues report that many patients want their physician to ask them about spiritual beliefs; indeed, this desire for inquiry about spiritual beliefs increases strongly with the severity of the illness. The MacLean study enrolled 456 patients who were dying. Seventy percent of these patients said that they would welcome physician inquiry into their religious beliefs, 55% said that they would appreciate silent prayer, and 50% believed their physician should pray with them.

So what’s the bottom-line? While most physicians focus on the physical aspects of illness, a more holistic approach may be what patients want. Arguably to be complete, physicians should consider discussing spirituality with patients. Christina Puchalski concludes: “I think we can be better physicians and true partners in our patients’ living and in their dying if we can be compassionate: if we truly listen to their hopes, their fears, and their beliefs, and incorporate these beliefs into their therapeutic plans.”


Harvard Medical School CME:
Lifestyle Medicine: Nutrition & The Metabollic Syndrome


Ajay Singh, MBBS, FRCP headshotDr. Ajay K. Singh is the Senior Associate Dean for Global and Continuing Education and Director, Master in Medical Sciences in Clinical Investigation (MMSCI) Program at Harvard Medical School. He is also Director, Continuing Medical Education, Department of Medicine and Renal Division at Brigham and Women’s Hospital in Boston.

 

HMS Responds to the Opioid Crisis with Education

Harvard Medical School’s dean, George Daley, recently hosted a panel presentation to highlight “the transformative role that education can and should play in solving the opioid crisis.” HMS speakers at the event presented a three-pronged approach taken by the medical school to address the current epidemic of opioid use and abuse which includes educating medical students, health care professionals, and the general public. Other notable invitees spoke about health care policy in our government.

The following is a summary of the event by Dean David Roberts, one of the presenting speakers:

By David Roberts, MD
HMS Dean for External Education
October 13, 2017

On October 3rd, my colleagues Todd Griswold, Bertha Madras, and I joined Massachusetts governor Charlie Baker and HMS dean George Daley to make a presentation on Harvard Medical School’s response to the opioid crisis. The live-streamed event held at the HMS Martin Conference Center was attended by a large in-person audience with an additional remote audience of more than 6,000 viewers.

For my part, I presented on the great work Harvard Medical School teams are doing creating free online learning resources for clinicians, recovery coaches, first responders, and family members who are wrestling with the opioid crisis every day.

Todd, who is responsible for educating HMS students on opioids, described the innovative ways that substance use and pain medication education is being integrated into all four years of our medical students’ curriculum. Of particular note, is a plan for HMS students to graduate with training in the administration of naloxone and buprenorhine as well as in safe prescribing techniques.

Bertha is a member of the President’s Commission on Combating Drug Addiction and the Opioid Crisis alongside Governor Baker and other national leaders. They each spoke to the policies being created on state and national levels to address the opioid crisis.

To view a recording of the event on YouTube, you may click on the following link: HMS Responds with Education/The Opioid Crises

Whether you are a health care professional or a member of the general public affected by the current opioid epidemic, we hope you will take the opportunity to check out the free online resources that Harvard Medical School has created, and we welcome your feedback and comments!

For Health Care Professionals

The Opioid Use Disorder Education Program (OUDEP) is an accredited, free, online medical education program for nurses, nurse practitioners, physician assistants, physicians and other health care professionals collaborating to treat patients with substance use disorder.

For the Public

HarvardX: The Opioid Crisis in America is designed for nonclinicians. This free online course provides critical information on the nature of addiction, pain management without opioids, harm reduction, and evidence-based treatment alternatives.

For Everyone

Breaking the Cycle is a free weekly e-letter with news, HMS faculty insights and personal stories on addiction, recovery, treatment options and more.