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20
2015

Internal Medicine’s Cultural Competency Program: “Bring Back the Humanism”

Krista Edelman

Krista Edelman, M’11

A patient doesn’t fill his prescriptions. Another doesn’t exercise, worsening chronic conditions. Still another is always late to appointments.

It’s frustrating for physicians, and easy to assume these patients just don’t care. But there are other sides to these stories, and an innovative program is helping interns find them.

“When there’s a disconnect between providers and patients, we sometimes don’t realize the issues that are affecting patients so they cannot adhere to a treatment plan,” said Bennett Lee, M’94, ambulatory clerkship director and associate professor in the Department of Internal Medicine. “We were thinking about how to really engage the interns with their patients and make sure they understand what a privilege it is to take care of them.”

Chief Resident Krista Edelman, M’11, along with Lee and Stephanie Call, M.D., M.S.P.H., associate chair for education in the Department of Internal Medicine, developed a cultural competency program, a four-week rotation designed to help the department’s interns:

  • Discover social and physical environments affecting health.
  • Reflect on how a better understanding of health is affected by the conditions in which patients are born, live, work and age.
  • Communicate and share these experiences.
Residents must learn sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation.
– ACGME


The program began in 2014, and about 30 interns have completed it so far. “The experience has been eye-opening,” said Edelman.

The interns are encouraged to go beyond standard medical examination questions to try to understand patients’ lives. They ask about family dynamics, income and whether or not they have convenient ways to obtain healthy food and necessary medicines.

They then go out into the community, sometimes using public transportation, and explore the neighborhoods where their patients live. Edelman prompts them to look around and see:

  • Are there signs of disrepair (broken windows, graffiti, overgrown grass)?
  • Are there parks or recreational areas in the neighborhood?
  • What supermarkets are available and do they carry affordable fresh produce, meat and other healthy food?
  • Are there functioning street lights or a sidewalk?
  • Where is the closest bus stop?

What they’re finding is changing the way they practice medicine and view patients, said Edelman. “They’ve taken photos of the food available, which might be something like a packet of bologna and potato chips, maybe an onion. It’s a revelation for these physicians, who wonder why patients aren’t eating more fruits and vegetables.

“Seeing the neighborhoods where the patients live, they come back and say, ‘I don’t think I would feel comfortable walking there alone either, let alone a 60-year old female patient.”

Interns might discover that a patient has to travel several miles in a wheelchair to get a prescription filled, or is too frightened to go out or maybe has to depend on three city buses to get to a physician’s appointment.

“In medical school, people are so keyed in to the science of how to take care of folks that sometimes they lose track of the idea that this is a person,” said Lee. “You need to ask, ‘how do I communicate with them? How do I understand?’”

The culmination of the cultural competency program is creating a reflection piece on the experience, usually a digital video on a subject or patient who affected interns deeply.

Edelman believes this reflection will make them better, more compassionate physicians.  She’s also heartened by recent updates to the MCAT exam that tests prospective medical students.  In 2015, the exam was expanded to include a section on behavioral and socio-cultural factors.

“My parents are social workers, and I’ve always had a passion for the service in medicine,” she said. “It’s easy to get so jaded when you’re working long hours and patients come in who are obviously neglecting their health.

“But that’s not acceptable for physicians. I want to bring back the humanism.”

By Lisa Crutchfield

16
2015

The Art of Reconstruction

Taking advantage of today’s emphasis on active learning, Jennifer Rhodes, M.D, director of VCU’s Center for Craniofacial Care, partnered with a local sculptor, creating a pilot program of art workshops to enhance the plastic surgery residents’ experience.

“We are trying to foster the residents’ imagination, to encourage creativity,” said Rhodes. “Learning about aesthetics of the human body through sculpture is ideal for plastic surgery residents. In sculpting, we can talk about the things we used to talk about in lecture: proportions in face, different features in face, concept of lighting and how it changes your perception of proportion…all things they must understand when they are doing a surgical procedure that affects the aesthetics of the face.

“I think it clicks much better in the residents’ minds when they learn these concepts during a hands-on approach in the artist’s studio rather than on the black board. I have never had the same kind of enthusiasm from them for a lecture.”

“Oh, we do enjoy a good lecture,” said Collier Pace, M’11, a fourth year plastic surgery resident. “But especially for us as surgical types, the hands-on stuff is what we remember and get excited about. Most of us are tactile learners.”

To reach those tactile learners, Rhodes works with VCU sculpture department alumna Morgan Yacoe to design programs that allow residents to learn sculptural techniques and see how they relate to surgery – allowing them to test out aspects of their skill set before they apply them in the operating room.

For example, Yacoe developed a workshop for residents to practice flap design, for which she created replicas of a face with silicone skin and underlying foam.

“They could practice local tissue rearrangement and then suturing to learn about how best to reconstruct different types of skin cancer defects,” said Yacoe. “I tested different silicones to get the elasticity right. They got to practice tool handling, cutting, suturing, rotating the skin and other aspects of flap design and execution before they cut a real patient.”

The lesson was invaluable. “The next time I do this flap, I will have vision in my mind of how I want it,” said Pace. “These are helpful, subtle points that are hard to learn outside the operating room.”

Other workshops have included sculpting clay busts and anatomical drawing. The skills they learn teach residents that healing the body is art as well as science.

“Historically, plastic surgeons had set numbers for things – this is normal range for how thick lips should be or how much eyelid you should see or how far apart the eyes should be,” said Rhodes. “Now, our sensibilities are evolving and in resident education, we stress getting away from the numbers and into developing residents’ own ways of looking at the face, understanding balance and harmony, and understanding what features would be appropriate for a particular individual.”

Mixing up the learning environment by going outside the hospital has another benefit. “Residents can get burned out,” Rhodes said, “and that affects not only their ability to learn, but their empathy towards patients, their outlook on life, their health and their perception of their career path and what they want to do.

“I think transforming a lesson into an experience that they might not have sought on their own and outside their comfort zone is a way to help not only learning but to keep them inspired, foster creative thinking, and enhance their connection to their chosen field.”

By Lisa Crutchfield

16
2015

Acting Up

Physicians Learn New Skills in the Theater

Catherine Grossman, M.D., H’06, doesn’t expect any of the residents she supervises to ever pursue a career on stage, as entertaining as they may be. But she does see the value in learning theatrical improvisation skills. This year she incorporated an improv workshop into residency training.

Medicine, like theater, she believes, is an art as well as a skill, and improvisation enables residents to use different parts of the brain and approach ideas through a new lens.

“The millennial learner needs to be actively engaged and this is one way we engage them,” she said.

Grossman, associate professor of internal medicine, is not the first to see the parallel between art and science. Medical improv is an emerging field designed to improve cognition, communication and teamwork in medical settings. Actor Alan Alda was recently honored by Stony Brook University for helping to establish a center using improvisation techniques to aid in communicating scientific information.

Grossman was introduced to improvisation during a medical simulation course at Harvard and recognized its value as a teaching tool. After an introductory class, she signed up for more.

“It was really neat looking at how the skills transferred back and forth. It made me think about how I teach, how I am at adapting rapidly, being in the moment and responding.”

When she returned to Richmond, Grossman contacted the Richmond Comedy Coalition.

“Improv can be very funny, but it’s more than making jokes on stage,” said Matt Newman, the Coalition’s managing director.  “You really need to listen and respond to your scene partner with openness, honesty and empathy. It helps you become a more thoughtful and responsive communicator.”

Grant Farr, D.O., a chief resident in internal medicine who participated in the workshop, agreed. “Improv can help you express yourself so people will listen,” he said. Besides being fun, he added, it also helped loosen up the Type A personalities in his class.

Grossman, who was honored last fall for her innovative approach to education with the medical school’s Irby-James Award for Excellence in Clinical Teaching, notes that improv also is used in the school’s simulation center, where actors portray patients and physicians-in-training are required to react quickly.

Grossman has found her improv skills handy in many areas. “In improv, like real life, you have no idea how someone is going to respond.

“We’re always looking for ways to apply techniques from other fields into the way we teach. It’s interesting for me to work through different problems with different approaches. We’re walking down different pathways to be better at what we do.”

 By Lisa Crutchfield

 

Tips from a Pro

To get the most from improv, performer and teacher Townsend Hart says you should:

  • Leave your ego at the door.
  • Be open to feedback.
  • Ask for help.
16
2015

“They are here because they have heart”

Capstone projects open doors to helping the medically underserved

Jeremy Powers, M’14, was driven by one thing and one thing only when he entered medical school in 2010. Like many of his classmates, his main mission in life was, and continues to be, helping people.

Especially the underserved.

“I feel drawn to helping those people from an underserved area,” he said.
So when he began considering his options for medical school, he immediately was drawn to the MCV Campus, in large part because of the school’s International/Inner City/Rural Preceptorship (I2CRP) Program.

All medical students can apply to the four-year program. It fosters the knowledge, skills and values needed by doctors to provide quality and compassionate care to the less fortunate.

A major focus of the program comes during the final year, when students complete a community-based capstone project. Each project has the potential to help communities – local, elsewhere in the U.S. or overseas – by addressing critical medical needs. It gives students the opportunity to serve patients before they even graduate from medical school.
“I feel very proud to have been part of this,” said Powers, who traveled to Cameroon to complete his capstone project. “It provided me with a way to focus on the things that drew me to medicine in the first place.”

Other schools across the country have programs similar to I2CRP, but VCU’s offering is unique in that it runs for four years, allowing classmates to remain together as they share life-changing experiences.

“The nature of the training is invaluable,” said Mark Ryan, M’00, H’03, medical director of I2CRP.

Ryan was one of just two students to be part of I2CRP’s first graduating class in 2000. At that time, the program focused on inner-city and rural communities. The international element was added in 2007.

“It started small as a test program,” said Ryan, assistant professor for the Department of Family Medicine and Population Health. “Now, it is getting increasingly competitive. The quality of students who are not accepted is remarkable. It’s really hard to make that final cut.”

This year, 69 students applied for 24 spots.

“There is more and more interest each year,” said Ryan, who leads the program alongside assistant professor Mary Lee Magee, M.S., who serves as I2CRP’s educational director. “My sense is there is a generational component to it,” Ryan said. “There is a generational movement to serving others.”

I2CRP students participate in community volunteer activities, monthly journal club meetings and annual elective courses designed to foster a deeper understanding of underserved populations. Students also complete semester-long rotations in underserved settings during their first- and second-years.

By their third year, students spend a total of 10 weeks in underserved communities during rotations in family medicine, general internal medicine, pediatrics and general surgery.
“These students are not just in the program because they have great credentials,” Ryan said. “They are here because they have heart.”

Ryan himself was attracted to the idea of helping the underserved after spending a weekend on the Eastern Shore during his undergraduate studies at William & Mary.

“Driving around rural Virginia, I began recognizing the barriers people there had to accessing health care,” he said. “There was a level of need that was compelling to me.”
Most I2CRP students come into the program with a long list of volunteer hours already logged. Many have completed mission trips overseas, spent weekends in this country at rural clinics or traveled with church members during summer vacation to provide health care to the poor and homeless.

“There’s a different level of visibility today on the part of students in terms of the roles they can play,” Ryan said. “There is so much more awareness. They know they can do meaningful things. They want to step in and do their part.”

Take a look at four recent capstone projects that are bringing change to underserved communities locally and around the world.

Capstone project shapes life’s direction – Jeremy Powers, M’14

Interpreting what’s best for patients – Scott Toney, M’15

Alerting Latinos and other minorities to skin cancer risk – Ashley McWilliams, M’15

Breaking down the barriers to good health – The Class of 2015’s Gordon Pace, Heather Root and Lauren Clifford

Capstone project shapes life’s direction

Jeremy Powers, M’14, traveled to Cameroon last year to find out if general surgery residents there could provide better care to patients if they had training in plastic surgery. The answer? A resounding yes.

“What walks through the door there is what they have to deal with, whether they have the training or not,” Powers said. “They see a lot, and a lot goes untreated because the expertise is not there.”

Patients may present with burns, soft tissue cancer, facial deformities, open wounds or other injuries that could benefit from plastic surgery but don’t, because the few surgeons who do practice in Cameroon don’t have the needed training.

“There are huge social and self-esteem issues associated with these types of cases,” Powers said. “Plastic surgery can often restore form and function, providing patients with a better quality of life.”

Medical care is hard to come by in Cameroon, where the doctor-to-patient ratio is about 1 to 15,000. Plastic surgeons are even more scarce.

That’s why Powers developed a survey and met with eight general surgery residents as part of his project. Because of the types of injuries these surgeons see and because specialists in plastic surgery are rarely available, all agreed more training would benefit patients.

“They want as much training as they can get, not just in plastic surgery, but in other areas as well, from experts in the field,” Powers said. “Medical aid is no longer simply about providing services to the underserved. In fact, if we just did that we may be doing a disservice to these communities, perpetuating a sense of dependency. We now have the opportunity to equip and train the brilliant and talented people who are already there with a heart to serve their own people.”

Powers graduated from William & Mary in 2009 and taught high school calculus, European history, physics and trigonometry before entering medical school to “make a positive difference in the world.” He remains at VCU as a resident in plastic and reconstructive surgery, and plans to one day practice and teach in underserved communities.
“My motivation comes from my faith, as Jesus teaches us to serve the poor,” Powers said. “I2CRP has taught me so much. I know that what I’ve learned will continue to serve my patients throughout my entire career.”

Interpreting what’s best for patients

Scott Toney, M’15, will never forget the frightened teenager who had been rushed into the emergency room. Doctors tried to explain the injuries he had suffered when he fell off the roof, but they weren’t sure he understood the fact that surgery would be necessary to stop the internal bleeding.

“He did not speak English,” said Toney, who was on surgical rotation that day during his third year of medical school. “It became apparent that he did not fully understand the gravity of his injuries.”

With the memory of that experience still vividly in place, Toney examined interpretation services in the inpatient setting as part of his capstone project. He wanted to know if the type of interpretation method affects patient and provider satisfaction and if certain interpretation methods are more appropriate in certain clinical scenarios.

“I want the patients at VCU who are not English speaking to receive the best possible care,” he said. “We have interpretation services available, and by law we must provide them. But which method is best?”

The VCU Medical Center averages five to 20 Spanish-speaking patients on any given day. Health care providers can call on live interpreters to visit patients and translate for them or use technology assisted interpretation that are phone or web based.

“With the live interpreters, patients build a trust,” said Toney, who is headed to the Naval hospital in San Diego to begin his residency in pediatrics. “But as society becomes more tech savvy, patients are growing more comfortable with that as well.”

Toney, who grew up in Atlanta, has an undergraduate degree in health science from James Madison University. He is no stranger to visiting the underserved, having taken 10 mission trips to such places as Mexico, Peru, Ecuador, El Salvador and the Dominican Republic.

“To see other places in the world that don’t have the freedoms and the resources we have here is incredibly humbling,” he said. “It has motivated me to treat everyone with the utmost respect. I’ve come to realize that everyone has the same wants and desires. Everyone wants to be healthy.”

Alerting Latinos and other minorities to skin cancer risk

“There are misconceptions out there that people with darker skin won’t get skin cancer,” said Ashley McWilliams, M’15. “That simply is not true.”

As part of her capstone project, McWilliams made it her mission to raise awareness.
“As the population of Latinos continues to increase, we need to target that population or there will be an increase in skin cancer cases,” she said. “We must get in front of the problem.”

According to the Skin Cancer Foundation, skin cancer rates among Hispanics rose by almost 20 percent in the United States in the last two decades. And since Hispanics are the fastest-growing population in the U.S., McWilliams cautions, the number diagnosed will only continue to rise.

To increase awareness, McWilliams surveyed minority patients at a local clinic to assess their knowledge and perceptions of melanoma, including risk factors associated with this form of cancer, their ability to recognize the early stages of melanoma and their willingness to have a suspicious spot examined by a physician.

“When melanoma presents in minorities, it presents differently,” McWilliams said. “For Caucasians, it presents on the face, neck and chest. For persons of color, it usually presents on the palms and soles of the feet as well as underneath fingernails or toenails. And the outcome is not as good in these groups compared to Caucasians.”

Her project not only helped educate minorities about skin cancer, but it also gave physicians a better understanding of their patients’ points of view. Because some patients feel they are not at risk, for example, they don’t think it is necessary to talk with doctors about a change in their skin’s appearance, chalking it up instead to aging or some other factor. Physicians, therefore, should discuss the risks and the warning signs.

“It was really a quality improvement study,” said McWilliams, who is headed into her surgery intern year at the VCU Medical Center. “The more knowledge patients and providers have, the better our quality of care.”

McWilliams, who grew up in Pensacola, Fla., received her undergraduate degree in biology from Howard University in 2008. She worked in research and health policy for a few years before entering medical school.

“I wanted to interact more with patients and help educate them in the healthiest ways to live their lives,” she said.

Her interest in dermatology dates to her middle school days.

“My science fair project examined which brand of sunscreen or tanning oil provided the best protection from the sun,” she said. “Of course we all know now that tanning oil doesn’t provide any protection at all, but the project demonstrated to me how the lack of proper protection from UV rays can cause lots of damage to your skin and over time can increase your chances of developing skin cancer.”

It also opened her eyes to the importance of skin cancer prevention. “The odds might not be as high that a person of color will get skin cancer,” she said. “But if we can educate and in the process save one life, that’s the most important thing.”

Breaking down the barriers to good health

The challenges of caring for the underserved are many. Communication. Transportation. Trust. Physicians can’t always get a clear picture of what’s going on in the lives of their patients.

To help sharpen the view in one underserved area, the Class of 2015’s Heather Root, Lauren Clifford and Gordon Pace traveled to Lima, Peru for 10 days to uncover the roadblocks many face to achieving good health.

“When physicians get to know the whole patient, they can provide a higher quality of care,” said Root, who’ll begin her internal medicine residency at Emory this summer. “I welcome that challenge.”

The group teamed with the family medicine residents on site to survey local neighborhoods. They went door to door, asking family members about their backgrounds, daily diets, lifestyles, family medical histories, neighborhood crime and more.

“What was nice was how closely we got to work with the medical residents,” Pace said. “They welcomed us right in.”

The group visited more than 100 homes during their stay. They plan to analyze the information they gathered to see if correlations can be made between a person’s home life and their health care.

“We’ll look at those who have been vaccinated, for example, and those who haven’t and cross-reference that with those who have insurance and those who don’t,” Clifford said.
They will share their findings with the medical staff they worked with. They hope this study will be the first of many.

“What excites me is the idea of a cross-cultural partnership,” Pace said. “This was such an exceptional experience, I would love to see it continue.”

Traveling out of the country is nothing new for Pace, Clifford and Root. All three had experience working in Central America as part of the I2CRP and HOMBRE (Honduras Outreach Medical Brigada Relief Effort) programs. They also have done mission work on their own.

“While volunteering in rural clinics, I’ve seen the sickest of the sick and the poorest of the poor,” said Clifford, who has an undergraduate degree in art history from William & Mary. “I’m always shocked by how the people most in need are the ones who aren’t getting it. That has spurred me to do what I can to serve.”

Clifford, who is set to begin her pediatrics residency at the Medical University of South Carolina, is following in her father’s footsteps by becoming a doctor. She counts her experience with the I2CRP program as one of the most important of her life.

“I feel like this is something every single physician should be exposed to,” she said. “It has been a true privilege.”

Pace, who earned his undergraduate degree in history from Mississippi State University in 2003, took a few years off after school to volunteer in Belfast, Northern Ireland, where he worked with inner city youth. He also spent time in Arizona working with immigrants. He is headed to Yale New Haven Hospital for a residency in internal medicine.

“It’s interesting to go to different metropolitan areas around the world and compare nutrition and other cultural elements,” he said. “When we were in Peru, one minute we were surveying the poorest residents, and then within walking distance we saw upscale homes.”

No matter the location, people want the same thing – good health.

“The challenge is giving them a clear path to achieving it,” said Root, who has a math degree from Emory University. “When we understand the whole patient and the challenges they face at home, good health care can become more attainable.”
Her trip to Peru reaffirmed that belief.

“Some people may shy away from helping the underserved,” she said. “It can sometimes be complex and frustrating. But I believe that it doesn’t get any better than giving help to those who need it most.”

By Janet Showalter

16
2015

Out of the Classroom, Into the Clinic

Streamlined pre-clinical curriculum lets students enter clerkships in second year

Physicians don’t practice medicine in a classroom. Yet for more than a century, medical students spent a great deal of their time in one.

Many medical educators today believe that developing problem-solving skills, teamwork and early exposure to clinical situations better prepares future doctors for residency and ultimately practice.

That’s the heart of the medical school’s new curriculum, which takes learning outside lecture halls and into real-life situations right from the start.

Students who arrived on the MCV Campus in 2013 were the first class to dive into an experiential-based curriculum, developed with input from more than 200 faculty members, administrators and students.

“We have moved on from just supplying students pearls of knowledge for them to give back to us,” said Isaac Wood, M’82, H’86, F’88, VCU’s senior associate dean for medical education and student affairs. “Now we expect them to problem solve, think critically, appraise literature, figure out what’s important and what’s not important and take ambiguous data and make sense of it before they get in the clinical situation. Because that’s what the clinical world is.”

An 18-month pre-clinical curriculum

“The goal of redesigning the pre-clinical years was to eliminate unintended redundancy and teach students in ways that mirror what we know about adult learning and best practices in education,” explained Michael Ryan M.D., assistant dean for clinical medical education. “In the clinical setting, much of what they learn is experiential in nature, learned on the fly at a patient’s bedside or in the context of a particular case.”

It’s a fairly radical change from the old curriculum, which relied on large-group lectures the first two years and a lot of memorization. Though it was occasionally updated, the basic model was more than 100 years old, reflecting medical education recommendations from a 1910 report by educator Abraham Flexner.

Other curriculum changes reflect how today’s physicians are treating patients, said Ryan. The old model was designed for a time when most people died of acute life-threatening illness such as tuberculosis or pneumonia. Today, a bigger threat is chronic disease such as diabetes and hypertension.

Though two years of learning is now compressed into 18 months, the new curriculum doesn’t skimp on the basics. But it’s more teamwork and technology-based, teaching students how to think, where to retrieve information and how to then apply it. A Practice of Clinical Medicine course, designed to integrate basic principles into clinical scenarios, is the core of the first year, getting M1s out of lecture halls and into situations requiring a hands-on experience.

The medical school’s new curriculum also helps eliminate what is perceived as a gap between what medical schools teach and what is expected for interns. (see sidebar)  

“It’s about cultural competency, safety training, clinical assessments of competency, truly measuring skills. It’s not ‘do one see one teach one.’ Instead, it’s life-long learning which they continue to refine,” said Craig Cheifetz, M.D., regional dean of the VCU School of Medicine’s Inova Campus, where about 31 M3s and 31 M4s study each year.

In addition to stressing high-quality care, teaching patient safety is always paramount today, said Wood. “You don’t lay hands on a patient until you have demonstrated competency on a standardized patient or a high-fidelity mannequin. And then, when you actually lay hands on a patient, there is a great deal of supervision.”

Teaching those competencies is easier because the new curriculum debuted at the same time as the opening of the $158.6 million James W. and Frances G. McGlothlin Medical Education Center. Located on the MCV Campus between Main and West hospitals, the 12-story, 200,000 square-foot building boasts areas designed for team learning and a state-of-the-art Center for Human Simulation and Patient Safety.

That 25,000-square foot space features high-tech mannequins to simulate procedures from childbirth to colonoscopy, as well as live standardized patients, often drawn from VCU’s Department of Theatre. From the time they enter medical school, students work in teams, using a specially designed computer system to order physical examinations and laboratory tests, diagnose conditions – and justify the time and money they spend.

“We’re giving them opportunities at lower stakes to practice skills before they hit the wards,” said Ryan.

“I’m starting to see more programs like ours with the pre-clinical piece involving an integrated curriculum of basic science information as it applies to the clinical care of patients,” said Wood. “I think we were pretty revolutionary in turning it upside down.”

The moment of truth

As a result of the compressed curriculum, M2s were able to take the U.S. Medical Licensing Examination’s Step 1 test this winter, months earlier than previous classes.

Just as the medical school’s curriculum is a far cry from the past, today’s Step 1 is a very different test than many physicians remember, said Wood.

“Every single question is a clinical question that tests basic science knowledge. So that’s the whole approach we’re taking, and we’re hoping they’re going to feel more comfortable, more confident and come out with a higher score.”

The test today is much more than just words on paper. “There are photographs, videos, you listen to heart sounds, to breath sounds. You can, with the mouse of the computer, move the stethoscope around parts of the virtual patient. You’ll do a biopsy and they’ll send you results you have to interpret,” said Wood.

“There is recognition now that unless you’re going to be a surgeon, it’s more important to understand functional anatomy than structural anatomy,” he said. “An example would be in an old practical exam, after someone had studied the brain, they’d put out a specimen of a brain and stick in a pin somewhere and ask what it is. Now, we might describe, for example, a 56-year old man presenting with slurred speech and weakness on the right side, and they’ll ask which area of the brain most likely has an occluded artery. They want you to know functional anatomy.”

Many wondered if paring down the pre-clinical curriculum would affect students’ performance. Would they have enough time to learn the materials and pass the test?

Wood expects to see excellent results from students, as good or better than recent years’ 94-95 percent first-time pass rate that’s been around the national average. At press time, 93 percent of the class had received their scores from the Step 1 examination. There had been only one failure (compared to the usual 6-8) and average scores were running 12-13 points higher than previous classes.

Clerkships Get Started in Second Year

Passing the test means students get to move on to the expanded clinical offerings sooner. “In third and fourth years, we’re giving them the opportunity to explore some specialties that they didn’t have in the past until the fourth year,” said Ryan. “So, all the students this year will have flexible elective blocks where they can try out something like anesthesiology or radiation oncology.

“About 25 percent of our students match into residencies in specialties outside of the core clerkships,” he said, referring to the seven core clerkships traditionally offered: family medicine, internal medicine, neurology, OB/GYN, pediatrics, psychiatry and surgery.

”Those students entertaining fields such as emergency medicine or radiology, for example, are especially excited about the chance to try them out earlier in the clinical curriculum, not just a month or two away from doing residency interviews in the fourth year.”

Some rotations have been changed to offer more diverse experiences. For example, said Wood, what used to be a 12-week rotation in internal medicine is now eight weeks, but students are seeing a wider range of conditions in that time instead of spending large blocks of time in one specialty area.

Increased flexibility in years three and four is a big draw of the new curriculum, said Wood. Students have about 62 schedule options so they can choose what they feel works best for their interests.

The curriculum also includes four weeks of flexible time off, something that stressed-out students can use.

If the flexibility of the new curriculum has been good for students, it’s also been good for faculty, who have had to think about new ways to engage students and present material. Wood noted that’s he’s seen some faculty members blossom with the new experiential focus.

As the results of this year’s Step 1 exam continue to come in, administrators will determine if the new curriculum is a resounding success or whether some tweaks are still needed.

“It’s keeping us on our toes,” said Cheifetz. “And the exciting time will be in a year or two when we see assessments. I think change is good. We have the opportunity to make things better.

“Medical school has been the same for 100 years. I believe that to work and develop better programs that will make better doctors is a welcome challenge.”

By Lisa Crutchfield

 

Medical School Joins Pilot Program to Ensure Core Skills

How well does the medical school’s new curriculum prepare students? We’re about to find out, along with some of the top schools in the nation.

The School of Medicine has been selected as one of 10 in the U.S. to make up a pilot cohort to test the implementation of the new Core Entrustable Professional Activities (EPAs) for Entering Residency. The guidelines, established by the Association of American Medical Colleges (AAMC), are intended to help bridge the gap between medical school curriculum and patient care activities all new physicians should be able to perform on day one of residency training without direct supervision.

VCU is part of an impressive group of institutions selected for the program, including Columbia, Yale, the University of Texas and Vanderbilt.

The 13 EPAs identified by the AAMC include skills like recommending tests, collaborating as part of a team and prioritizing differential diagnoses. All are designed to increase patient safety and quality of care.

“Our focus is to eliminate what is perceived as a real gap between how medical school typically trains students and what is expected when they are interns,” said
Michael Ryan, M.D., assistant dean for clinical medical education, one of the medical school’s team members for the pilot program.

He believes the school’s updated curriculum is preparing students well for the EPAs. “They’re functioning in an inter-professional team and learning how to deliver high quality care. In addition, with a required ambulatory clerkship, students will have more exposure to real-world medicine outside the academic setting. That gets students thinking about cost-effective treatments, working with insurance companies and other experiences.

“We’re trying to ease the transition at all stages, from the pre-clinical to clinical years, medical school to residency, and eventually, residency or fellowship to clinical practice.”

 

 

16
2015

Combatting Tick Borne Disease

Mentor and protégé pursue parallel paths to combat tick-borne disease

Two MCV Campus researchers are making significant headway in the development of a novel multi-pathogen based vaccine that will protect people from Lyme disease and other tick-borne illnesses.

Jason A. Carlyon, PhD’99, associate professor of microbiology and immunology, and Richard T. Marconi, Ph.D., professor of microbiology and immunology, were graduate student and mentor at VCU back in the 1990s, working on Lyme disease only a decade after ticks were confirmed as transmission vectors. “Jason was an outstanding student and the first to earn a Ph.D. In my lab,” Marconi says.

Carlyon headed to Yale to do a postdoctoral fellowship and then went on faculty at the University of Kentucky. During that time he took a different path than his advisor and established a research program on granulocytic anaplasmosis — another tick-borne disease.

“It’s an emerging disease, transmitted by the same ticks that carry Lyme,” Carlyon says. Indeed, the two diseases can be co-transmitted. Long known as a veterinary disease, it sickens horses, sheep and domestic animals. In the mid-1990s the first human cases were confirmed. Since then the number of reported cases has increased every year and now runs in the thousands.

In the meantime, Marconi continued his focus on the pursuit of new preventive strategies for Lyme disease. His laboratory developed a canine Lyme disease vaccine that has been patented, licensed and is now undergoing USDA field safety trails.

The Marconi lab is now aggressively working to modify the vaccine and tailor it specifically for use in humans. Lyme disease infects an estimated 300,000 people a year according to the US Centers for Disease Control and Prevention, with most of those cases occurring in the Northeast, the Mid-Atlantic and the Midwest.

While a human Lyme disease vaccine was briefly available in the United States, it was voluntarily pulled from the market by the manufacturer in 2002 after concerns about potential serious side effects were raised. Marconi says his vaccine — which targets the three primary bacterial species that cause Lyme disease in North America and Europe (Borrelia burgdorferi, B. garinii and B. afzelii) — differs from the previous one in several important ways.

The old vaccine prompted the body to make antibodies against a bacterial protein known as outer surface protein A, or OspA. The new vaccine triggers antibody production against a different target — outer surface protein C, OspC.

“The life cycle of the Lyme pathogen goes from ticks to mammals to ticks,” Marconi says. “Those are radically different environments and the bacteria changes the proteins on its surface in response to changes in their environment.”

When it’s in the gut of a tick, the bacteria produces OspA. The old vaccine was reasonably effective — although it required three shots for year-long protection —antibodies in the blood killed the bacteria in the tick during a blood meal.

Marconi believed targeting OspC was a better strategy. Once a tick starts feeding, the bacteria senses mammalian blood, OspA production stops and OspC production ramps up. Production of OspC continues for the first few weeks of infection, presenting a longer window for antibodies to neutralize the bacteria. Marconi says OspC also is a powerful antigen, stimulating a robust antibody response. So the OspC-based vaccine provides great protection, Marconi says.

There’s another distinguishing feature of Marconi’s vaccine that’s based on years of painstaking research identifying the precise features of OspC that trigger the immune system to make antibodies. “We conducted extensive epitope mapping analyses,” he says, and identified two regions of the protein that elicit bacteridical antibody responses — “antibodies that will kill the bacteria.” The vaccine contains only those segments, not the whole protein.

Because the Lyme disease spirochetes and OspC are highly variable, Marconi designed his vaccine to contain protein segments from a large set of OspC variants. His novel OspC epitope based chimeric vaccine has the potential to provide protection against diverse strains from both North America and Europe.

Human granulocytic anaplasmosis (HGA), Carlyon’s research interest, can resemble Lyme disease, causing flu-like symptoms such as fever, body aches, headache and malaise, although there is no rash. In severe cases, decreases in white and red blood cells can occur, as well as liver damage, shock and seizures. “Death is rare, but can occur,” Carlyon says.

The pathogen — Anaplasma phagocytophilum — is very different however. It’s an intracellular bacterium that finds, binds and enters a type of white blood cell called a neutrophil.

Carlyon has spent the last 15 years studying the molecular mechanism of how the bacterium invades the host cell. He’s learned the bacteria’s surface proteins bind to a neutrophil receptor, somewhat akin to a key in a lock that is the first step to entry. Carlyon’s team has proven that antibodies to the bacterial keys prevent them from opening the host cell’s lock to block invasion.

Working with his former advisor and now collaborator, Carlyon has performed epitope mapping on the bacterial keys and identified the specific region of each that is necessary for function.

And, as in Lyme disease, the proteins he’s targeting get turned on during transmission. “When the tick starts feeding, signals in mammalian blood turn on the key,” Carlyon says. “The pathogen readies itself for the mammalian host.”

Now that they are reunited on the MCV Campus, Carlyon and Marconi have landed pilot funding from the Virginia Innovation Partnership to develop a broad protection vaccine that would contain segments of proteins from both Borrelia and Anaplasma. This highly novel “multi-pathogen” vaccine could be used to immunize and protect people against both Lyme disease and HGA. The researchers are currently seeking both federal support and the support of private investors to bring their new vaccine to the market.

 By Jill U. Adams

 

Lyme disease in the clinic:

There’s controversy in the medical community on how to diagnose and manage Lyme disease, says Gonzalo Bearman, M.D., professor of medicine and chair of the division of infectious diseases. He follows the guidelines set by the US Center for Disease Control and Prevention and the Infectious Diseases Society of America. (Different guidelines have been put forth by the International Lyme and Associated Diseases Society.)

When should you test for Lyme disease?

It’s based on symptoms and likelihood of exposure to ticks, Bearman says. If a primary care physician is not sure how to interpret serology, they should consult with an infectious disease specialist.

Diagnosis:

  1. Clinical symptoms, including red, expanding rash; fever and malaise; and swollen, painful joints
  2. Serologic evidence, including the presence of IgM and IgG with Western Blot confirmation.

Treatment:

Antibiotic treatment in early stage Lyme disease usually allows full and rapid recovery. Doxycycline, amoxicillin or cefuroxime axetil are commonly used.