Super Star Blogs!

Social Determinants of Medical Education

When considering the barriers to medical education for minorities and low-income groups, it is quickly apparent that there is great overlap between these social determinants and the social determinants of health. Indeed, much discussion has centered on the role of social and economic factors in the context of healthcare (Marmot & Allen, 2014). Similarly, the externally-derived barriers that limit access to medical education have been heavily explored from this perspective, and there is value to considering other categorical divisions for these issues, as new insights may be gained. There are some splitting of hairs necessary to discuss socioeconomic status as separate from social networks, but perhaps a different method of categorizing will minimize such entanglements.

From a broad perspective, where categories can be simplified, the following categories should be considered. The first is the availability of means, commonly thought of in terms of currency, as being the simplest way to assess the availability of means to pursue opportunities. The second category is social connections. This includes family members, friends, teachers, mentors, employers, etc. Of course, it cannot be forgotten that there is a relationship between the community that one belongs to and the availability of means, and this relationship can become exquisitely complicated in individual circumstances.

Availability of means

The cost of tuition for medical education in the United States is extraordinarily high. This high cost is even more notable when compared to other developed nations, where the cost of education is borne by the taxpayer base, rather than by the individual student. Here, in the United States, the cost of tuition for medical school ranges from approximately $16,000 per year to approximately $60,000 per year. This is the cost of the tuition alone, and does not include expenses for the cost of living. Cost of living expenses also vary widely, depending on the city where the medical school is located. For example, the estimated cost of living for medical students at the University of Arkansas for Medical Sciences is $20,780, whereas the estimated cost of living for medical students at the University of California at San Francisco is $31,656. Additional factors can also play a role, such as whether or not a student has in-state status at publically supported medical schools.

There have been some efforts to reduce the barrier imposed by the cost of attendance. The availability of federal student loans, for example, ensure that United States citizens who are accepted into medical school in the United States can generally have access to the funds to pay for it. However, these loans are administered at interest rates that are relatively high, although lower than the loan rates available through most consumer loan mechanisms. There is some controversy over the effectiveness of loan programs in improving minority access to education (Long & Riley, 2007). Beyond loans, many medical schools are part of larger, state-sponsored university systems. These medical schools typically offer residents of the state to attend the school at a significant reduction in tuition. For public medical schools, the difference in tuition for in-state students as compared to out-of-state students can be nearly two-fold. However, even with this subsidization of medical education, in-state tuition can cost tens of thousands of dollars per year.

However, looking only at the direct cost of medical school, one fails to capture the larger barriers imposed by the limited availability of means. Acceptance into medical school requires a number of academic and experiential qualifications to be met. Beginning with the academic requirements, it is worth keeping in mind that there are great disparities in the United States regarding high school graduation rates amongst minority and low-income groups (Heckman & Lafontaine, 2010). In general, families of similar financial means live in the same neighborhoods, and subsequently, their children attend the same schools. In many areas, school funds are related to property taxes. As a result, regions where the majority of the population is wealthier have more funding, compared to areas where the majority of the population is low-income. This creates a fundamental differential in what resources are considered standard. For example, at present, there are school districts that provide an iPad to every student, while there are also school districts struggling to maintain an adequate supply of classroom textbooks. Of course, education is about far more than the cost of the provided resources, and the value of an educator cannot be understated. However, teacher salaries also vary significantly across school districts. This, in turn, leads to a differential in educators as well. This is not to say that there are not many exemplary educators in low-income school districts, but it warrants acknowledgment that even a subtle differential can lead to significant consequences on a larger scale.

Therefore, before yet considering the impact of social connections, it is important to highlight that there are broad, system-level barriers affecting minority groups and those raised in low-income households.

The impact of social connections

It would be exceedingly difficult to overstate the importance of social connections, and the impact that they have on medical school matriculation rates. Children begin developing dreams and aspirations from a very young age. Indeed, it seems that perhaps the only limit to a child’s imagination is the breadth of their experience; therein lies the problem. Children that are exposed to professionals outside of a professional context (that is, a child that knows a doctor as a family friend, and not merely as the scary person with a white coat) have the concept that this profession is a real and viable option for them to pursue. This may not be the case for children who only meet the doctor in the doctor’s office.

There is also much to be said for the importance of family support. Familial networks that are fundamentally supportive in nature will encourage children to work towards dreams and aspirations, even if those aspirations are difficult to achieve. Alternatively, if the family environment is one in which such goals are scoffed at, a child will quickly become discouraged and choose to pursue more socially acceptable goals.

The process of pursuing post-secondary education can be overwhelming. The cost of applications alone can dissuade students. While there are fee waivers available, they require additional paperwork that is yet another barrier. Students who are surrounded by others going through this process have the benefit of peer support, which can also influence academic performance (Zimmerman, 2003). However, students who do not have peers or role models assisting them often drop out of the educational training pipeline at this juncture. Many schools employ counselors exclusively for the task of guiding students, but the utilization and quality of these resources vary greatly from school to school.

For students who overcome the aforementioned aspirational barriers, experiential barriers may still remain. Acceptance into college, and especially acceptance into medical school, require applicants to have pursued a certain set of baseline experiences, most often emphasizing community service. Students who have a rich social network are aware of this and can prepare accordingly. However, students lacking informal information resources may not realize that these non-curricular requirements exist, and may struggle to prepare a competitive application as a result.

Finally, the importance of developing social connections with mentors is essential. These mentors not only advise students but also endorse them through letters of recommendation. Depending on the social norms that a child is raised in, developing any type of personal rapport with an instructor may seem odd or even disrespectful. Yet this, once again, could serve as a barrier. A strong letter of recommendation can explain and even supersede a lack of experience or lapses in academic performance. But a recommendation letter of this sort would rely on there being a connection between the student and the mentor that exceeds the standard relationship.

The intersection of means and social connections

While the main focus here is on the consideration of broad categories of barriers with less overlap than those typically considered, it is important to still address the intersection of financial means and social connections. For this, two scenarios will be presented.

First, there are the students who overcome all aspirational and support barriers, yet social responsibilities are forced to take priority. For example, there are many students who must work full-time, even at the cost of ceasing their academic pursuits, in order to take care of their families. In this case, the financial resource systems designed to aid in the accessibility of medical education are insufficient. As discussed, the financial resources available involve loans and reducing the cost of tuition. However, neither of these mechanisms would help the student to fulfill their family obligations.

The second scenario is systemic in nature and related to the differential in opportunities provided by various school districts and education systems. As discussed above, there are a number of non-curricular, experiential requirements for post-secondary education as well as medical education. School districts with a greater availability of resources often organize opportunities for their students that meet these requirements. For example, volunteering opportunities around the community, and supplemental training that is outside of the formal coursework. Students from school districts with fewer resources likely need this assistance more to reduce barriers, but in the absence of sufficient resources, the point is simply unfeasible.

Using availability of means and social connections to reduce barriers to medical education

While it is clearly impossible to truly generate categories of barriers that are independent of one another, this perspective of the barriers to medical education is helpful from the perspective of implementation. To begin, a stronger education system nationwide is needed, but of equal importance are mechanisms needed to equalize the opportunities provided through education. Particularly when considering public education, resource re-allocation (though controversial) can significantly offset many of the opportunity barriers discussed here. There are many organizations and institutions that strive to help students through career and academic planning. Many of these resources are very good, however, they exist independently from one another. Some efforts have been made to aggregate these resources, but it is often still unintuitive and difficult to navigate without assistance. Improved promotion of and user interfaces for these resources would make them far more effective.

The fundamental cost of higher education, including medical education, must also be addressed. College tuition rates are ever increasing as the demand for non-curricular opportunities puts pressure on colleges and universities to spend increasing amounts of money on non-academic topics. Therefore, the cost of these additional programs must first be addressed. Additionally, the financial responsibilities of higher education should be considered separately from the perspective of social benefit. Increasing the educational level of a population also increases the quality of life in that population. While specific estimates on the ultimate size of the economic benefits from socially funding higher education are controversial, it is broadly accepted that this effect exists. In regards to medical education specifically, both the social value of a strong healthcare system and the economic benefits of a healthier population are great.

There is evidence that indicates that the diversity of healthcare providers has an effect on the extent to which patient populations pursue care (Komaromy et al., 1996). Therefore, as an increasing portion of the United States population is comprised of minority groups, the health of our overall population relies upon improving the diversity of our healthcare providers. Reducing barriers to medical education not only reduces barriers to education as a whole but also improves the health of the population. The need for these solutions are both social and economic in nature and therefore warrant broad support.

References

1. Heckman, J. J., & Lafontaine, P. A. (2010). The American high school graduation rate: trends and levels. Rev Econ Stat, 92(2), 244–262. http://doi.org/10.1162/rest.2010.12366.THE

2. Komaromy, M., Grumbach, K., Drake, M., Vranizan, K., Lurie, N., Keane, D., & Bindman, A. B. (1996). The role of black and Hispanic physicians in providing health care for underserved populations. The New England Journal of Medicine, 334(20), 1305–10. http://doi.org/10.1056/NEJM199605163342006

3. Long, B. T., & Riley, E. (2007). Financial Aid: A Broken Bridge to College Access? Harvard Educational Review, 77(1), 39–63. http://doi.org/10.17763/haer.77.1.765h8777686r7357

4. Marmot, M., & Allen, J. J. (2014). Social determinants of health equity. American Journal of Public Health, 104(SUPPL. 4), 517–519. http://doi.org/10.2105/AJPH.2014.302200

5. Zimmerman, D. J. (2003). Peer Effects in Academic Outcomes: Evidence from a Natural Experiment. Review of Economics and Statistics, 85(1), 9–23. http://doi.org/10.1162/003465303762687677 

 

How PreMed StAR Can Work for You

There is no better time to be a premedical student! In this information age, there are a lot of amazing tools out there to assist in the premed journey. As premed students roughly a decade ago (wow, time flies!?), we had very few resources available to us. I was very grateful to have wonderful, knowledgeable friends and a great premedical advising program that made sure I stayed on track. For the past decade, I have been honored to mentor hundreds of premedical students and hear awesome stories from students all across the world. One of the biggest joys I get in life is to watch the MD/DO dream come to reality. However, the biggest heartbreak always comes when I hear stories of rejection or giving up on medical pursuits due to finances, lack of resources, misinformation and other hardships. It is true that some students weren’t in it for the right reasons but for the many students who without a doubt would have been excellent doctors, I have literally spent nights crying with them. My profession has missed out on a number of amazing people.  With this in mind, we struggled for years to find an innovative solution to give these worthy students a better shot at bringing their dreams to fruition.

So, in comes PreMed StAR! This has been an amazing journey for us over the past few years putting together something completely designed with premeds in mind. A platform that allows premedical students to shine and network while at the same time providing medical schools with the opportunity to find premeds who they would have never had the opportunity to connect with. PreMed StAR continues to grow rapidly with amazing premeds, excellent post bacs, and some of the worlds best medical schools. We listen very carefully to the students and understand that many of you are still figuring out how to best use PreMed StAR (there are a LOT of great things here) and how to maximize your chances of getting into medical school.  Our team is fortunate to have years of experience in technology focused on premedical students.  This experience has given us the opportunity to acquire unique perspectives and feedback which in turn have allowed us to develop a platform you have told us you want and need. We appreciate your feedback and are here for you.  This article is to ensure you are getting the most out of PreMed StAR.  So, here is how PreMed StAR can work for you:

Network, Network, Network:  Remember, we are all in this together. It is important to share your stories with others across the country going through the same journey. We can make each other better and stronger doctors to be. It brings me joy to see members of the PreMed StAR community at national conferences.   So many new friendships have formed online and I love to see them in person at these conferences and summer programs. PreMed StAR is a great tool to stay connected with new friends you meet at fairs and in summer programs. Also, using tools like NoteShare gives you the opportunity to share and modify each other’s notes.

Keep You from Going Broke  PreMed StAR is FREE. After paying for premedical fairs/conferences, MCAT class, MCAT registration, application fees, transcript fees, secondary fees, interviews, and acceptance deposit you can easily be in the debt $5-10K…BEFORE starting medical school. Hey, we were premeds too and know what you’re going through.  Because of that, we are doing our best to provide resources that can help you save money.  Financial strain was a huge factor behind why so many of my mentees did not apply to as many schools as they should have or did not have an opportunity to attend national conferences or premed fairs to give them a fighting chance. Applying to medical school is expensive! As we continue to grow, PreMed StAR serves as a free online recruitment fair to meet schools from across the country.  Major organizations have partnered with us because they understand our social mission and goal. With their support, we are able to provide you with awesome discounted and free resources such as MCAT courses. And stay tuned, many more wonderful deals are coming your way!

Track Your Progress  Many premeds have made the very same mistake I did many years ago; losing track of activities, awards, and times from 2 or 3 years ago. It is important to provide data as accurate as possible on your medical school application. Make sure to track these things in the PreMed StAR Portfolio. The CV generator is also a useful tool. This allows you the opportunity to always have access to this data! No need to carry a jump drive with your data on it anymore. When application season comes around you will be grateful for this.

Learn about and Communicate with Schools  We are very excited that more and more schools understand the vision and are using PreMed StAR. As we grow, more and more med schools and post-bac programs will be excited about sharing info about their programs with you and answering your questions. Schools are provided with rotating list of students that fit what they are looking for so it is important that you keep your profile accurate and up to date. The schools are watching. They have the opportunity to see you grow over the years on the site. Becoming the student of the week will give you a great opportunity to share your story and passion for medicine with the schools and the rest of the PreMed StAR community. This is also a nice addition to your resume. Schools are also impressed with those bold students who share pics of their mission trips, volunteer experiences and poster presentations. I understand this may be uncomfortable at first, but for many premeds without a perfect MCAT and GPA these experiences are the things schools are looking for. Besides, this is a lot more interesting than posts of what we ate for lunch we sometimes put up on other websites. These are the things that will make you unique and a good fit for some schools. This way, you are no longer simply a number. Here is your chance to show your personality and why medicine is for you.

Have Fun PreMed StAR is more than simply assisting you in applying to med school. It is a place to journey with one another. The path to becoming a physician does not have to be entirely stressful. Sharing fun pictures with one another, surfing through your friend’s profiles and joining in on the premed games and discussions allows you to take a study break and not feel so guilty doing so. We’ve got great feedback on popular resources like MChAT. There is a lot to come so stay tuned as our community continues to grow. We are honored to be a part in this premed journey with you and hope you can use PreMed StAR to shine.

 

 

Written by Dr. Daniel

Communication and Healthcare

Patients often complain that they are unable to spend an adequate amount of time with their healthcare provider during a medical visit; these complaints are not unfounded. According to the Medscape Physician Compensation Report 2016, most physicians spend an average of 13-16 minutes with a patient during a single visit (Peckham, 2016). Healthcare providers take an oath to care for the well-being of all patients, and I believe that this begins with each visit. It is imperative that healthcare providers offer patients respect, empathy, and attention during each visit. In my own experience, I have witnessed patients complain that their physician does not pay attention, or even provide eye contact, when speaking to them, and they feel rushed and unwelcome during their visit. Physicians may type away on their computers and direct questions at the patient in a robot-like manner. Such behaviors leave patients feeling unsatisfied.

Patients feel more comfortable when the doctor provides them with undivided attention. Open and adequate communication supports shared decision-making and feelings of respect and dignity in the patient (Paddison, et al., 2015). An adequate amount of time for communication between physician and patient allows the physician to ask more in-depth questions regarding the patient’s symptoms and conditions and to formulate a more accurate diagnosis.

I recently had the opportunity to learn first-hand the value of physician-patient communication. I attended a patient panel last month, consisting of critically ill patients classified as survivors of their conditions. The two patients included a five-year old girl, who survived a rare form of leukemia, and a traumatic-brain-injury survivor. Both patients received excellent clinical care at the University of Virginia and Duke medical systems. The mother of the leukemia survivor stated that she believes the physicians, who are fully invested in the health and well-being of their patients, are what separates great medical centers from average ones. These physicians give their undivided attention to patients at each visit. The traumatic-brain-injury patient concurred, stating that all of his doctors went the extra mile by calling to check on him and his family, as well as answering insurance questions typically answered by the administrative staff. Elite medical centers staffed with physicians, such as these, not only care for the patient but also for the family and friends, which ensures that the doctors meet the needs for information, support, and care.

Effective communication between the physician and the patient, as well as interdisciplinary collaboration, can lead to positive outcomes. Physicians, who are effective communicators, positively influence the emotional and physical health of the patient, leading to the improvement of symptom resolution, more effective pain control, functional status, and patient satisfaction (McAlinden, 2014). Interdisciplinary collaboration is another key element of effective healthcare. Just as with effective communication, the collaboration of multiple care providers in determining an appropriate treatment plan for a patient is associated with improved quality of care and safety (Ponte, et al., 2010).

Clinicians are human, just like everyone else, but the ability to remain upbeat, positive, and genuinely care for patients, and their families, sets them apart as true professionals. Communication and the willingness to devote time to the patient are essential components of effective and emphatic care. This sense of caring can make a world of difference in the life of a patient.

References

McAlinden, C. (2014). The importance of doctor-patient communication. British Journal of Hospital Medicine, 75(2), 64-65.

Paddison, C.A., Abel, G.A., Roland, M.O., Elliot, M.N., Lyratzopoulous, G., & Campbell, J.L. (2015). Drivers of overall satisfaction with primary care: Evidence from the English General Practice Patient Survey. Health Expectations, 18(5), 1081-92.

Peckham, C. (2016). Medscape physicians compensation report 2016. Retrieved from http://www.medscape.com/ features/slideshow/ compensation/2016/public/ overview#page=26.

Ponte, P.R., Gross, A.H., Milliman-Richard, Y.J., & Lacey, K. (2010). Interdisciplinary teamwork and collaboration: An essential element of a positive practice environment. Annual Review of Nursing Research, 28, 159-89.

Congratulations to Holly! Premed of the Week!

Hello. My name is Holly and I am a native New Yorker predominantly raised in the tropical paradise of Puerto Rico. Currently, I am a Medical Laboratory Scientist professionally certified by the American Society for Clinical Pathology, MLS(ASCP), working for the Johns Hopkins Hospital as a Clinical Laboratory Scientist II in Special Chemistry. I hold a Bachelor of Science degree in Microbiology and a minor in Chemistry from the InterAmerican University of Puerto Rico (UIPR). I am also a Master of Public Health candidate at George Washington University’s Milken Institute School of Public Health.

When I was in high school I swam competitively and volunteered as a cadet in the Civil Air Patrol, the auxiliary of the US Air Force. During my time as a cadet, I attended many special activities, including civic leadership academy, where I lobbied my Congressional representative for CAP funding, Hawk Mountain Ranger School and the National Flight Academy. I have approximately 30 logged flights in a glider and pre-solo wings.

As an undergraduate student, my favorite teacher was my general microbiology professor. Her love of teaching and of all things microbiology inspired me to become a professional who is passionate about her career. I chose chemistry as my minor because it was a subject that I initially struggled with. Overcoming a challenge is something I take innate pride in so it was quite rewarding to finally grasp and attain a solid understanding and foundation of the subject. Although I am an avid cat aficionado, having five fur babies of my own, my favorite undergraduate experience was dissecting a cat during anatomy lab.

When I originally enrolled in the medical technology program at UIPR, my intent was to acquire a profession that would subsidize my graduate studies through to completion and provide me the necessary skills to strengthen future applications to biomedical research institutions. It has since evolved into a passion to not only gain research experience in the biomedical sciences but for studying medicine as well. It was at that time that I realized that I wanted to know the exact biological mechanisms and pathogenesis of diseases. My research interests encompass the following: elucidating the pathogenesis of diseases that haven’t been fully characterized, such as neuroborreliosis; exploring the myriad immune mechanisms designed to ward off specific diseases; delving into the biochemical, cellular and histological changes induced by pathogens during infection; and evaluating the mechanisms employed by pathogens to evade the immune system, remain latent in tissues and organs, and avert detection by conventional diagnostic methods. Notwithstanding my evident passion for infectious disease pathology, my medical interest includes neurosurgery and/or neurology.

Aside from my passion for biomedical science, I am a voracious bibliophile and enjoy all things water sports/activities. Ironically, my favorite book is Rubin’s Pathology Clinicopathologic Foundations of Medicine. I am also a gamer with a particular affinity for the Resident Evil franchise and I strongly advocate for and support various civic and humanitarian causes such as autism inclusion, disaster relief, disability and civil rights. To alleviate stress, I enjoy taking long, leisurely walks by the harbor, singing my heart out and expanding my culinary palate by dining at cultural/ethnic restaurants.

Cross Culture: ISL Nicaragua Trip

I recently had the privilege of helping people in need by participating in a medical mission trip to Nicaragua with International Service Learning. In response to the shortage of healthcare professionals in developing countries like Nicaragua, our team of six Americans, including two physicians and one dentist-provided healthcare services to two communities. This rich learning experience provided me with insights into cultural values that differ from my own. It enabled me to not only witness, but participate in, the creation of a healing environment.

Healthcare Needs of the People of Nicaragua

Although Nicaragua is the largest of the Central American countries, it is also one of the poorest in the Western Hemisphere. Almost one-half of its residents live below the poverty line. The average per capita income is equivalent to $2,720. Up to 40% of the population has little to no access to health services, and 78% of the individuals who are employed lack health insurance (Sequeira, et al., 2011). It was not surprising to read these statistics after visiting the country, as the families we served in San Isidro and San Sebastian lived modestly, with limited healthcare access.

Residents of Nicaragua experience a number of health issues due in part to their poverty. Child malnutrition is not uncommon, as one in five children suffers from this condition. Acute respiratory illnesses, mental illness, and infectious disease are also widespread, (Sequiera, et al., 2011), as well as chronic conditions of hypertension, diabetes, and arthritis (Emmerick, et al., 2015). As a medical missionary to the country, I observed residents who suffered from respiratory illnesses, rashes, parasites, and hypertension. Given that the majority of people in the two communities I visited had virtually no access to healthcare, my trip provided me with the ability to facilitate a healing environment for those who desperately needed it.

Home Visits

Our first team assignment was to knock on the doors of residents living in the small, rural community of San Isidro and offer a free medical examination. The people of the community were kind and respectful, yet some were initially hesitant to accept our offer. Others took advantage of the opportunity, recognizing that most healthcare providers were remote and inaccessible, and that few residents possessed means of transportation. In fact, given the dates on the prescriptions bottles that people had from previous visits, it was evident that they were unable to obtain refills for medications used to treat chronic conditions.

Our team provided basic medical care to community residents, which included vital signs, triage, and prescriptions. I observed a number of common health issues in San Isidro, including respiratory illnesses, rashes, hypertension, obesity, and the occasional colicky baby. As previously mentioned, most residents were unable to fill prescriptions due to lack of access to pharmacies and healthcare providers. This was disconcerting, as many of the prescriptions I viewed were written to treat chronic conditions and needed to be taken on a consistent basis. I realized that without traveling clinics like ours, many of these people would not receive life-sustaining medications. While it was rewarding to be able to provide them with the medication, I knew that after we left, access would once again vanish for a time.

In addition to medications and medical examinations, culture is an essential aspect to a healing environment. Culture encompasses the beliefs, values, and behaviors of a people group. No one can operate outside of culture. Thus, culture has a significant impact on healthcare. In the case of this Nicaraguan community, it was evident that cultural beliefs affected their approach to health. Nicaragua is a Christian country, with a majority of its citizens active in the Catholic Church. Prayer is emphasized as a central part of life. I observed prayer in the home as part of the healing process. People would frequently offer thanks to God for receiving medications from us, or a family member would pray aloud for healing. Another cultural aspect of health is home remedies. Many homes contain jars, resting on the floor or on shelves, filled with liquids and plants. One of the physicians on our team who had previously traveled to Nicaragua explained that herbal remedies for illnesses were common and valued. I realized that it was important to respect this prevalent cultural belief, even though I had never encountered it before.

Clinics

After traveling to individual homes in San Isidro, our team temporarily settled in a small building in the town and provided a health clinic for several days. Just as with the home visits, the people who greeted us were warm and kind. They had faced much adversity in recent years. Several years back, a devastating flood leveled the town, and most residents lost all of their belongings. Not only did the flood take their material possessions, but it took away their sense of security and safety. A healing environment comprises more than just assistance for physical problems; it is important to address emotional and psychological needs as well. As the town’s residents received medical care and prescriptions, they simultaneously gained a sense of hope. Sometimes lending someone your ear, empathizing with their problems, and being truly present in the moment can promote healing.

After leaving San Isidro, we traveled to San Sebastian. At first glance, this town stood in stark contrast with the previous town in that it was a newly-built, middle class community. However, despite the appearance, the people faced health issues very similar to those in San Isidro. They had limited access to healthcare, as all clinics and healthcare providers were very far away. Over the course of three days, our team served over 60 individuals. Many suffered from respiratory illness, hypertension, and most notably, obesity. I observed that cultural issues once again played a role in our visit. For example, according to one of our physicians, the residents placed great value on receiving something–anything–when visiting a healthcare provider. If they do not receive a tangible good, they tend to believe that their care is inadequate. In the past, this issue has prevented some residents from seeking medical care at the free clinics offered by missionaries. Out of respect for this cultural belief, our team provided medications when necessary, and handed out vitamins if medication was not warranted.

In addition to medications and vitamins, education is a key element for holistic healthcare. Since obesity was a prevalent concern in both communities, education that stressed the need for a healthy diet and adequate physical activity was important. I realized very quickly that my knowledge about the types of foods preferred by Nicaraguans was deficient, and that I couldn’t effectively counsel them on how to prepare a healthy diet. Fortunately, both physicians on our team were familiar with local foods, and were able to offer insight into this issue.

One troubling issue with our ability to facilitate a healing environment was the lack of possible follow-up care. Although I believe we contributed to the health and wellness of the individuals we served, our time there was temporary. I knew that when we left, these people would again be in need of healthcare. Many town residents only receive healthcare when a traveling clinic comes to their town. This is particularly problematic for those with chronic health conditions that need regular monitoring and medication, such as those with hypertension. A healing environment is an ongoing endeavor, not one that ends when the client leaves the care provider’s presence. In order to best facilitate a continued healing environment for the people of these small Nicaraguan towns, clinics like ours must return on a regular basis.

Conclusions

My medical mission trip to Nicaragua gave me an opportunity to facilitate a healing environment within communities suffering from poverty and loss. In addition to serving these residents by providing medical examinations and prescriptions, our team offered a listening ear, a sincere heart, and a willingness to respect their cultural beliefs and practices. A healing environment is holistic, addressing physical, psychological, emotional, and spiritual needs. It was truly a privilege to create this type of environment among the people of San Isidro and San Sebastian, and one that I look forward to again.

Research: Creating Your Own Experimental Design

I am a graduate of Eastern Mennonite University’s M.A. in Biomedicine program. A part of the curriculum requires that a student design their own research project using the fundamentals of the scientific process. I have included my entire design along with a snapshot for each of the outcomes. This is something I am passionate about and plan to pursue as a future practitioner. Clinical research is extremely relevant and leads to better patient outcomes. Let me know if any of you have questions or please post a comment!

Background:

When patients experience trauma in the field, pre-hospital rapid sequence intubation (RSI) is often the course of action. Despite the fact that RSI is associated with favorable outcomes it also carries the risk of increased hypotension and bradycardia. Ketamine is a very attractive anesthetic for RSI because it does not impair breathing and is thought to increase catecholamine levels, ultimately increasing heart rate and blood pressure. Thus, if a patient demonstrates bradycardia and hypotension as a result of intubation, ketamine may be able to the raise heart rate and blood pressure closer to normal levels. But the research literature regarding the effects of ketamine on patients with varying baseline hemodynamic measurements is variable and somewhat unclear. Some studies showed the use of ketamine raises both HR and BP, while others showed the opposite. As a result, it may be difficult for first responders, ER personnel and trauma surgeons to determine who will benefit from ketamine’s hypertensive and tachycardic effects versus those who will develop hypotension and/or bradycardia. Therefore, we sought to clarify the determinants of the ketamine response in patients undergoing rapid sequence induction of anesthesia. 3 post-ketamine primary outcomes / or responses were examined: 1) development of bradycardia; 2) development of hypotension 3) development of hypertension. The predictors / risk factors for the ketamine response that we tested included: Subject age, category (trauma vs. medical), and pre-ketamine vital signs (HR, SBP, DBP, MAP, and SI). We also studied the effect of ketamine dose on the response.

We hypothesized the following:

Hypothesis 1: Vital signs prior to administration of ketamine (i.e. BP and HR) predict the development of hypotension and/or bradycardia in patients undergoing RSI;

Hypothesis 2: The relationship between baseline vital signs and the development of hypotension, hypertension, and bradycardia is moderated by the dose of ketamine given.

Methods:

Data was obtained from PHI Air medical group (a Helicopter emergency medical service that safely transfers trauma and emergency patients across the nation). A total of 1516 subjects were enrolled, out of which 730 were medical patients and 786 were trauma patients. Study subjects received ketamine doses that were categorized into four dose groups: < 100 mg/ml, 101-150 mg/ml, 151-200 mg/ml, and >200 mg/ml. Data regarding subject demographics, patient category (medical vs. trauma), drug doses and hemodynamic measures were obtained and used in the analysis.

Results:

1) Predictors of bradycardia:

• Older age was a predictor of post-ketamine bradycardia (Patients who developed bradycardia were on average 13 years older than those who didn’t).

• Medical patients were more likely to develop bradycardia than trauma patients.

• Patients who developed bradycardia had lower baseline pre-ketamine vitals signs (SBP, DBP, MAP, HR) and higher Baseline SIs.

• Higher doses of ketamine were also associated with bradycardia.

2) Predictors of hypotension:

• Older age was a predictor of post-ketamine hypotension (those who developed hypotension were on average 10 years older than those who didn’t)

• Patients who developed hypotension were more likely to be medical patients.

• Lower pre-ketamine (baseline) SBP, DBP, MAP, and SI were associated with development of hypotension, while higher HRs at baseline were associated with the development of hypotension.

3) Predictors of hypertension:

• Younger age was associated with development of hypertension. (were on average 4 years younger)

• Trauma patients were more likely to develop hypertension than medical patients.

• Higher baseline SBP, DBP, MAP, and shock indices were associated with the development of post-ketamine hypertension.

Note: Higher doses of ketamine were significantly associated with bradycardia and hypertension.

Conclusion:

We found that older age, lower baseline vitals, and being a medical patient vs. a trauma patient is more likely to predict the development of bradycardia and/ or hypotension following the administration of ketamine during RSI. On the other hand, younger subjects, higher baseline vitals and trauma patients were more likely to develop hypertension following ketamine administration. It also seemed that higher doses of ketamine were associated with developing bradycardia and hypotension / or hypertension. Knowing how baseline subject characteristics including vitals signs effect the response to ketamine administration will help first responders and trauma/ emergency care personnel better identify who may benefit from the administration of ketamine versus those who may potentially develop adverse events such as hypotension and bradycardia. This will enable healthcare professionals to improve upon current mortality and morbidity rates associated with RSI.

Post-Bac Journey: Success through the lens of a non-traditional student

  Success in the future is attainable, no matter what your academic past may look like. I am a second year graduate student at Eastern Mennonite University (EMU) in the Master of Arts (MA) in Biomedicine program. Despite my own academic highs and lows, my passion for pursuing a career in medicine and global health has not faded. It has kept me grounded through times of uncertainty. When trying to prove yourself beyond your academic history, it can be difficult to find a program that fosters personal growth in work and study habits, as well as academic achievement. I am fortunate to have found the “right fit” with EMU’s MA in Biomedicine program. Regardless of a student’s background, I believe that those who have the desire to excel and the tenacity to pursue their goals will benefit from the small, collaborative environment found within this program.

While many post-bac programs in the biomedical sciences exist nationwide, it is vital to choose a program that works with you, as a student, to help achieve your academic goals; a program that holds students to high academic standards while also providing opportunities to flourish in the basic sciences through the support of faculty and staff. At EMU, I have been able to tailor my curriculum to incorporate my own specific interests and needs. Additionally, faculty and staff welcome student feedback about the program, which greatly enhances the quality of instruction and education that my peers and I receive. Excellent instruction demands academic excellence from the students as well. However, the faculty and staff provide the necessary support in order for students to meet, and even exceed, those expectations.

In addition to academic rigor and faculty/staff support, there are other important qualities to consider when choosing a post-bac medical program. Things to look for are a small student-to-faculty ratio, a program that emphasizes collaborative approaches to teaching/learning, passionate professors who give priority to teaching, and a program with a thesis/research component. While it may be rare to find all of these qualities in a single program, I am fortunate to have found them within EMU’s MA in Biomedicine program.

A multidisciplinary approach to healthcare focuses on the mind, body, and soul. I have had the opportunity to apply this integrated perspective to health in a variety of leadership roles, including serving as an ambassador for a healthcare organization, shadowing and engaging with patients through my practicum experience, and performing research for my thesis. The program also incorporates a cross-cultural component, which enables students to gain exposure to international health and volunteer opportunities abroad. I chose to participate in ISL’s Global Health program in Nicaragua, allowing me to volunteer and serve medically underserved populations. All of these opportunities have enriched my academic experience, teaching me things that cannot be learned in a classroom.

As you consider your own academic future, I leave you with one final consideration: if you have the will and the desire to succeed, don’t sell yourself short! It does not matter how old you are or what circumstances you face. “You can’t go back and make a new start, but you can start right now and make a brand new ending” (Sherman, 1982, p.45). EMU can help shape your new future by instilling the confidence that is necessary to excel and attain your goals.

The Art of Believing

The word, “believe”, is magical and powerful.  Say it with confidence and internalize the word. In psychology, belief is defined as what you deem to be true. With the exception of being delusional, believing in something– in your abilities, in your actions, in your statements, and in your stance– changes your perspective positively.

Believing means internalizing that the impossible is possible. Imagine countless stories of patients who have been told that they have less than two months to live or that they would never be able to speak fluently after a procedure. Such patients are those who refuse to let those predicted uncertainties suppress their strong will of belief. Their positive outcomes and mind-boggling stories are, in part, as a result of believing.

Believing means being in the dark and choosing to be the light. We have certainly all being in a negative environment, surrounded by pessimistic friends, or placed in a glass ceiling house (this is your limit, remain within it). These situations hamper our ability to think clearly, create self-doubt, reduce our vision and productivity and most importantly, stomps on our ability to believe. Simply, step back, take a deep breath, say with affirmation that this is what you want, this is what you will do, and this is the impact you plan to make. Then, insert I believe in all of those statements and internalize them. I guarantee you that you will become unstoppable. Sometimes, it could seem like the negativities are pushing you further down the scale. But with constant renewal of your beliefs in your abilities and in your goals, you will eventually create your path, illuminated with light and filled with like-minded positive individuals who are willing to help you on your journey.

Believing means elimination of doubts and uncertainties. This is a bit difficult because there are healthy doubts protects us and ensures good decision-making. However, when doubts become prevalent, it leads to learned helplessness and low self-efficacy. This impedes one’s growth mentally and emotionally. The fact that you doubt passing the MCAT or getting accepted into medical school does not mean that you should BELIEVE that you will not pass the MCAT or get accepted into medical school. See the difference? The gap that lies between those two statements is your volition, your tenacity, your work ethic, your dedication, and your internalization of your goals. I second guess myself every single time. I remember telling my mentor that I doubt that I am going to pass this physics class and he replied I believe you are going to pass it. That single word resonated with me and I started putting in more effort to realize his statement. As they say, “you want it, GO for it.” Discard every itty-bitty doubt that does not align with what you believe you can do and Enrich your mind with thoughts that sprout your beliefs. You always have to believe because that is the one thing that would keep you on your journey to reach your goals and that would provide you with the strength to realize your dreams.

I believe that we would all get that great GPA, attain that high score on the MCAT, excel at that medical school interview, receive those medical school acceptance letters, get that residency of our choice, and become the best and exemplary physicians we deserve to be. It all starts with believing….

Land the Plane 

The MCAT can be a touchy subject. While it cannot be taken too lightly, it should not be looked at as a burden. The pre-medical culture has turned the MCAT into this stress inducing word- “he who should not be named” so to speak. Being in the midst of preparing for it now, has made me reorient the way in which I think about things. While I recommend this mental practice to all those preparing for the MCAT, I think it can also be applied to many areas of life.

First, appreciate the position you are in. You have made it this far in your pre-med journey- not all people can say that. You have been given the opportunity to pursue your passion of medicine, and have kept with it this far! Congrats! Think of all of the classes you’ve taken, all of the opportunities you’ve had to learn, and the breadth and depth of the knowledge you’ve gained. That is an accomplishment in itself. When you take the MCAT, or should I say prepare for the MCAT, all of this information comes together. It’s given me the unique perspective to look at how the things I’ve learned in physics apply to concepts learned in physiology- the two really cannot go without one another. The education you’ve received thus far is a gift. Acknowledge that. It will make you grateful for all that you’ve received. 

Secondly, allow that ceiling you’ve built, that limitation, you’ve constructed to break. By this I mean putting labels and constraints on yourself. Telling yourself that there is no possible way you can get [insert MCAT score here]. By telling yourself that, you are subconsciously ruling that option out. Now, I’d like to counter this to say that you cannot expect to study a week ahead of the exam and get a perfect MCAT score. The chances of that are slim. You must be realistic and attribute a good deal of preparation into the MCAT. But do so with a happy heart. Stay hopeful and know that you are going to do great! If you let this spirit of hope flow, it automatically puts you in a better disposition during your preparation. And, what is the harm of staying positive? Opportunity looks to take hold of positivity. 

Lastly, stay in the present. I am notorious for catching myself outside of this one. While reading my prep books, I will often find my mind wandering to the worries of if I will get accepted into medical school or not. I like to call this concept “tunneling.” So for a brief second let me show you what I mean by giving you my train of thought during “tunneling.” Here is the context: *I am reading my physiology book about how ADH affects the renal system* “Ok, so the ADH release causes water reabsorption, is released by the posterior pituitary, then…. hmm.. I wonder if this will be tested on the MCAT. Am I spending my time right studying this? I sort of already know it, but do I know it well enough? What if I don’t score well? This has been my life long dream and all that is separating me from med school is this test. Jeez. No pressure or anything…. Do I have a back up plan? What would I even do with my life…?” Ok, STOP. Really quick, let’s examine my tunneling. I went from about 0 to 1000 in the period of about six sentences. I went from ADH to questioning my life path. HALT. And did you notice the self-doubt? If there is one tip I can give you during this process it is that self doubt will not serve you well. Let’s imagine for a second that you are 5 years older than you are now (already in your residency) and your younger sibling is preparing for the MCAT. In a frenzy, they FaceTime you and you can hear and see the distress they have on their face. They’ve just experienced tunneling. Recalling your past journey through the pre-med process, you tell them that it will all be alright. Everything will workout. Calm your mind, and believe in what you CAN do. Not what you CANNOT do. Would you give your sibling poor advice? “Ya know, you might as well give up now. You probably can’t do it…” NO! Because you know that’s not true, they have every capability of doing it. They just have to keep going. Just as you wouldn’t give your sibling bad advice, don’t give yourself bad advice. Know you’re doing your best and keep pressing forward. The positivity will only push you to go further. Negativity puts roadblocks in the pathway to success.

I would like to end this with one example of how peace of the mind can truly lead to success. His name is Captain Chesley “Sully” Sullenberger. If you’ve never heard of him before, search his name. He also has a book, website, and movie devoted to him. To put it shortly, he landed a failing plane on the Hudson River, saving 155 people. There were very few injuries and no deaths. As both engines began to fail from flying through a flock of birds, he decided that the best plan was to land in the river. “Prepare for impact,” he said. Both the crew and passengers remained calm. He has since been recognized as a national hero. His calm, determined mind allowed him to save 155 people. That in itself is testimony to the power of a calm mind. And is this not symbolic of what you will be doing one day? Whether you become a high-pressure ER doc, or a family physician, keeping a calm mind will benefit you in all regards.

So as you continue through this pre-medical journey, step back for a minute. See how far you’ve come. Know that the present moment is the only moment you have- so keep pressing on. Keep doing your thing. Trust the journey you are on, the path that God has for your life. Keep your mind calm because you can and will land this plane.

~~~~~~~~~~~~~~~~~~~~

155 people safe and sound.

 

Here is the man himself, Captain Sully. If I were ever to be able to have lunch with one person, it would be him. 

More Than a Premed! Get Outside The Box!

I HATE the Box!  I absolutely HATE it!

You know…the Box! That thing everyone tries to put you inside. You can’t do this, you can’t do that. You’re a pre-medical student, you’re supposed to study, become a doctor, and do nothing else. Yep, that’s the entire extent of your life, premed to medical student, medical student to doctor, then you’re done! That makes me sick!

Two years ago, I was invited to present at a national conference and was excited because I’d meet some leaders who were doing things that interested me. Towards the end of the conference, I sat down with a few relatively prestigious doctors and took the opportunity to pick their brains. After all, they had been doing this a lot longer than I had so I was sure they’d provide great insight on my endeavors. After explaining to them how I wanted to give everything I had to help develop premedical students and provide resources for them to matriculate into medical school via platforms such as PreMed StAR, I was laughed at. “Dale,” I was told, “You’re a doctor! That’s your brand, we’re not business people. Master your craft in medicine and stick to it.” Do you think I took that advice? No!

Sometime after that, I was walking the hospital hallways with a senior physician. It had been a long day and I told him I still had a long night ahead because we had some company tasks to finish. “You have a business,” he said sarcastically. “Yes I do,” I didn’t think too much of it. “For me, it’s always been more about giving everything I can to develop premeds than a business. It’s my calling and the right thing to do.” He looked at me, then walked away laughing.

I’ve been told no, laughed at, and ignored too many times to remember. But the whole way through, I’ve followed my calling faithfully. Why take the torture? First and foremost, because others benefit from the work, and that’s more than worth the beatdown. Second, because I hate the ‘Box’ and nobody’s going to put me in it. When people tell you that you can’t do something, always remember that means they can’t do it. One of my favorite quotes is, “The man who says it cannot be done should not stand in the way of the man who is doing it.” Another of my favorites is, “My mother said to me, if you are a soldier, you will become a general. If you are a monk, you will become the Pope.’ Instead, I was a painter, and became Picasso.” Just be you! Nobody else; just you!

As a premedical student, you are MORE than a premed. You don’t have to sit in that dreadful box. Your God given gifts are to be used for the betterment of society, not to be hoarded for waste. I want you to forget what everybody else has said you can’t do, and instead remember that I am telling you YES, you can do it! Why not? If you don’t, someone else will.

So don’t think outside of the box. Get outside of the box! If I can do it, so can you!

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