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School of Medicine Virginia Commonwealth University VCU Medical Center
School of Medicine discoveries

27
2014

5 Commandments for Young Scientists from alumnus Sebastian Joyce

Chair of surgery

Sebastian Joyce, PhD’88

When Sebastian Joyce arrived on the MCV Campus to pursue his Ph.D. in microbiology and immunology in the early 1980s, he’d come farther than most: more than 12,000 miles, from Bangalore, India.

“I was as fresh off the boat as it gets,” says Joyce, “and I left a man. I came here a peasant, and walked away a scholar.”

He credits his transformation to the freedom he was given by his mentor T. Mohanakumar, D.V.M., Ph.D., to think independently and pursue scientific discovery in his own way.

He’s still doing that today. As a professor in the Department of Pathology, Microbiology and Immunology at Vanderbilt University, he’s developing the unconventional approach of using T cell-targeted vaccines against infectious diseases.

“He is on the cutting-edge of finding the most effective approaches for preventing infection,” says Phillip B. Hylemon, Ph.D., a professor of microbiology and immunology who was on Joyce’s dissertation committee when he was a Ph.D. candidate in the 1980s.

Joyce described his novel approaches to vaccine development when he spoke at VCU earlier this month at the Department of Microbiology and Immunology’s Research Seminar Series. “Vaccines are man’s greatest inventions,” he told his audience as he enthusiastically recounted for them his lab’s efforts to design vaccines to prevent and treat infectious diseases that plague humankind.

Joyce’s creative and innovative science has won him sustained grant funding from the National Institutes of Health, and his publication record includes the prestigious Journal of Clinical Investigation.

Nurturing the next generation of scientists is a priority for Joyce. He challenged established scientists to take seriously their responsibility to their trainees with the sentiment expressed in his own lab’s motto: “Inspire young minds: to wonder and imagine; to explore and innovate; to discover and evolve.”

5 Commandments for Young Scientists

1. Be curious
2. Read widely and think broadly about everything, and particularly your own project
3. Question everything, especially dogma
4. Devise simple yet clever experiments
5. Find answers by yourself

Joyce also spoke directly to the students in the audience, encouraging them with his 5 Commandments for Young Scientists. On his last commandment — “Find answers by yourself” — Joyce challenged students: “You don’t have to listen to the gray haired, the balding [older generation] or go to them with all your questions. If they already knew all the answers, there would be no point in you doing the experiment!”

Read about Joyce’s scientific odyssey on the his lab website.

26
2014

Housestaff alumna Cynthia Romero honored by the Medical Society of Virginia

Cynthia C. Romero

Cynthia C. Romero

Cynthia C. Romero, H’96, has been honored for her outstanding contributions promoting the art and science of medicine and the betterment of public health through political service. She accepted the Clarence A. Holland, M.D. Award during the Medical Society of Virginia’s annual meeting on Oct. 26. The award was bestowed by the MSV Political Action Committee.

A family physician from Virginia Beach, Romero currently serves as the director of Eastern Virginia Medical School’s Brock Institute for Community and Global Health. She also is the physician manager for Romero Family Practice in Virginia Beach.

She has a distinguished record of service, including being named Virginia’s Commissioner of Health by then-Gov. Bob McDonnell in 2013. Upon completing her term, she returned to EVMS to lead the Brock institute’s effort to leverage its clinical, research and educational programs to positively affect specific health priorities in Hampton Roads.

In his nomination, MSV Past-President Sterling N. Ransone Jr., M.D., cited Romero’s leadership as president when MSV participated in a year-long negotiation with the Virginia Council of Nurse Practitioners. “Not only did Dr. Romero represent the physician position well, she also developed strong relationships with the NP leadership,” Ransone said. “MSV gained through the eventual passage of the team care bill, but we have also developed a much stronger relationship with an organization which had been seen as an adversary up until that point. We could not have done that without Cyn’s leadership and commitment to doing what is best for the patients and physicians of the commonwealth.”

Romero also has served as president of the Norfolk Academy of Medicine, the Virginia Academy of Family Physicians and MSV in 2011. She was founding president of the Organization of Young Filipino-Americans at the University of Virginia where she received her undergraduate degree, president of her medical school class at EVMS and chief resident at the Riverside Family Practice Program with the VCU School of Medicine.

The MSVPAC’s award honors Clarence A. Holland, M’62, and his long and distinguished record as a public servant. Holland was elected to the Virginia Beach City Council from 1970-1982 and was mayor from 1976-1978. From 1984-1995, he served in the Virginia Senate. The MSV Political Action Committee is the political arm of the Medical Society of Virginia, representing more than 18,000 Virginia physicians and approximately 1,000 Alliance members.

25
2014

Alumna Janet Eddy honored for her longstanding commitment to the uninsured and underserved

Chair of surgery

Janet M. Eddy

The Class of 1987’s Janet M. Eddy has been honored by the Medical Society of Virginia Foundation with its Salute to Service award for her service to the uninsured and underserved. She accepted the award on Oct. 25 at the MSV Foundation’s Gala in Wiliamsburg.

Eddy has a longstanding commitment to providing care to those without insurance. Even before medical school, she worked at Richmond’s Fan Free Clinic, and she continued volunteering at the clinic during medical school. She became its director after completing her residency with the medical school’s Department of Family Medicine.

Since 2008, she has served as medical director of the Bon Secours Richmond Health Care System’s Care-A-Van and helped lead the mobile outreach program’s expansion into Hampton Roads. Under her leadership, it has grown from 8,000 patient visits in 2009 to more than 19,500 in 2013.

Eddy was instrumental in the creation of Access Now, a network of physician specialists and surgeons who provide care to those without insurance in the Richmond area. She has also served as medical director of Craig Health Center at St. Joseph’s Villa, where patients can access services not offered on the Care-A-Van. She also regularly participates in medical mission work, most recently spending a month in New Mexico working on a reservation.

21
2014

Match hysteria

An unprecedented Match year left hundreds of U.S. medical students with no residency destination, a trend experts say will increase in future years. But MCV Campus students proved to be strong contenders, especially in highly competitive programs.

Chris Woleben’s tool kit is one reason why.

Match Day is supposed to be the culmination of four years of medical school, an exciting day of tearing open the envelope and learning your destiny.

For some students, though, that envelope doesn’t come.

That doesn’t mean they’re not qualified to practice medicine or even that they’re below-average students, says Christopher Woleben, M’97, H’01, who is associate dean for student affairs at VCU’s School of Medicine.

It could mean that their strategy for the Match wasn’t adequate – or unfortunately, there are just not enough residency slots available in the system.

Christopher Woleben, M’97, H’01

WHAT’S THE PROBLEM?
By the year 2020, the United States will face a shortage of more than 91,500 physicians, according to the Association of American Medical Colleges (AAMC). By 2025, that number is expected to grow to more than 130,600. It’s a shortfall that’s equally distributed among primary care and specialists.

At first, the solution seems obvious: increase the number of students in medical school. And so VCU and other schools have increased class sizes (the incoming class on the MCV Campus is 216 strong, with plans to increase to around 250) and new programs have sprung up around the country.

But there’s a catch. To complete training, of course, physicians must complete a residency program.

Unfortunately for today’s students, the number of federally funded residency training positions was capped by Congress in 1997 by the Balanced Budget Act.

“The concern is that as medical class sizes increase, as more schools come on line and as more international medical students apply for positions in the United States, the number of open residency first-year positions is remaining stagnant, and the Match process is becoming more and more competitive,” says Woleben.

It’s a basic economic conundrum: demand exceeds supply, and so some students won’t get an envelope. That affects not only the student’s future, but the future of medicine in the U.S.

John F. Duval is chief executive officer of MCV Hospitals and chair elect of the Accreditation Council for Graduate Medical Education’s board of directors. He has a keen interest in ensuring an adequate workforce for the coming physician shortage, and the VCU Medical Center, like many other institutions, funds some residency positions without federal support. But it’s not enough. “There has been some growth, because individual institutions have elected to try and address local needs,” he says. “However, growth is not proportionate to the expansion in the number of medical graduates, be they allopathic or osteopathic.

“And so you have a train wreck in slow motion because you have the rate of growth for residency positions that is lower than the growth rate of new graduates.”

So what can be done? Budgets are tight everywhere. The AAMC and other organizations have lobbied legislators to fund more residency positions, an attempt that has not yet been embraced by Congress.

HEADING OFF THE HYSTERIA
In the meantime, universities have tried to make their graduates as competitive as possible.

VCU’s School of Medicine typically equals or exceeds the national average of 92-94 percent of students matching, and the school is nationally recognized for measures it takes proactively to ensure stronger matches.

Several years ago, Woleben developed a “toolkit” – a series of student surveys to identify and troubleshoot potential issues students may face in the residency application process. The AAMC recognized its value and published and shared the toolkit with its members nationwide. Since then, other institutions have looked to Woleben for guidance on dealing with potential Match problems.

The toolkit is used during the fourth year of medical school, as students are preparing their rank lists and seeking interviews. It helps spot students who are not receiving as many interview offers as other students. With that knowledge, advisors can intervene to encourage students to apply to more programs or change tactics early enough to be effective.

LOOMING PROBLEM?
In 2013, 26,504 students started medical school in the U.S. In a few years, they’ll be competing against more than 14,000 international graduates and graduates from previous years for fewer than 27,000 residency positions.

In fact, Woleben hones in on students’ aspirations well before that.

“I think we do focus a little more individual attention on our students than other schools,” says Woleben. “We’ve developed a four-year comprehensive career advising program so that each year, students are getting key pieces of information that will help them in the Match. We’ve strategically designed our curriculum to be longitudinal. We take time to meet with each student, to develop an individualized plan and track their progress.”

Obviously these are bright students – they got into medical school – but some face unforeseen challenges with family, health or other issues.

“We look at the total academic progress of the student,” says Woleben. “We want to make sure we’re graduating students who meet the competencies that are required to be effective, safe healthcare providers. At Promotions Committee meetings, that’s where we focus our discussion regarding individual students who are struggling. Is this student going to be an effective care provider? That question often goes hand-in-hand with whether they’re going to match into a residency program.”

VCU offers myriad resources to students, says Woleben, including help with study skills, time management, test taking and determining disabilities that may require accommodations. Deans and advisors regularly discuss student progress and work to create individual plans for students.

MAKING A PARALLEL PLAN
So if the surveys and administrators identify a student who might be at risk of not matching, what can they do? Advisors are asked to provide realistic expectations, encourage applications to “safety” schools and guide students to consider a residency that might not be as competitive but will still align with their career goals. Students need to have a parallel plan to increase chances of matching.

“When students are selecting programs for their application, I encourage them to have a balance between ‘reach’ and ‘safety’ programs,” says Woleben. “Often, our students find that they end up matching into their reach programs.”

For some specialties such as pediatrics, family medicine, psychiatry, neurology, physical medicine and rehabilitative medicine, students may safely apply to 15 to 20 programs, he says. For residencies that attract a higher number of applicants – surgical subspecialties such as urology, ophthalmology, otolaryngology, orthopedic surgery, dermatology or plastic surgery – looking at 60-plus programs with a goal of getting 10 to 15 interviews is often recommended.

Even with that strategic planning, sometimes the worst can happen.

“In 2014, we had 14 students go unmatched, a little bit higher than usual,” says Woleben. “We saw a similar trend that other schools saw: students applying to more competitive programs were going unmatched in higher numbers.

“We all did a good job of advising weaker students to make revisions to their plans, but we saw some of our stronger students were not as successful as in the past.”

“I don’t sleep well for a week before the Match, and I don’t think the students do either,” says Woleben.

By noon on Monday of Match Week in March, students learn if they’ve matched or not (though they don’t find out where they’re headed until Friday, when the envelopes are distributed around the country).

So what happens to those who don’t have a match?

SOAP OPERA
Since 2012, the National Resident Matching Program (NRMP) has run the Supplemental Offer and Acceptance Program (SOAP) for students who come up empty-handed on the Monday of Match Week. Those students submit applications to programs with unfilled slots. For many, it’s a second chance to get
the coveted envelope on the Friday of Match Week.

It’s a very emotional time, says Woleben.

MCV Campus administrators, program directors, career counselors and personnel from University Counseling Services are on high-alert starting at noon Monday to meet with students who might need to consider other specialties.

“By 2 p.m., they have to start applying to open programs, and sometimes that requires they apply to
a specialty they haven’t applied to before. It’s really fast-paced, and there is a lot of emotion in those two hours. We try to supply as much support as we can,” says Woleben.

Over the course of Match Week, applicants who did not match or only matched to an intern year may endure multiple supplemental rounds. Applicants can receive multiple offers during each round and must decide quickly since these offers are valid only for a two-hour period.

Adam Carter, M’13, was shocked on the Monday of Match Week to learn that he only matched for his intern year and not into a full dermatology residency. “Everyone had told me I had nothing to worry about,” he said. “It seemed so simple before Match Day: you go to med school, apply for a residency in dermatology, get it and go. And then Monday hit, and suddenly everything was very complicated.”

He knew he was applying for a competitive specialty and would have a better shot at something less competitive. “It made me step back and think about whether this was something I really wanted to do. And through not matching, I realized that this was absolutely what I wanted to do and nothing else in medicine would make me as happy as dermatology.”

While Carter completed his intern year, he reapplied for dermatology and accepted a dermatology position he acquired outside the Match and SOAP processes. In doing this, he was able to begin his residency this year and is currently a dermatology resident at New York Medical College. He volunteers to talk with fourth-year students who find themselves in the situation he faced last year.

“One of the things I learned from people I met ‘on the trail’ this year was that these applicants are very, very bright individuals,” he said. “But the numbers just aren’t working out for everyone.”

In 2014, by the end of Match Week, only five VCU students remained unmatched. Across the nation, several hundred U.S. seniors still did not have a residency position. Some opted to take a “bridge” year – perhaps earning a master’s degree or doing research – and come up with a new strategy to get a residency position the next year.

Administrators at VCU and other schools ponder whether it’s fair to let students continue on if they’re not good candidates for Match, perhaps racking up more debt. It’s an ethical dilemma, says Duval, without a clear solution. Another topic of discussion at American institutions is whether or not U.S.-trained students should have priority over foreign students, helping the Match numbers, perhaps, but taking away valuable diversity.

For now, the problem is only going to get worse as medical schools graduate more and more students who need residency positions. The AAMC has urged lawmakers to lift the cap on the number of federally supported residency training positions and increase funding soon to avert the looming crisis of physicians.

Lawmakers have responded with proposals in the House and Senate to increase the number of residency positions, but those bills have languished in committee.

What can today’s physicians do? The AAMC encourages them to contact lawmakers to explain the problem and make the case for taking action.

“There is not a front-of-mind awareness that this train wreck is occurring,” says Duval. “I do believe that we need to take the opportunity and start educating the broader medical community about forward-looking issues within the workforce.

“That is a right, reasonable thing for us to do.”

By Lisa Crutchfield

21
2014

Tackling Concussions

Awareness, Better Diagnosis and Management are Key

Cade Harris was hit so hard last season that he blacked out for a few seconds. After gathering himself, he walked to the opposing team’s huddle. “The next day, I had a terrible headache,” he says. “It was a little scary.” Doctors confirmed that Cade, a senior at Patrick Henry High School in Hanover, Va., had suffered a concussion, his second in three years.

“There have been thousands of concussions in every war we’ve fought and scores in every football season that’s been played. But for so long there was no awareness. That’s all changing,” says David X. Cifu, M.D., chairman and the Herman J. Flax, M.D. professor in the Department of Physical Medicine and Rehabilitation.

Did you know?

• The Centers for Disease Control reports that about 3 million concussions occur each year in the United States.
• Symptoms include headache, difficulty concentrating, dizziness, nausea, sensitivity to light and noise, fatigue and difficulty remembering new information.
• Long-term effects can include dementia and other mental issues.

Cifu is the principal investigator of a $62.2 million federal grant to oversee a national consortium of universities, hospitals and clinics studying what happens to active duty service members and veterans who suffer traumatic brain injuries. And he is working closely with the NFL, NHL, NCAA and high schools to develop better diagnosis and management of concussions. Gone are the days when a coach asks a dazed player how many fingers he is holding up or what day of the week it is.

“Ninety-five percent of all brain injuries are mild concussions – more than half of all people never see a doctor and probably don’t tell their coach or parents,” he says. “But it can take six months or longer for the brain to return to its normal function. We need to test the brain’s ability to perform multiple functions at once before we let an athlete get hit again, give a soldier a gun or let someone drive a car.”

He hopes to release specific findings and guidelines in the next few months. Already, he has helped develop a Concussion Coach app that supports self-management of symptoms for the U.S. Department of Veterans Affairs.

“Concussions are the oldest injury out there, dating back to when cavemen hit each other over the head with animal bones,” he says. “But we are still improving how we diagnose, assess and manage them. We are making great strides to bring about better health for everyone.”

The Concussion Coach App

The Concussion Coach app is a self-help tool for anyone with persistent symptoms after a concussion. The free app is available for iPads and iPods, and it will be available for the Android platform later this year.

By Janet Showalter

21
2014

Football injuries place the need for team doctors in the spotlight

It’s every coach’s worst nightmare.

With time running out in an intense football game, the quarterback drops back and hits his receiver for a first down. The safety comes out of nowhere to deliver a bone-crunching tackle.

A hush falls across the high school stadium as the receiver lays motionless, face down on the hard turf. The coach rushes in from the sideline. With no training to handle such a crisis, he calls 911.

In a perfect world, high school athletes would have access to both team physicians and athletic trainers,
a luxury enjoyed at Hanover County’s Atlee High School thanks to the services of Sally Marks, ATC, and Mike Petrizzi, M.D.

Scenes like this are not uncommon, because less than 20 percent of high schools have a working relationship with a team doctor. And only about 55 percent of high school student athletes have access to a licensed athletic trainer.

“It can be very scary,” says Mike Petrizzi, M.D., clinical professor of family medicine on the MCV Campus. He’s the medical director of Hanover Family Physicians and has been team physician at the county’s Atlee High School since 1991. “I think there are many family doctors and pediatricians who know they are needed on the sidelines, but are insecure about whether they have sufficient training.”

That’s why Petrizzi teamed up with Steve Cole, certified athletic trainer and associate athletic director at the College of William and Mary, to create the Sideline Management Assessment Response Technique (SMART) workshop in 2003. The course teaches physicians the skills necessary to be both competent and confident in their ability to serve the community at athletic events.

“The better trained providers are, the better chance we have of avoiding a catastrophic event on Friday night,” says Jeff Roberts, M’04, program director for the St. Francis Primary Care Sports Medicine Fellowship Program in Richmond.

Jeff Roberts, M’04

Roberts, team physician for Virginia’s Powhatan High School, is a SMART instructor. The four-hour course emphasizes hands-on learning, with volunteers in football gear bringing the Friday night experience to life. Participants practice how to recognize and manage football injuries, including concussions, stingers, separated or dislocated joints, torn or sprained ligaments and broken bones. They practice the log roll – moving a player with a suspected neck injury onto a backboard.

“Thankfully, I have never had an athlete suffer a c-spine fracture,” Petrizzi says. “But you never know what you might face. It sure does help to have practiced what to do in the event of a catastrophic injury. Our student athletes deserve the best care.”

As a high school athlete, Petrizzi remembers watching a news program that asked, “who’s watching your kids?” Even then, he was alarmed to discover that first-aid training was not a requirement for coaches.

“I couldn’t believe it,” he says. “It became a passion of mine to develop a program that would help make sports participation safer for our youth. Trained personnel are needed whether the team is having a bad year or a winning year. If something should happen, these athletes need to be with someone they know and trust. That’s important.”

In an ideal world, Petrizzi says, schools would have an athletic trainer and team doctor working together to provide the best care. He is hopeful that SMART one day will be part of family medicine and pediatric residency training across the country and that those completing the course will, in turn, teach others – a vital step in providing more coverage at the high school level.

“Unfortunately, injuries are part of any sport,” Roberts says. “The question is, how prepared are you to handle them?”

By Janet Showalter

Tips for High School Team Physicians from Mike PetrizziCONCUSSIONS
• When in doubt, keep them out.
• You can have a concussion and NOT lose consciousness.
• Learn the five steps to a graduated return-to-play protocol.

NECK INJURIES
• Master the log roll.
• If an athlete remains unconscious, you must assume a broken neck.

STINGERS
• If an athlete’s arm is stinging or burning but there’s no neck pain, assume an injury to the brachial plexus. Sideline him unless the injured side can move as easily and with the same strength as the uninjured side.

DISLOCATIONS
• With a normal neurovascular exam and lacking the experience to reduce the dislocation, immobilize in a splint and transfer to the ER.
• If no pulse and a long drive to the hospital, one attempt to reduce it with longitudinal traction might save the limb.

RETURNING TO PLAY
• Perform a functional assessment by asking the athlete to show you he can use the affected side doing what his sport demands. For instance, very few sports rely only on running straight ahead, so ask the athlete to cut, twist and stop on the injured joint.

Want to learn more?
Since Petrizzi and Cole started SMART, more than 500 physicians, athletic trainers, coaches and emergency personnel have completed the workshop. It has been offered at medical conferences across the country as well as local events and in small group settings. It is also a highlight of the VCU Sports Medicine Update in Primary Care conference. Sponsored in part by the VCU Continuing Medical Education Office, this year’s conference will be held Dec. 5-7 at Kingsmill Resort and Spa
in Williamsburg. Learn more and register at www.vcuhealth.org/cme.