The StethoSCOOP

Cornel l Universi ty Pre-M edical Society Spr ing 2015

Ed i tor -i n -Ch i ef : Rachel Chuang

Con ten t Ed i tor s: Chr ist ine M athew, Zachary Kassir, Ak i la Venkataram any, Aleena Jafr i

Layou t Ed i tor : Cour tney Stevens

W r i ter s: Olivia Chukwum a, Alex Gordon, Aleena Jafr i , Anand Jayakum ar, H enry Kanengiser, Zachary Kassir, Aaron Lee, Chr ist ine M athew, Devon M cM ahon, Al l ison Pei, Antoine Saint-Victor, Chen Shen, Jul ie Urgi les, Ak i la Venkataram any

The StethoSCOOP

Analysis of Anti-Vaccination M edicines 4Is Pay-for-Performance Doing M ore H arm than Good? 6It Takes Three: How Three-Parent Babies Could Be the Answer to M itochondrial Disease 8The Gap Year Advantage: Exploring Graduate Education 10PCSK9 Inhibitors and the Future of H igh Cholesterol Treatment 12Out With the N ew, In With the Dirt 14Global Health Opportunities in M edical School 16

A Conversation with N atalie Krumdieck, Weill Cornell M edical College StudentPatient Autonomy in Organ Wait List Decisions 18The Importance of Technology in M edicine Today 21A N ew Epidemic: America's Over-Prescription Addiction 22Ethni-cine 24The Reality of "M cDreamy" 26

M odern Television Portrayal of M edicine and its Influences on Health-Related Public Perception

Fetal Keepsake Imaging: The Controversial Commercialization of the M edical U ltrasound 28Revolutionizing Primary Healthcare Delivery 30References 32

Table of Contents

Analysis of Anti-Vaccination Messages

Take a moment to think about your childhood visits to your pediatrician. Considering the medical requirements for Cornell students, most of you probably remember getting a few shots at that time. Regardless of whether you liked getting injections or not, you or your parents made the decision to trust this preventative procedure. However, not all parents in the U.S. share this viewpoint, as is evident from the 2015 measles outbreak that started in Disney Land and mainly affected unvaccinated children. M easles cases usually total less than 100 people annually in the US, but around 150 cases have been linked to an origination from Disney within about three months. Although this related specifically to the M M R vaccine, it represents a broader struggle influenced by incorrect rumors and personal opinions.

Let?s start with some historical data. Vaccines were introduced as a way to strengthen a person?s immune system against certain pathogens so that real infections could be prematurely fought off. As statistics from the CDC show, this effort has been extremely effective: smallpox has been globally eradicated, diphtheria and polio are mostly eradicated from many countries, and hepatitis cases have been reduced by about 85%. These stats simply compare pre- and post-

vaccine eras, so it is obvious that other things like sanitation and urban infrastructure also helped in these efforts.

What is the point of continuing immunizations for semi-eradicated diseases then? At face value, stopping some extraneous injections into our bodies sounds better. The reality is that continued vaccinations promote herd immunity, the idea that having a significant proportion of the population vaccinated prevents the spread of an infection. Stopping this spread helps protect those who cannot be vaccinated because of their age, allergies, or other immunocompromised conditions. In other words, vaccines against some rare infections benefit the general public health over an individual.

As was briefly mentioned before, not everyone supports the individual or group benefits of this practice. The 2013 N ational Immunization Survey shows that 8% of infants in the M M R age range did not receive the vaccine, with 1/12 receiving it late. The majority of this dissent originates from a famous study by Andrew Wakefield in 1998. Using a group study of 12 children, Dr. Wakefield suggested that the M M R vaccine specifically was correlated with an increased incidence of autism. This incited the

By Anand Jayakumar

4

controversy and the two sides of the vaccination debate, and since then, the anti-vaccine movement has only grown, even though the study was retracted due to possible data tampering, Dr. Wakefield lost his medical license, and many other larger studies showed no such links. This has led to the vast amount of misinformation and anecdotal advice that is around today.

A 2012 study of common internet/blog justifications on this subject shows great examples of how this information drives personal beliefs. This logic can be categorized into a general misunderstanding of what science can prove, being anti ?Big Pharma,? or believing evidence that only affirms their thoughts. As an outsider to both the doctor and patient sides of this issue, I can see how neither side can easily convince the other group of their opinion. Doctors today make diagnoses supported by accepted scientific studies and use drugs or medical technology for the treatment. If a patient is morally opposed to vaccine companies, does not believe the studies that the doctor cites, and wants complete proof of safety (which science can never prove), no progress can be made. Dr. Dasgupta, a health humanities professor at Columbia University, echoes this thought by stating that science alone can no longer make people follow recommendations in an age of independent patients who can do their own research.

So what are pediatricians to do, and what are they doing, in response to such advocates? Although there does not seem to be any one demographic division on this issue, there have to be some people who are more undecided on vaccinations and others with entrenched beliefs in either direction. Those who are radically set on no vaccinations will likely have some religious basis or associate so strongly with the movement that any evidence against them is proof of the ?establishment? or ?Big Pharma.? Thus, convincing those undecided parents might be the most effective option. The American Academy of Pediatrics? recommendation in such instances is to be honest throughout the process. Admitting that being unvaccinated is less problematic in an already immunized population, but that vaccines will benefit the child despite any rare risks is one way to show this honesty. Educating parents on the herd immunity factors mentioned previously is also advised. Learning that their decision might make them ?free riders? who unintentionally make an immunocompromised person sick is a good motivator for parents. In the end, however, physicians only have as much influence as their patient relationship allows. If parents do decide to not vaccinate, doctors can only respect their wishes and continue or refuse to keep them as a patient.

Personally, I believe that this communication between medical professionals and parents is the only realistic way to convince skeptics of vaccines. We are living in an internet age where people can always find some blog or health site that supports their preconceived notions. These anecdotal stories of an allergic reaction or an incidence of autism seem to connect more with people than the statistics that their doctors offer. Unless there is some dramatic change of vaccine policies in the future, this fact will unfortunately remain unchanged.

Is Pay-for-Performance Doing More

By Chen Shen

Isn?t it obvious that we should pay for quality rather than quantity? In the US, the fee-for-service system led to increased costs by rewarding providers for the volume and complexity of services and not for higher quality care. M anaged care arrangements reduced excessive or unnecessary care by paying providers through lump sums per patient to cover a given set of services but compromised quality and constrained patients on their access to providers of their choice. Because of the deficiencies in the quality of US healthcare, pay-for-performance emerged as a way to have providers focus on quality, while reducing costs. This program provides a bonus to providers for meeting certain quality or performance measures and may also reward improvement in performance over time or impose financial penalties for failure to achieve specified goals or cost savings. The Affordable Care Act even includes programs such as M edicare?s Hospital Readmissions Reduction Program, Hospital Value-Based Purchasing Program, M edicare Physician Quality Reporting System, and M edicare Advantage plan bonuses, which all aim to incentivize providers to improve quality through bonuses and penalties.

The concept that hard work pays off is an integral

of pay-for-performance. A pay-for-performance program can be a powerful tool to focus healthcare providers? actions to improve care and ensure patient satisfaction and well-being. This program can highlight key medical priorities. In addition, pay-for-performance can help hospitals attract and retain physicians with a passion for providing effective care in efficient manners. A healthcare provider?s drive to help others and make services affordable could, thus, align with the hospital?s interests in meeting certain quality and performance measures and become a positive motivating factor in daily work. Since this program is also tied to performance, it can also act as an effective cost control mechanism to mitigate financial risk by only paying for high quality and necessary care. Implementing pay-for-performance could have several potential benefits for hospitals, healthcare providers, and patients. In reality, however, pay-for-performance has shown mixed results.

Sometimes the reason for disappointing results is that providers do not change the way they practice medicine, or that outcomes do not improve even when they do change. A study published Fall of 2013 found that paying doctors $200 more per patient for achieving certain performance criteria

Harm than Good?

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resulted in improved care.1 Good blood pressure control increased more in clinics with pay-for-performance than prescriptions and 38% without proper hypertensive care. This study was only for one year, so it is not clear what will happen in the long term.

In addition, some hospitals do not have high incentives. A study by Dr. Rachel M . Werner at the Philadelphia Veterans Affairs M edical Center calculated that payments to almost two-thirds of acute care hospitals would be altered by only a fraction of 1%.2 This low of an incentive might not substantially alter the quality of hospital care. Werner also studied the effects of government partnership with Premier Inc., a national hospital system, and found that while hospitals in a pay-for-performance project initially outpaced those not in the project, all those differences were gone in five years.3 Changing physician behavior is difficult, even with incentives.

Studies showing failure to change physician behavior also show little change in performance. A study by Dr. Ashish K. Jha of H arvard School of Public Health revealed almost no improvement in 30-day mortality between hospitals participating in the Premier pay-for-performance program and hospitals not part of the intervention.4 This study covered millions of patients in over 3000 hospitals in 12 states over a six-year period. M oreover, they found that conditions explicitly linked to incentives showed no signs of improvements compared with conditions without financial incentives.

Even refusing to pay for bad outcomes does not appear to improve hospital care. Dr. Grace M . Lee from the Center for Child Health Care Studies looked at how the 2008 M edicare policy to refuse payment for certain hospital-acquired conditions affected the rates of infections and found almost no measurable effect.5

It is difficult to measure quality of life and

improvements in functioning, and the metrics chosen by M edicare for their programs included measurements that were outside of the control of the providers. Using factors such as income, housing, and education can affect the metrics more than what doctors and hospitals are able to do. A study by Dr. Alyna T. Chien, a specialist in General Pediatrics at Boston Children?s Hospital, found that medical groups caring for patients in lower- income areas of California received lower pay-for-performance scores than others.6 These reasons were attributed to serving patients with language barriers and limited access to transportation, child care, and other resources. Hospitals that serve a large number of low-income patients may be hit especially hard from penalties for having overly high ratios of avoidable hospital readmissions.

Studies in other fields show that offering extrinsic rewards can undermine intrinsic motivations.7 There is fear that rewarding healthcare providers with financial incentives for achieving particular goals could backfire and damage the desire to help people. Thoughtful monitoring and evaluation to identify design elements that positively affect outcomes should help structure pay-for-performance as an emerging reform tool. Evaluation of these programs should also take into account variations in healthcare markets in an attempt to isolate the effects of pay-for-performance from other factors as to not declare successes and failures prematurely. These evaluations will also need to be conducted over sufficiently long periods to identify any unintended consequences, especially effects on safety-net providers who serve poorer and disadvantaged populations. M any healthcare providers and policy makers agree on the need to focus on quality improvement. It would be a tragedy if pay-for-performance did more harm than good from unintended consequences and a misaligned incentive system.

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It Takes Three:How Three-Parent Babies Could Be the Answer

By Alex Gordon

to Mitochondrial Disease

M edical innovations are often controversial, but rarely has a new technique created as much controversy as ?three-parent babies.? This is the name given to a new procedure intended to prevent mitochondrial disease, a category of illnesses in which defective proteins prevent proper mitochondrial function. M itochondrial disease often impedes growth and decreases muscular strength and control. Because mitochondrial DN A is directly passed down from a mother to her children, mitochondrial disease is highly inheritable. It seems the only way to prevent mitochondrial disease is to use mitochondria from a healthy donor, accomplished by replacing the nucleus of a donor egg or embryo with the nucleus from the biological mother?s egg or embryo.

In February of 2015, the British House of Commons voted 382 to 128 in favor of three- parent babies. Though the House of Lords has yet to vote on this, the United K ingdom is expected to become the first nation to legalize the technique. This could pave the way for other medically-advanced countries to implement the technique. The United M itochondrial Disease Foundation estimates that in the United States, between 1000 and 4000 babies are born with a mitochondrial disease every year. Yet while legalizing three parent babies could drastically reduce this figure, many people are against adopting the technique.

Some criticism of the new technique could be due to the partial misunderstanding that the genes of all three parents determine the child?s traits. While the name of the procedure does seem to imply this, the role of the donor parent is merely to provide working mitochondria. In theory, the donor?s genes would not affect the child?s visible traits like hair color or height. To the unknowing observer, a three-parent baby should appear as any other baby of two parents.

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Similar to the case of stem cell research, much of the dissent against three-parent babies results from the ethical dilemma of genetically modifying humans. Some believe, often for religious reasons, that intervening in a person?s genetic makeup is morally wrong. There is no definitive answer of whether the procedure is ethically sound, making this a moral gray area.

The most prominent counterargument to the immorality of three-parent babies is that there may be negative ramifications of allowing babies to be born with a preventable disease. This sentiment is clearly present in British Prime M inister David Cameron?s statement that ?we?re not playing God here, we?re just making sure that two parents who want a healthy baby can have one.? Still, this argument does not address all of the criticisms of three-parent babies.

A corollary to this critique is that the three-parent baby technique opens the door to other forms of genetic modification. Critics may fear that legalizing the technique will set a precedent for selecting traits in babies. It is possible that the use of three-parent babies could lead to genetic intervention to treat certain diseases. The problem arises when this devolves into the selection of traits for reasons other than health, such as appearance. For example, a couple could decide to give their child a genetically improbable phenotype like a desirable eye color. However, there is a fundamental difference between the three-parent baby technique and true genetic modification: the three parent-baby technique does not actually change the genes

from the biological parents, so there is no effect on non-mitochondrial traits. Though the legalization of three-parent babies may establish some precedent for genetic modification, it is not completely accurate to draw parallels between both techniques.

Other critics question the practicality of the procedure itself, claiming that it would be impossible to determine if the procedure is necessary until after the child is born. This concern is valid for many people, but it is far from universally applicable. For example, prospective parents with family histories of mitochondrial disease might consider having a three-parent baby. Parents who have already had a child with a mitochondrial disease would know that their future children may also be at risk. Additionally, patients of mitochondrial disease may live to reproductive age; if a female patient wanted to have a child, it would be very possible for the child to inherit the same defect. Looking at the health of the prospective parents and their relatives could determine the potential necessity of the three-parent baby procedure.

There is no clear answer of whether the creation of three-parent babies is perfectly moral, but it is a solution to preventing mitochondrial disease. The current effects of mitochondrial disease are undeniable, and clearly some form of prevention is needed. If the British House of Lords chooses to weigh the health of its future citizens over the questionable morality of three-parent babies, mitochondrial disease prevention could become a reality in the United K ingdom, encouraging similar changes in other nations.

The Gap Year Advantage:

By Christine Mathew

Today, an increasing number of premedical students are considering the idea of a gap year or two before applying to medical school. N aturally, questions arise as to how this time should be spent. Volunteer in an underserved community? Acquire work experience? Enjoy a rejuvenating recess prior to the demanding journey of earning an M D? Another option to explore is graduate education.

For some, the amount of time required to kickstart a career in medicine seems sufficiently overwhelming to dismiss the idea of additional schooling altogether. Yet, graduate school appeals to aspiring physicians for a variety of reasons. Some students are interested in improving their academic profile. Whether it be a difficult adjustment to college or extenuating circumstances, it is not uncommon for premedical students to earn subpar grades at some point in their college career. Even after great improvements over time, they may not feel confident enough to apply just yet. Others wish to pursue another passion, such as public health, before diving into medical school. N ot only is such a degree useful on its own, but it would also supplement a career in medicine. It might also strengthen an otherwise marginal application to medical school.

There are different categories of graduate and postbaccalaureate programs, each serving a different purpose. The Association of American M edical Colleges (AAM C) lists most, if not all available programs on its website. They are primarily categorized as either career changers or academic

record enhancers, with certain programs geared toward underrepresented minorities or economically disadvantaged students. Career changers are targeted toward those students who want to switch careers, as the name implies. It allows them to take course requirements for medical school that they were unable to complete as a part of their undergraduate curriculum. On the other hand, students enrolled in academic record enhancers have already completed their admissions requirements, but wish to become more competitive applicants through advanced coursework and additional experience.

Among the various academic record enhancers, a particularly valuable subset to discuss is the Special M aster's Program (SM P). In most of these programs, students take science courses at the graduate level. Since these programs are comprised of graduate level courses, they do not influence undergraduate GPA. This is relevant for those who want to demonstrate a strong upward trend in their BCPM GPA.

However, in select programs, students may take classes alongside medical students, allowing medical schools to evaluate their real time academic performance, which they would otherwise have to infer from undergraduate coursework. This is the best kind of program to apply to when pursuing graduate education before medical school, especially if the primary intention is to boost academic profile. Because these SM P students are taking classes with medical students, there is relatively little question about the

Exploring Graduate Education

10

quality and rigor of coursework, and therefore the credibility of the program itself. Additionally, it provides an opportunity to show admissions committees whether students are comparable to those who have already been accepted to medical school.

It is important to understand that enrolling in such a program is simultaneously risky as it does not guarantee admission to medical school. Students who perform poorly after voluntarily participating may solidify the notion that they are not ready for the challenges that await them in medical school. Leaving college with a strong upward trend in GPA is a good indicator that students are prepared to handle the heavier load of an SM P. On the other hand, excelling in the program may greatly bolster chances of acceptance. For example, The M aster of Science in M edical Sciences (M AM S) program at Boston University boasts a 70% admission rate to US M edical Schools. In a similar program, the Special M aster's Program in Physiology at Georgetown University, around 85% of students were accepted to a medical school within two years of completion.

Alternatively, a M asters in Public Health (M PH) is a great option for those who are interested in public health. It builds leadership skills that would undoubtedly enhance a career in medicine, as clinicians carry an obligation to advocate and understand public health policy and its implications for patients. In fact, some medical students pursue an M PH after receiving their M D or even during a gap year in medical school. This is definitely a degree that should be sought out of pure interest, rather than as a gateway

to medical school. M PH programs entail broad coursework to expose students to public health issues, rather than advanced science courses.

Understandably, many students pass up these opportunities due to financial constraints. Graduate schools generally do not provide much financial aid in terms of scholarships and grants. Chances of having to take out a loan are high, which is undesirable for students wanting to eventually matriculate into medical school, an expensive pursuit in itself. One suggestion is to look into graduate programs at public institutions within your state of residence, which offer discounted tuition rates to residents.

A variety of situations might provoke interest in graduate studies during the gap year. It is critical to evaluate the motivations behind pursuing another degree. While it is appropriate to take this step with the eventual goal of medical school in some situations, it is inappropriate in others. If one is committed to medicine, but has doubts about whether one?s undergraduate record will make the cut, SM Ps may be a saving grace. On the other hand, pursuing an M PH without true interest in public health is impractical. There are more unique and productive ways to utilize gap year time. An important part of choosing the right program is connecting and networking with students who have been in a similar position. One of the invaluable resources available at Cornell is a vast alumni network ready to provide insight based on shared experiences and goals. U ltimately, it is up to students to decide whether the program in question suits their needs.

PCSK9 Inhibitors

By Zachary Kassir

And the Future of High Cholesterol Treatment

It is a commonly known fact that cardiovascular disease is the number one killer of both men and women in the United States. According to the CDC, in 2014 over 610,000 people died of CVD, one quarter of all American deaths. In that same year, 735,000 Americans suffered a heart attack, with 75% being first timers.

Indeed, heart related illness is an issue of overwhelming magnitude in this day and age, made so by the prevalence of its many causes in our society. Smoking, obesity, and high blood pressure are renowned critical risk factors for cardiovascular illness, and it?s no coincidence that the United States leads the world in occurrences of the last two. However, none of these factors come close to rivaling the contribution of high cholesterol to the CVD epidemic. According the American Heart Association, one in every three American adults suffers from high cholesterol with only 33% having the problem ?under control.?

N eedless to say, high cholesterol levels do not bode well for one?s health. LDLs (low density lipoprotein) function as the major carriers of cholesterol to cells in the human body. When levels of cholesterol become too great, LDLs are synthesized without the necessary receptors to be absorbed by cells, and in turn are trapped in the walls of blood vessels. This in turn causes inflammation of the vessel walls and a narrowing of the passageways, severely limiting blood supply to other parts of the body.

M ost doctors agree that preventative measures like proper diet and exercise are the surest ways to protect one?s self against the consequences of high cholesterol. However,

for the unfortunate millions that suffer from the condition already, a strict treatment plan must be followed. Today, the most commonly employed treatment for high cholesterol is a class of drugs known as statins. Biologically, statins function as inhibitors of HMG- CoA reductase, a liver enzyme that produces approximately 70% of total cholesterol in the body.

That statins work has been a widely accepted fact since the late 80s when the FDA first approved them as effective anti-cholesterol medication. As a standard of reference, a six month course of Lipitor has been shown, on average, to decrease blood cholesterol levels by up to 15%. Today, they are the number one selling pharmaceutical in history with one in every four Americans age forty-five and older being prescribed the medication. Lipitor, Crestor, and Lescol are just a few of the most popular brand name stains on the market, with sales of these three alone totaling over twenty billion dollars in 2014.

Unfortunately, for a great many people with high cholesterol, statins are either insufficient or are simply not an option for treatment. For some, cholesterol levels are so high that not even the inhibitory effects of the drug can curb the condition. For others, side effects that include muscle inflammation, liver damage, and increased risk of diabetes prove intolerable. And for the millions that do take statins, the sheer restriction of having to take a pill at least once a day for periods of time lasting up to decades can be a major inconvenience. In 2003, a crucial first step in finding an alternative to statins was taken. A team of French researchers found that LDL levels appeared to be higher in people who

PCSK9 Inhibitors

By Zachary Kassir

PCSK9 Inhibitors

By Zachary Kassir

It is a commonly known fact that cardiovascular disease is the number one killer of both men and women in the United States. According to the CDC, in 2014 over 610,000 people died of CVD, accounting for one quarter of all American deaths. In that same year, 735,000 Americans suffered a heart attack, of which 75% were first timers.

Indeed, heart-related illness is an issue of overwhelming magnitude in this day and age, made so by the prevalence of its many causes in our society. Smoking, obesity, and high blood pressure are renowned critical risk factors for cardiovascular illness, and it is no coincidence that the United States leads the world in occurrences of the last two. However, perhaps the greatest contributions to the CVD epidemic are those made by high cholesterol. According to the American Heart Association, one in every three American adults suffers from high cholesterol with only 33% having the problem ?under control.?

N eedless to say, high cholesterol levels do not bode well for one?s health. LDLs (low density lipoprotein) function as the major carriers of cholesterol to cells in the human body. When levels of cholesterol become too great, LDLs can become trapped in the walls of blood vessels. This results in inflammation of the vessel walls and a narrowing of the passageways, severely limiting blood supply to other parts of the body.

M ost doctors agree that preventative measures like proper diet and exercise are the surest ways to protect one?s self against the consequences of high cholesterol. However, for the unfortunate millions that suffer from the condition

already, a strict treatment plan must be followed. Today, the most commonly employed treatment for high cholesterol is a class of drugs known as statins. Biologically, statins function as inhibitors of HMG- CoA reductase, a liver enzyme that produces approximately 70% of total cholesterol in the body.

That statins work has been a widely accepted fact since the late 1980s when the FDA first approved them as effective anti-cholesterol medication. Today, they are the number one selling pharmaceutical in history with one in every four Americans age forty-five and older being prescribed the medication. Lipitor, Crestor, and Lescol are just a few of the most popular brand name stains on the market, with sales of these three alone totaling over twenty billion dollars in 2014.

Unfortunately, for a great many people with high cholesterol, statins are either insufficient or are simply not an option for treatment. For some, cholesterol levels are so high that not even the inhibitory effects of the drug can curb the condition. For others, side effects that include muscle inflammation, liver damage, and increased risk of diabetes prove intolerable. And for the millions that do take statins, the sheer restriction of having to take a pill at least once a day for periods of time lasting up to decades can be a major inconvenience.

In 2003, a crucial first step in finding an alternative to statins was taken. A team of French researchers found that LDL levels appeared to be higher in people who had overactive levels of the human liver enzyme PCSK9. A regulator of cholesterol uptake by the liver, PCSK9 binds to

A Revolutionary Step Forward in the Treatment of High Cholesterol

LDL receptors on the surface of liver cells, causing them to be degraded. As a result, LDLs cannot be absorbed and remain in blood vessels where they can cause blockages. Since this discovery, a number of pharmaceutical companies have invested in finding a drug that can inhibit the effects of PCSK9, thus indirectly increasing the uptake of LDL cholesterol and lowering blood cholesterol levels in the human body.

At the recent annual meeting of the American College of Cardiology, the results of the first clinical trials for evolocumab, a PCSK9 inhibitor developed by Amgen, were presented. After a one year period of injectable therapy administered on a bimonthly basis, not only did blood cholesterol levels decrease in patients by over 60%, but frequencies of stroke and heart attack decreased by over 50% in a range of patient populations.

Simply put, the significance of these findings cannot be overstated. ?What we?ve seen here this weekend puts these drugs on a solid footing for early approval,? says Steven N issen, chair of cardiovascular medicine at the Cleveland Clinic. ?This is probably the most important class of drugs we?ve seen in a decade.? Indeed, the possibilities reflected in these results are enough to captivate anyone who takes cholesterol medication. Immediate interest in the drug of course lies in its potential as an alternative medication for those who cannot tolerate statins or for whom statins are simply insufficient. "We badly need something for people who are statin intolerant," said Anthony DiM aria of the University of California San Diego. "Given these data we have right now, if I have someone in the 40- to 60-age group with a high LDL who is statin intolerant, yes, I would use this drug." However, in terms of its long-term potential, many experts have considered whether PCSK9 could in fact reach larger patient populations as a supplement to statins, or even as a permanent substitute.

It is worth noting that initial impressions of PCSK9 inhibitors have not been without concern. Common side effects were quite mild and most prominently included irritation at the site of injection. However, a more serious

albeit rarer side effect was neurocognitive impairment characterize by memory loss and confusion, an occurrence observed in varying degrees in 0.9% of patients. Furthermore, while initial results reflect the drug?s ability to lower LDL cholesterol, more evidence is needed to solidify a correlation with its effects and a reduction in heart-related illness (heart attack, stroke, etc.). N eedless to say, such concerns elicit the need for more clinical trials before the drug merits approval by the FDA.

Additional concerns regarding PCSK9 inhibitors arise from anticipation of their economic impact. CVS Health estimates annual pricing of the drug will be between $7,000 and $12,000, far greater than the average price of statins (some of which cost as little as $12 a month). N eedless to say, such estimates raise large concerns, especially with regard to our current health-care system. As explained by William Shrank, M D., Chief Scientific Officer at CVS Health, ?...the resilience and ability of our health-care system to absorb such high costs will be tested if rigid cost control mechanisms are not put in place."

Pharmaceutical companies are currently expending every possible effort to commercialize PCSK9 inhibitors as soon as possible. Pfizer is expected to begin trials later this year of its own version of a PCKSK9 inhibitor, and Amgen is expected to gain FDA approval for evolcumab no later than August 2015. This being said, it is a distinct possibility that injectable PCSK9 inhibitors could hit the market as soon as next year, pending the results of further clinical trials.

Should they gain FDA approval, PCSK9 inhibitors could very well come to reshape the world of healthcare and improve the health of millions in the very near future. Like any new drug, there remain a number of questions regarding its long term effects and its place in our healthcare system. However, as a promising answer to one of the first world?s most rampant health issues, PCSK9 inhibitors seem poised to forward the pursuit of optimum health for our society.

Out With the New,

By Allison Pei

In a society today where a Hepatitis C cure has been developed, robots have helped perform surgery, and sight has been restored to the blind, it is rather daunting to realize that antibiotic-resistant bacteria are still such a large threat in the medical world. A few weeks ago, I learned about two recent deaths at the University of California, Los Angeles M edical Center. The patients were both exposed to carbapenem-resistant enterobacteriaceae (CRE) through endoscopic procedures. Because of the bacteria?s antibiotic resistant properties, they could not be treated effectively. It was especially shocking for me to realize that even at one of the nation?s best hospitals, patients could still die from bacterial infection related causes.

Antibiotics have been actively utilized in the medical field for almost a century. The first antibiotic was discovered by Alexander Fleming in 1928 and is known as penicillin today. Although this discovery had immediate effects in revolutionizing the way infected patients could be treated, it also carried a tremendous consequence. Fleming immediately recognized and warned against the potential for bacteria to become resistant to antibiotics through overdosage. Today, Fleming?s prophecy can be seen in full effect: there exist bacteria resistant to almost all known kinds of antibiotics. Although researchers and scientists have tried over the years to develop and find new types of antibiotics to target increasingly fatal bacterial strains, the trend of discovery had been coming to a halt in recent years due to the limitations of researchers in finding entirely new antibiotics. These limitations stem from the inability to draw conclusions from mechanisms discovered about resistant bacteria strains.

In With the Dirt

14

Recently, the University of Birmingham announced a breakthrough discovery while working with a strain of Salmonella resistant to the antibiotic drug ciprofloxacin. They found that a particular mutation in the bacteria?s genome allows it to push antibiotics from inside of itself to the outside, which drastically reduces effectiveness of the given antibiotic. However, researchers at the University were not able to propose any methods to combat this particular trait. This illustrates a common trend amongst all types of antibiotic research. Researchers are able to identify the cause of resistance, but are unsuccessful in either destroying such a cause or finding new strains of bacteria.

However, hope exists in the antibiotic world. In the recent year, researchers have discovered an entirely new strain of antibiotics. This particular antibiotic is known as teixobactin, and its anti-bacterial properties stem from its role as a cell wall inhibitor. The key to their success in isolating a unique type of antibiotic was through an entirely ?revolutionary? method of finding new strains of bacteria: growing bacteria in their native environments in the soil. This environment alteration has seen changes in bacterial

growth and secretions, both of which had been extremely useful in isolating and discovering teixobactin. This finding is particularly important for future research in antibiotics, as it presents an entirely plausible method to tackle the bacteria issue: revert back to a more primitive technique and grow bacteria in the natural world.

This breakthrough not only offers potential for the future of antibiotic research, but also implies the consequences of our overdependence on laboratory mechanics and technology. Overly mechanical research methods may not be advantageous in the search for new antibiotics in that they present unnatural environments that prevent bacteria from exhibiting undiscovered characteristics. Rather, through placing bacteria in their true homes, a simple environment, bacteria are better able to flourish, and at the same time scientists can more easily isolate their unique traits. As seen from the unexpected effectiveness of the seemingly inadvanced ?soil hotel? experiment, perhaps it is not always best to look towards the future, but instead to learn from the past. After all, that is the only way to get to the ?root? of a problem.

Global Health Opportunities in Medical School

By Devon McMahon

Undergraduate premedical students increasingly complete global health experiences, typically in developing countries throughout Latin America, Africa, and Asia. During my time at Cornell, I have undertaken global health projects in Peru and South Africa, and have studied abroad in N epal. As a second semester senior with a strong interest in global health, I wanted to learn more about opportunities available to medical students for global health projects. Although global health is increasingly important in medical education, with 30% of medical students participating in global health projects, there is a surprising lack of information regarding specific programs on the Internet. I had the pleasure to learn firsthand from N atalie Krumdieck, a fourth year medical student at Weill Cornell M edical College, about her involvement with global health and the opportunities available to medical students.

A Conversation with Natalie Krumdieck, Weill Cornell MedicalCollege Student

N atalie is originally from Albany, N Y, and completed her bachelor?s degree at Smith College, where she majored in mathematics. Her interest in global health began at Smith, especially after she studied abroad in Durban, South Africa. N atalie also travelled to the Dominican Republic to assist plastic surgeons with cleft palate repairs. After graduating from Smith, she took a few gap years, when she worked as a nurse?s aide in Albany. N atalie was attracted to Weill Cornell as a globally focused medical school. Weill Cornell is highly supportive of global health projects, with

much funding available for independent research. For example, many summer opportunities are available, and students can take time off between third and fourth year to complete global health research. Research projects can range from biological to anthropological, such as culturing TB samples or studying childhood trauma as a predictor of H IV drug adherence. Additionally, during fourth year there are clinical electives available in H aiti, India, Tanzania, and Brazil.

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N atalie has taken advantage of many of these global health opportunities. In the summer after her first year, she travelled to H aiti to work on cervical cancer research. She is currently taking a gap year between her third and fourth year to conduct research with Dr. Sera Young, a faculty member in the Department of N utritional Sciences on the Ithaca campus. N atalie is specifically working on Dr. Young?s Pith M romo project, a non-interventional, longitudinal cohort study looking at food insecurity and nutritional status for H IV-infected and H IV-uninfected

lactating and pregnant women, in Kenya. N atalie went to Kenya in July 2014 to start enrolling women into this study. She will be involved until the end of June 2015, when she begins her fourth year rotation. N atalie described the experience as ?nothing that I expected it would be...As all great research projects are.?

Of course, both premedical and medical students alike should acknowledge the ethical issues of becoming involved in global health. In N atalie?s experience:

?I worked in the DR for a week and a half, where they do a bunch of cleft lip, cleft palate, and burn scar repairs. And then they leave. When I first went, I thought ?This is life-changing.? And it is true that you are fixing someone?s cleft palate, and that will change their life. But the more I?ve worked in global health, the more of a gut reaction I have against it. I feel like they having been going in there for many years. You don?t speak any Spanish. Who is going to take care of these kids if they have complications? What gives you the right to do this? This is not sustainable at all. That is why I would only want to work internationally if it is long term, and I am teaching. That is the great thing about Weill Bugando Tanzania, which makes it much more sustainable. Short term trips are not the answer.?

Long-term, N atalie would like to practice medicine in South Africa for a few years, and then have a practice that splits time between South Africa and the Unites States. Her goal is to fit global health into her medical practice, research, and family life. She plans on practicing family medicine,

which gives her a more holistic, natural, and non-medicalized approach to human medicine. It is also more applicable to a community completely lacking health services.

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Patient Autonomy in Organ Wait List DecisionsBy Henry Kanengiser

As it stands today, organ donation in the United States is in a crisis. The number of people on the waiting list for an organ in the U.S. was 121,272 at the end of 2013, but less than one quarter of those on a wait list actually received an organ (The Gap Continues).This inevitably results in more patients putting off palliative care in hopes that their personal panacea, an organ straight from a deceased, will be bestowed to them any minute. Every year, more than 6,500 people on American organ wait lists die before receiving an organ (Facts and M yths). To ameliorate this issue, doctors and public health organizations advertise heavily for people to sign themselves or their sick relatives up as organ donors, hoping for a spike in available organs to counteract the ever- lengthening wait list. However, the rate of organ donors has remained relatively static, and has in fact been decreasing since 2009 (The Gap Continues).

What can be done to address this issue? Besides attempting to collect a larger number of organs, medical professionals should begin to have more significant discussions with patients about their decision to add their name to a waitlist. Currently, the discussions that doctors and patients have about this decision are fraught with subtle, subconscious attacks on the autonomy of the patient to decide on their treatment in the case. These limitations on patient autonomy bring into question whether or not all the people on the wait lists elected to be on a list, or were pressured onto the list. Acknowledging what these issues are and determining the best way to combat their prevalence is vital to preserve both the ethical right of the patient to make their own autonomous decision and the maintenance of organ donation as a logistically viable medical treatment for those who choose it.

To understand what issues exists within these conversations, we must first understand how the ideal interaction between a doctor and patient in this situation should occur. M odern biomedical ethicists have settled on a dynamic between doctor and patient called the ?logic of care?. Logic of care, a term coined by ethnographer Annemarie M ol and her book with the same title, requires a series of meaningful discussions between all people involved in the patient?s life, encompassing the entirety of the patient?s life, and act as a running analysis of the patient?s outlook on potential treatment paths. Rather than encourage entirely independent decisions made by the patients without incorporation of any medical information or return to a system of medical paternalism, the logic of care encourages medical professionals, ?to open up and share the crucial substantive questions publicly.? (M ol 9).

In reality, these discussions between doctor and patient are far more toxic. Doctors address end of life discussions about organ care often with their own agenda, and always with their own opinion. Whether they choose to or not, their position often leaks into their discussions, resulting in treatment decisions for patients that are not made

of their own accord. For example, doctors often leave out palliative care when listing treatment options, already changing the entire dynamic of the conversation and keeping some patients from selecting the path of medical treatment best suited to their case (Kurtz 300). They also commonly fail to keep their position as the more powerful in their dynamic with the patient in check, and thus limit their patient?s agency (Kurtz 302). This dynamic is especially significant in doctor-patient relationships with patients classified as a part of the ?other? in society. As Kathleen S. Kurtz asserts in her article ?Organ Transplantation and Community Values,? ?there are systemic forces inside and outside the institutional medicine that limit a person?s ability to act as a genuine moral agent in making medical decisions ? especially if that person is a member of a socially oppressed group? (302). Perhaps this dynamic contributes to the fact that African Americans make up a disproportionately larger part of the national organ wait list ? 30.1 percent on the list to their 12.6 percent of the U.S. population ? and Caucasians make up a disproportionately smaller part of the list ? 42.4 percent of the list to their 72.4 percent of the country (Organ by Ethnicity) (Overview of Race). Following this logic, there appears to be an enormous portion of the wait list population in the United States that is now waiting for an organ to save their lives, who statistically would have chosen another option if their treatment conversation was done with more attention to the power difference. Agency in these important decisions is limited by the patient?s position in America?s social structure, and is often further twisted and manipulated by doctors.

What can be done to solve this significant issue? Clearly this reaches far beyond a dismaying statistic about organ donation and snakes through historical prejudices and medical instruction. Perhaps the first thing to address is the lack of attention given to these discussions in the medical dialogue surrounding organ donation. All focus is on increasing the number of organs available for donation. At the same time, deciding to join the wait list is a life-changing

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decision?the patient has only a small chance of surviving past a wait period while unknowable physical and psychological tolls may occur while waiting. Rarely do these statisticians, public health officials, or researchers stop to evaluate whether or not the patients have made the decision for themselves. Yet ensuring that these decisions are made autonomously is something that every person in the medical industry can and must be doing. The only way to encourage honest discussions is by making sure the doctors who have intrinsic power do not abuse it, whether they intend to or not.

The best way to actively change these discussions and the flaws within them is to enact changes in the medical school curriculum. Ethical conversations and ethics in the curriculum was only added to the first medical school in 1977 and has only become widely included in schools in the past 30 years, so the idea of amending it to focus on certain aspects of the doctor-patient power dynamic is not outlandish (Lakhan et al.). By teaching doctors to spend more time

ensuring they are not compromising their patient?s autonomy and preparing them with tools to detect their own encroachments, the crisis of the organ donation wait list and countless other medical issues could be ameliorated in a very salutary manner.

Logically, attempting to address the difference between the supply of organs for transplantation and the demand for those organs should involve addressing the demand if the supply is static. Changing the way doctors handle patient discussions surrounding whether or not to sign up for the organ donation wait list could have several benefits. It ensures the patient is more comfortable and confident with their medical decisions, creates more comfort for the patient before death, decreases the number of people on the wait list (thus decreasing the number of people dying on the wait list), and would defend patient autonomy from doctors? subconscious and conscious acts to subvert it.

The Importance of Technology in Medicine TodayBy Aaron Lee

The 21st century can easily be identified with the rapidly increasing advancement of technology, a pace that sometimes we can?t keep up with. Engineers, scientists, researchers?any member of these professions have contributed significantly to this technological change. Unknown to most of society, these advances in technology have brought on indirect effects in other areas, such as the health industry, impacting those both in physician and non-physician roles. Doctors, surgeons, administrative assistants, interns ? all are undoubtedly affected.

In the summer before my senior year of high school, I had the opportunity to intern at the medical devices company N europace. The company specialized in developing devices that could be used to treat epilepsy through electrical stimulation, such that a patient would not have to have regular physical interactions with a physician;? rather, the device was the object that would directly treat the patient. Apart from this device, there are many others that physicians use in the hospital today. There are other innovative tools that assist surgeons during procedures, devices to help researchers analyze samples, and tools to facilitate hospital and health care processes. Consequently, a multitude of cultural and physical questions arise, bringing into question ideas such as whether or not the role of the physician changes.

On the other hand, an article was published in January 2013 detailing the impact of technology on the field of a medicine. N ot only was the role of the physician affected, but the health care industry as a whole was being affected, thereby changing the future of any healthcare-related profession. A report from the Congressional Budget Office in

2008 estimated that 38% to 65% of all new health care expenses were accounted for by technology, displaying how big of a role technology has made for itself in today?s health care business. Although these changes may be seen as negative, they may merely be interpreted as a reflection of humanity?s ever-evolving society.

However, an additional paper published by the N ational Bureau of Economics in 2012 discusses that there are positive aspects to this increased emphasis on technology. The paper eventually concluded that increased usage of technology actually improved hospital efficiency by improving how the system was run. The article can be seen as evidence of a shift from medicine being just a traditional physician-patient role to it taking on the role of a standardized field assisted by technology.

These changes not only have huge immediate effects but also have a formidable impact on the future of medicine. Thousands of students both in the US and other countries aspire to become physicians, to become like the very doctors they see and admire in clinical settings. Consequently, it is important for them to understand the constantly changing nature of medicine.

All in all, the increased emphasis on technology cannot necessarily be concluded to have a solely detrimental effect. However, we should take notice of the changes being made to the medical profession right before our eyes, as these changes bear important sociocultural implications. Even if we can?t keep up with technology, we should take a step back sometimes and just learn to take another closer look at this ever-evolving profession.

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A New Epidemic:America's Over-Prescription AddictionBy Aleena Jafri

Research has shown that the average American takes 12 medications annually ? compared to about 7 on average 25 years ago ? to treat chronic disease or control its symptoms. With our increasingly busy lifestyles, reaching for some painkillers or getting antibiotics seems like the quick fix we need. But this ubiquitous trend is leading to a dangerous dependence on drugs (See Fig. 1).3

One of the better-known effects of the over-prescription of antibiotics in particular is the rise of highly resistant bacterial strains, or ?superbugs.? Improper use or unnecessary prescription of antibiotics will leave behind a fraction of the pathogenic species that was tough enough to withstand the effects of the drug. What began as a mutation in the bacteria quickly propagates, and those resistant genes spread. While this process would have occurred naturally as an inherent effect of treating infections with antibiotics, their overuse and misuse is accelerating the process. Exposing these pathogens to so many antibiotics is allowing them to rapidly mutate, to the point where many commonly used drugs lose effect, causing thousands of deaths every year.1 Even a number of recently-developed antibiotics have been rendered ineffective, and although scientists are constantly working on new drugs to keep ahead of the threat posed by superbugs, their endeavor is proving to be rather Sisyphean.1 Regarding the global threat of antibiotic resistance, Dr. Steve Solomon, the director of the Centers for Disease Control and Prevention?s (CDC) Office of Antimicrobial Resistance remarked that,

"During the last 70 years, bacteria have shown the ability to become resistant to every antibiotic that has been developed. And the more antibiotics are used, the more quickly bacteria develop resistance." He added: "The use of antibiotics at any time in any setting puts biological pressure on bacteria that promotes the development of resistance. When antibiotics are needed to prevent or treat disease, they should always be used."5

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Unfortunately, research has shown that as often as 50% of the time, antibiotics are prescribed unnecessarily or incorrectly, and this inappropriate usage of these drugs needlessly promotes the development of resistance.5 But do the detrimental effects of over-prescription extend beyond antibiotics? The leading cause of death in the United States is heart disease, which claims more than 600,000 lives every year.5 It?s really no surprise that some of the most commonly prescribed drugs in this country are those that help treat cardiac conditions, such as statins, a family of drugs used to reduce cholesterol levels in the blood.5 According to the Centers for Disease Control and Prevention (CDC), our use of statins has increased six-fold since the 90s.2 But what the overwhelming majority of patients fail to acknowledge is that a few simple lifestyle changes would be just as effective, if not more so, than turning to prescription drugs.5 Furthermore, maintaining a healthy diet, avoiding tobacco, and exercising provides a number of health benefits beyond preventing heart

disease, while avoiding the dangerous risks that all drugs carry with them.2 Statins have been known to cause muscle pain and in some cases muscle and liver injury, and cause an increase in blood sugar that could lead to diabetes.4 U ltimately, no drug is free of unwanted side effects and health risks, which should be balanced against the potential benefits prior to prescription. While some portion of the $200 billion increase seen in spending on prescription medication during the past two decades is accounted for by an increased lifespan and thus a larger populace of elderly people relying on various drugs, this is only one part of a multi- faceted issue.2 Direct marketing to patients and many physicians? failure to thoroughly discuss a patient?s illness with him or her increase the frequency of improper drug usage.2 Any given medication, whether it is a physician-prescribed antibiotic or an over-the-counter aspirin should be used sparingly and only when its benefits definitively outweigh its detriments.

Unfortunately, research has shown that as often as 50% of the time, antibiotics are prescribed unnecessarily or incorrectly, and this inappropriate usage of these drugs needlessly promotes the development of resistance.5 But do the detrimental effects of over-prescription extend beyond antibiotics?

The leading cause of death in the United States is heart disease, which claims more than 600,000 lives every year.5 It?s really no surprise that some of the most commonly prescribed drugs in this country are those that help treat cardiac conditions, such as statins, a family of drugs used to reduce cholesterol levels in the blood.5 According to the Centers for Disease Control and Prevention (CDC), our use of statins has increased six-fold since the 90's.2 But what the overwhelming majority of patients fail to acknowledge is that a few simple lifestyle changes would be just as effective, if not more so, than turning to prescription drugs.5 Furthermore, maintaining a healthy diet, avoiding tobacco, and exercising provides a number of health benefits beyond preventing heart

disease, while avoiding the dangerous risks that all drugs carry with them.2 Statins have been known to cause muscle pain and, in some cases, muscle and liver injury, and cause an increase in blood sugar that could lead to diabetes.4 U ltimately, no drug is free of unwanted side effects and health risks, which should be balanced against the potential benefits prior to prescription.

While some portion of the $200 billion increase seen in spending on prescription medication during the past two decades is accounted for by an increased lifespan and thus a larger populace of elderly people relying on various drugs, this is only one part of a multi- faceted issue.2 Direct marketing to patients and many physicians? failure to thoroughly discuss a patient?s illness with him or her increase the frequency of improper drug usage.2 Any given medication, whether it is a physician-prescribed antibiotic or an over-the-counter aspirin, should be used sparingly and only when its benefits definitively outweigh its detriments.

Ethni-cineBy Antoine Saint-Victor

The world is constantly growing and advancing, not in terms of physical size but in terms of population growth. In a matter of thirteen years, the world population has increased from 6 billion to 7 billion, and this trend is predicted to continue with the population growing to 8 billion within the next decade. Among this growing population, minorities are increasing at a significant rate.

Due to historical prejudice and racism, minorities are overly represented in low-income communities. When it comes to healthcare and disparities, the inability for minorities to receive adequate healthcare is a common focus. There are systemic issues that place minorities in low-income areas, limiting their access to quality care. Subpar government involvement and poor school systems are among the many reasons why these challenges exist. Without the proper resources and knowledge, it is difficult to seek proper medical attention and care. However, one aspect of healthcare as it relates to minorities that is crucial but does not receive much attention is the intrinsic differences between the biological makeups of various minority groups and its effects on their medical needs. A number of biological factors, such as differing levels of melanin production, causes people of different ethnic backgrounds to appear different. Deeper than that, there are slight inconsistencies in the enzymes involved in the immune systems of various ethnic groups, which contribute to differences in disease tolerance.

During clinical trials, the pharmacokinetics and pharmacodynamics of drugs are observed in African American, Asian, Caucasian, and Latino populations. Studies have shown that genetic polymorphisms, variations in bioavailability, and steep dose-response curves play a role in ethnic sensitivity. Differences in alleles affect cellular elements such as metabolizing enzymes, permeability, and transporters. Inadequate consideration of these factors by physicians during treatment can lead to dire consequences. While doctors might prescribe a drug to treat kidney disease in one dose to a Caucasian patient for whom it proves to be effective, the same dose may be ineffective in a Korean patient. Due to cellular differences, the Korean patient may need a higher dose. With a smaller dose, their condition will only worsen and potentially lead to death because the physician did not take into account the cellular differences and did not care to properly review the suggestions on the drug label provided by the FDA.

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Prescribed use of tacrolimus, a drug that decreases immune system activity in transplant patients to prevent organ rejection, provides a detailed example of the aforementioned issues. Tacrolimus is highly metabolized by the CYP3A enzyme. In order to reach sufficient concentrations in the body to be effective African American patients require higher doses than white patients, which may be a result of differences in membrane permeability. Additionally, the oral bioavailability was 1.2-1.8 times higher in Caucasian and Latino patients than in African American patients, which accounts for increased efficacy of the drug in Caucasian and Latino patients.

Another example of the importance of understanding the ties between ethnicity and medicine is the misuse of Warafin, an anticoagulation drug commonly used to prevent heart attacks and strokes. As it stands, the recommended initial dose is 5 mg daily. This only applies to white patients and is considered an ?overdose? in Asians. This important detail is emphasized by the FDA and indicated on the drug label. However, if physicians do not pay close attention, they can easily make mistakes that could lead to further injury.

In these cases, if studies and variability were not taken into consideration, patients could have suffered organ rejection and lost their lives. This is not an isolated incident and can occur in treatments that range from cancer to Parkinson's diesease. Knowledge of small but significant

differences in people of different backgrounds may improve diagnostic medicine. Knowing that dark-skinned people sometimes lack vitamin D, people from the Indian subcontinent commonly suffer from diabetes, and that hypertension differs by race can make physicians better informed about the wider context that their patients are involved in.

All people are created equal and have their own caveats that define them. From a medical standpoint, individual caveats include antibodies, receptors, and most importantly genes. Fields like psychology and sociology allow us to learn about one another on a personal and emotional level. Clinical research gives us the opportunity to learn from one another on a molecular level, and we should not hesitate to take advantage of that. By learning more about our systems we learn about more ways to protect one another and to prolong a healthy, joyous life. It is time to practice the same care and humanism used in social sciences and apply it to the clinical world.

M edicine is a field that requires precision and patience to be practiced. The necessary detail to take care of a patient holistically is similar to an artist and their canvas. Diagnosis and treatment go deeper than bone fractures and organ malfunctions. Physicians need to work towards understanding people and their origins. Through a holistic view, the quality of treatment for all people can improve.

The Reality of "McDreamy"Modern Television Portrayal of Medicine and Its Inf luenceson Health-Related Public Perception

By Olivia Chukwuma

It's 4 AM , my alarm goes off in a few hours, and my eyelids seem to have lost sensation. H aving surpassed the point of shamelessness three episodes ago, I continue to glare at the generous 15-second N etflix countdown as it nears zero, promptly transitioning into the next Ellen Pompeo voiceover as I succumb to yet another 43-minute episode--a situation all- too-familiar for the countless other Grey's Anatomy fans guilty of binge-watching stretches of the award-winning medical drama.

As the bonafide "medical soap opera" and iconic medical series such as House MD have been known to generate these cult- like followings, their power to influence masses and shape the public perception of medicine remains the most underrated.

Society?s image of health care is predominantly, if not entirely, dictated by the media and its most prominent form of consumption: television. M edicine has long been an enticing subject for T V writers and producers due to its complex and passionate nature illustrated throughout the nearly 90 American medical dramas broadcasted in the past

60 years, many amongst the highest-rated shows of their time. Though the portrayal of medicine in earlier shows faintly resembles that of their modern counterparts, as it was strictly regulated for almost four decades by the American M edical Association (AM A) and affiliated physician organizations to ensure credible depiction of the medical field (2).

Over the years following the eventual decline of the AM A?s T V influence, the representation of medicine in television has become increasingly convoluted, currently unrecognizable from its former guarded state. Autonomous medical shows and respective writers of this era have instead, resorted to fast-paced and exaggerated storylines in effort to understandably attract viewers, at the unfortunate expense of medical accuracy. This, perhaps, explains why the amount of screen time given to the rare diseases that make for good T V is dramatically disproportionate to the actual occurrence of such conditions in real life (1). Consequently, more common and less sensational diseases like diabetes are left underrepresented as fans develop a distorted perception

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towards the prevalence of health issues in the real world. While some doctors today are essentially indifferent

about this skewed representation of their field and simply dismiss it as ?just T V,? many remain heavily concerned with the way medicine is being portrayed in television and its power to influence patients, markedly their current views of doctors. A 2009 study in the Journal of Broadcasting and Entertainment Media, for example, found that watching Grey?s Anatomy was correlated to doctors being seen as more courageous and was subsequently linked to better patient satisfaction (5). M isinformation in medical shows further disenchants individuals and patients alike, giving them unrealistic expectations of health outcomes and idealization of doctors as miracle workers. This, in turn, may lead to a patient discontinuing care and personal dissatisfaction of their own health care providers, putting doctors in a precarious position to educate their patients about the differences between the reality of medicine and the medical myths found in its flawed primetime depiction.

Additionally, medical dramas may be doing more

understand that many of these medical discrepancies do exist and ultimately take them with a grain of salt. However, those with unwavering loyalty to medical dramas as well as the millions tuning in every week may not be as quick to dismiss these fallacies. At a glance, viewers may seem perfectly capable of distinguishing fact from fiction without considering how readily impressionable audiences can be. Furthermore, many fans and non-health professionals watching medical shows, lacking knowledge in the field as it is, may take any number of inaccuracies for truths and subconsciously rely on the show?s content as their primary source of medical information. In 2005, a Clinical Transplantation study actually demonstrated that people who viewed organ donation unfavorably frequently cited what they'd seen on T V as evidence for their opinions (7). In another study, author Dr. Jae Eun Chung similarly found that heavy viewers of medical dramas in her study were more likely to undermine the societal importance of cancer and cardiovascular disease although they are, in fact, the top two causes of death in the U.S. (1).

?The commercial necessity of modern television shows makes it hard to accurately depict the reality of being a

physician.?

harm than good by inadequately informing patients of their and misconstruing life-saving procedures in producing ?as seen on T V? rescues such as those observed with CPR, where patients tend to survive cardiac arrest more often in television than they do in real life. In fact, according to the Journal of the American Medical Association, only 2% of adults who collapse on the street and receive CPR fully recover and just 15% of patients who receive in-hospital CPR are successfully resuscitated? in comparison to past and current medical dramas boasting heroic CPR survival rates of nearly 70% (6). Seemingly harmless narratives are especially deceptive as they can disillusion pre-med student viewers by promoting unrealistic views about being a doctor including the success rate and speed at which problems are solved within a sub hour- long episode along with various ethical issues.

Doctors in these shows may sound like they know what they?re talking about, however, that doesn?t mean they get everything right. Even though many series have physicians to consult for accuracy, inconsistencies still exist. Treatments illustrated for patients with seizures are downright dangerous, with T V doctors inappropriately attempting to hold a person down or stop involuntary movements while seizing, as analyzed in another study (4). People watching these shows might get a false impression of how to provide first aid in emergency situations and end up causing harm based on something they saw in an episode of their favorite medical drama. As a consulting doctor for medical dramas puts it: ?The commercial necessity of modern television shows makes it hard to accurately depict the reality of being a physician. You have to condense and dramatize stories to make them compelling and doing that means the sort of doctoring you see on television is hard to recognize in any real hospital? (3).

While I?m admittedly entertained by such shows, I

mandatory to have any number of them on-air at a time. With the development and popularity of streaming platforms, successful shows that are no longer on-air such as House M D and Scrubs have even found new life on N etflix, perpetuating their potential to influence masses of individuals.

Though some points can seem possibly over-analytical, it has been verified that medical shows indeed provide many Americans with much of their medical knowledge, influence public perception, and shape overall attitudes of our health system. With all of this being said, however, there are numerous benefits that can come out of watching medical T V shows whether it?s destigmatizing certain illnesses, bringing awareness to larger societal issues, exposing the public to controversial topics in healthcare and framing informative dialogue, or simply for feel-good entertainment. In fact, there have been many real- life cases documenting life-saving events in which the rescuer claimed that they learned CPR or another emergency medical treatment by watching it on television.

With their widespread appeal, medical dramas remain such a significant part of mainstream culture today that many unabashedly flock to week after week, myself included. So clearly I?m neither ready to give up my M cDreamy delusions just yet nor have a problem with suspending belief for those 43 minutes, but as long as we can seek knowledge beyond T V shows and recognize what we watch for entertainment as just that, a little indulgence never hurt anybody.

Those who don't watch medical dramas aren't necessarily exempt from their effects either, as they may be unknowingly influenced by other viewers or become part of a certain conversation/ cultural opinion. M edical T V series have established such a presence amongst the landscape of American television that it has become almost

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Fetal Keepsake Imaging:The Controversial Commercialization

By Akila Venkataramany

of the Medical Ultrasound

The excitement of a new addition to the family can certainly be an important and defining time in life. Thus, the tendency for expectant mothers and fathers to treasure every moment of the pregnancy period with intricate scrapbooks or journals is understandable. In fact, most parents often save the first sonogram, which paints an unclear black-and-white picture of the fetus during pregnancy. But in recent times, the sonogram has failed to meet its rising expectations of uniting the parents with their unborn child and has left them wanting much more. A recently commercialized trend known as fetal keepsake imaging caters to this need, and though it satisfies some parents? needs, health care professionals and researchers are seriously questioning its medical and ethical implications.

In 1958, a Scottish physician named Ian Donald engineered the use of ultrasounds to examine fetuses, but its initial goals have now expanded to allow physicians to determine a fetus? ?growth, gestational age, placental location, and...anomalies.? M any picture the traditional ultrasound in the following way: expectant mothers lie on a table while the physician applies a cold jelly and uses a white wand to project the fetus onto a computer. But in more complex terms, a device called a transducer emits high-frequency sound waves, and the ultrasound machine produces an accurate, two-dimensional image after the return of captured waves rebounding from body tissues. U ltrasound imaging can also take several other forms, such as transvaginal scans, Doppler ultrasounds, and fetal echocardiography. Currently, fetal keepsake imaging centers employ 3-D and 4-D ultrasounds, which have specialized scanners and computers to develop higher resolution sonograms.

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Though the basic principle behind 3-D and 4-D ultrasounds remains the same as the standard procedure, health care authorities are concerned that the centers are using the technology to provide non-medical services. The FDA has recently published an article entitled ?Avoid Fetal ?Keepsake? Images, Heartbeat M onitors? that details its growing concerns. It states that people who are not medical professionals operate the ultrasound technology for up to one hour in an imaging session. Therefore, the organization strongly discourages people from utilizing the services of over-the-counter ultrasounds and Doppler heartbeat monitors to make fetal keepsake images and videos. Dr. Shahram Vaezy, an FDA biomedical engineer, has spoken on behalf of the FDA to communicate her views about extensive ultrasound use. ?U ltrasound can heat tissues slightly, and in some cases, it can also produce very small bubbles (cavitation) in some tissues.? The European Committee for M edical U ltrasound has also released a similar statement: ?The embryonic period is known to be particularly sensitive to any external influences... Investigations should be carried out with careful control of output levels and exposure times. With increasing mineralization of the fetal bone as the fetus develops, the possibility of heating fetal bone increases.? The FDA and other such organizations are concerned with the increasing use of the ultrasounds in the fetal keepsake imaging centers.

In fact, Pasko Rakic of Yale University conducted a study on mice that analyzed the effects of ultrasounds on neural migration in mice. After chemically marking newborn neurons in the heavily pregnant mice, he and his team performed ultrasounds lasting varying periods of time over the course of three days. H is experiment contained three groups of mice: a control group that did not receive the procedure, a second group that underwent the ultrasound from 5 minutes to 420 minutes, and a third group that received the ultrasound for the same amount of time with

the machine turned off. As the pregnant mice became increasingly exposed to the ultrasound, the number of neurons developing in the incorrect place also rose. The control group and the mice with the fake treatment shared similar results. Rakic concluded that extra ultrasound exposure may result in neurological changes, including left-handedness and delayed speech. In commenting on this study, pediatric neurologist Verne Caviness of M assachusetts General Hospital in Boston said, ?The basic guidelines in this country suggest using ultrasound as little as possible...Baby pictures aren?t a justifiable use for this technology.?

In response to such claims, expectant mothers and fathers still insist on the value of the interactions made possible by companies like M eet the Baby, which claims to offer ?the finest 4D prenatal experience available [that combines] cutting-edge technology with a family viewing environment.? From their point of view, the characteristic images of a smiling or yawning baby establish a parental bond coming at a price ranging between $300 and $490. The FDA acknowledges the importance of maternal bonding and believes that opportunities to interact with the child already exist in medically-relevant settings. As a result, medical professionals and researchers insist on more studies that delve into fetal keepsake imaging and its effect on maternal attachment to fully determine its value.

While ultrasounds are an essential tool in obstetrics today, their commercial use continues to stir controversy across clinical fields. The use of ultrasounds for fetal keepsake imaging purposes begs the question of how safe the technology is in non-medical settings. The debate regarding the usage of such health care equipment relies upon the compilation of more technical research that can elaborate on the risks and benefits. But until this point in time arrives, the evidence currently stands in the form of discouraging statements, a few studies, and enticing advertisements.

By Julie Urgiles

Revolutionizing Primary Healthcare Delivery

In the early stages of most industries, before standard processes and innovative technology are developed, obtaining high quality products and services is expensive. Identifying the specific job or experience that a customer wants from a product or service enables efficient delivery systems to emerge as companies compete for their share in the market. Eventually everyone benefits from lower prices and improved access to the product. Why should healthcare be any different? The reality is a faulty reimbursement system that rewards patients? illness, and escalated costs that are not correlated to quality. This is surprising given that all

the advancements in imaging technology, telecommuni- cations, pharmaceuticals, and the understanding of disease and genetics. Less invasive surgical procedures have been developed, and people with previously fatal diseases such as AIDS can live longer and healthier. However, these innovations have not made healthcare more affordable or accessible as expected. The issue narrows down to the business models that deliver healthcare and the skewed incentives that prevent competition focused on keeping the patient healthy.

Iora Health is a medical practice focused on primary care that has an interesting business model aligning profit with patient wellness. Dr. Fernandopulle, the chief executive of Iora Health began developing his model for medical care on the insight that the healthcare system is tailored to providing hospital treatment, the most expensive form of health treatment. Emphasizing on primary preventative care reduces costs from hospitalizations and improves patient wellness. Iora contracts with either an employer that finances its workers? health insurance or a private M edicare company. Iora receives a flat monthly fee per patient, and if it saves the company money on overall health costs, then it takes a percentage of what is saved. The monthly fee allows the company to swerve from the fee-for-service model that profits on patient illness. Doctors do not have to bill for every service provided, and they do not have to document specialized codes for every patient visit. This means that doctors do not have the incentive to provide overtreatment or send patients to higher venues of care. They can encourage patients to come in as often as needed, which can save costs through early detection and treatment. For example, early detection of harmful cysts and adequate treatment can prevent more invasive procedures to treat breast cancer. This monthly fee also allowed Iora to invest in an electronic record system that can better coordinate patient care and is essential for Iora?s expansion. Iora?s business model focuses on improving customer service to enable better healthcare delivery. Health coaches, without formal healthcare training but from customer service backgrounds, assist patients with non-medical needs such as accessing transportation for office visits or exercise classes, diet changes, and accessing medication or supportive equipment such as orthopedic shoes. Typically physicians avoid phone calls and emails that do not generate payments.

However, this level of customer service has been efficient in addressing more complex socio-economic issues that interfere with the health delivery process and adherence to treatment. Iora helped reduce hospitalizations for high-risk casino workers in Atlantic City by 40 percent for a total of 12 percent savings in healthcare costs. To provide these services, Iora convinced the casino workers? union to pay much higher per patient monthly fees instead of charging for every consultation.

Investment in primary care is essential for reducing hospitalizations, which comprise the most expensive healthcare costs. The customer service emphasis is a new angle to healthcare delivery that maximizes treatment efficiency. A healthcare delivery model that enables caregivers to profit from reducing excessive costs and giving more attention to the patients is a step in the right direction. Where is the benefit in the most helpful and efficient plan to control diabetes if the patient does not stick to it? For many chronic diseases such as heart disease and diabetes, the consequences of not maintaining a healthy lifestyle are not immediately felt. A person who smokes even after being diagnosed with heart disease might not quit until a heart attack. A diabetic patient who consumes excess sugars and fats may not feel an incentive to watch his/her diet until an appendage needs to be amputated. The investment made in understanding why the patient is having trouble adjusting to treatment and providing a support group to help the patient manage the disease more efficiently helps the patient avoid life-changing invasive procedures and saves the healthcare system money in the long run. These savings amount to an overall improvement in the quality of healthcare people receive and greater accessibility for more members of society to better healthcare.

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