August 2011 Diary of an MSTAR Student
August 2011 Diary of an MSTAR Student

Annie Levenson: Advice from Many Mentors

August 31, 2011

After our didactic session last night, we went out to dinner with Dr. Rudolph and a few Geriatrics Fellows.  I just finished my first year of medical school, so I have only rarely had the opportunity to interact with Fellows, especially in a social setting.  I found it really helpful to get the chance to talk to them.  We pumped them all for their stories about how they decided to go into the field (nicely, of course).  Hearing their perspective was helpful, since they had just recently made the decision to pursue geriatrics and could give a reasonably accurate explanation of why they'd made that choice.  It also helped that they were really warm, kind people who were willing to share their experiences.

I took the opportunity to ask a question I'd been too embarrassed to ask Geriatrics attendings: as a woman with a somewhat high voice, how do you handle communicating with hard-of-hearing patients?  It seems silly, but I have had a lot of trouble communicating with geriatrics patients for that reason, and hadn't found a good solution to the problem.  The fellows took my question seriously and shared some tips they had picked up along the way.  All in all, I really appreciated the opportunity to get to talk to them and hear about why they chose to pursue Geriatrics.

Annie Levenson
Mount Sinai School of Medicine

 

Kendra Reed: Learning about Osteoarthritis

August 30, 2011

It was a beautiful Monday morning today in San Diego, California. I was able to get a lot of work done today. Osteoarthritis (OA) is a progressive disease that significantly impacts the quality of life of approximately 48 million people in the US and unfortunately most of this population is of geriatric age. I have learned that mitochondria plays a central role in many theories of cellular aging, therefore I will be looking at mitochondria and aging as it relates to osteoarthritis. This morning upon my arrival to the lab, I had two papers waiting for me. The first suggested recommendations for histological assessments of osteoarthritis in mice, and the other discussed surgical destabilization of the medial meniscus model of OA. My mentor reminded me the summer is not long enough for me to use the strain of aging mice… I think you can guess what he suggested next. So today I met the mice I would be surgically inducing osteoarthritis in. After the initial shock of seeing the live mouse I would work with, I felt a bit calmer to learn he would be anesthetized for surgery. After meeting the mice, we then began to go over the anatomy of the mouse knee. It is practically identical to the human knee, just 50x smaller! Now that’s the true meaning of microscopic surgery!

After my encounter with the mice, lunch was definitely out of the question. So over the break I learned how to histologically grade mouse knee samples using a modification from Chambers system—a skill that will surely come in handy. My mentor pointed out key observations, such as identifying the tide/water mark, loss of proteoglycan staining, and fibrillations on the articular surface. When I expressed I was getting the hang of grading, he replied “Great! I’ll give you some slides to practice on.” He gave me 362 slides to be exact—practice makes perfect! Much later that day, we spoke a little more about OA being such a disabling disease. There are currently no cures or even disease-modifying osteoarthritic drugs. Current treatments include intra articular injections, anti-inflammatory drugs and pain relievers, but nothing to even slow down the progression of this disease. Luckily I am researching with one of the trailblazers in the field and I’m looking forward to all the research and techniques I will learn.

Kendra Reed
University of South Alabama College of Medicine

 

 

Amanda Leiter: Transitioning from Basic to Clinical Research

August 29, 2011

This summer, I am working on a lab project that investigates the mechanism of prostate cancer metastasis to bone. I hope to focus on gaining information to prevent morbidity and mortality associated with prostate cancer, a disease that commonly affects many aging men. I am working with Dr. Alice Levine to examine a marker of prostate cancer, prostatic acid phosphatase (PAP), and how this compound affects prostate cancer metastasis to bone. At this point, Dr. Levine and I have formulated two hypotheses on this mechanism, both involving RANKL signaling (a major mediator of bone growth and metastases), but differing in the mediation of this signal.

I've learned that it's hard to predict the trajectory of a research project several months in advance, as my project design has already changed slightly from the plan back in January. I was originally going to do further tests on tartrate-bisphosphonate compounds, but Dr. Levine and our research collaborators realized that we should study the mechanism of how PAP affects bone and how these bisphosphonates actually affect PAP signaling in bone. Dr. Alex Kirschenbaum, a urologist at Mount Sinai, is another mentor for my project and he is really great at explaining the clinical relevance of my project and how PAP could become a crucial clinical marker for prostate cancer. We are hoping that my basic science experiment will provide information that will lead to more effective treatment and/or prevention of bone metastases in prostate cancer.

I have started by familiarizing myself with the lab and the specific cell lines I'll be working with. Lab research, as expected, does not always go according to plan and one of the cell lines that I need for my experiments is taking a longer time to grow than anticipated. At this point, I am continuing to design my experiment, reading literature about prostate cancer, and practicing cell culture and lab techniques. In addition to my own experiment, I am also collaborating with Dr. AnaLisa DiFeo, who has another lab at Mount Sinai that is also working on PAP signaling in prostate cancer. This lab is conducting mouse in vivo experiments and I am very interested to learn about using mouse models in cancer research. At this point, I will soon be transfecting prostate cancer cells with the PAP gene for her experiments and I am looking forward to working with her.

I have already learned a lot about bone modeling, the mechanism of prostate cancer metastasis, and about current treatments for prostate cancer. I have built a foundation on which I will execute my co-culture experiments and analyze the results. I am continuing to read literature on the topic of prostate cancer bone metastases and hopefully will be well versed in the topic by the end of the summer. And finally, I have enjoyed working with great research mentors like Dr. Levine, Dr. Kirschenbaum, and Dr. DiFeo.

Amanda Leiter
Mount Sinai School of Medicine

 


Sana Hava: Developing a Manuscript

August 26, 2011

Although I have been heavily involved in clinical research in the past, this is the first time that I am working with researchers to develop a manuscript, which will be the end product of the program. I have very little knowledge about writing manuscripts and have been busy figuring out how to approach it. Fortunately, my mentors and some students in the program are familiar with the in’s and out’s of writing these types of papers, and their advice has been really helpful in clearing up some of my confusion. But there is still a lot that I need to learn in order to complete this part of my project.

I am currently working on a stroke assessment study, with my tasks mainly consisting of data entry and patient follow-up interviews. I have some experience in data entry and conducting patient interviews in the past, so luckily this part of the project was not too hard to figure out. I am also currently trying to keep up to date with different articles in order to prepare for writing my manuscript.

Aside from being able to partake in a great research project, the opportunity to gain clinical experience in a real-world medical setting was another major factor that attracted me to the MSTAR program. So far I have been on rounds in the Acute Care Unit for Geriatrics and Geriatric Psychiatry, and I better understand how rotations help students realize what specialty they may want to pursue for the rest of their lives. The attendings, residents, and third year medical students with whom I have been rounding have truly gone out of their way to help me gain a better understanding of the different clinical scenarios that each unique patient presents with. Seeing everything that I have been learning about throughout the past year being applied to real cases was exciting and scary at the same time. Exciting because it’s nice to see all the different connections between everything that I have learned about so far; scary because of how much everyone knew and how much I didn’t know or couldn’t remember! I expressed my fear to the third year medical students and residents who smiled at me and knew exactly how I felt, having been in my shoes not so long ago. They reassured me that eventually, everything I am learning now will come together in my head and things will make more sense, especially once I start rotations. I’m still skeptical, but hopefully I’ll be ok.

One of the best attributes of the MSTAR program has been the exposure and experience with the geriatric population. Although I have gained some knowledge in the classroom about the factors that make the geriatric population unique, it was not until the MSTAR program that I realized the importance in gaining a better understanding of the dynamics of the older population. When I started the program, I did not have enough knowledge about geriatrics to assess how I felt about the field, but this program has provided me with great insight, which is truly helping me realize importance of learning about the unique characteristics that define this specific population.

Sana Hava
New York College of Osteopathic Medicine

 

 

Rosemary Bailey-Pridham: Palliative Care Lessons

August 25, 2011

The first thing I noticed from the door of the patient’s room was her little feet sticking out from under the covers; I will always remember her sheer will and grace. She was slight; I suspected 5 feet tall in her prime. Even in sickness she put on a strong front and a smile for her family. Following several chemo treatments she wore a wig that never would sit quite straight while laying in that hospital bed. I learned from one of her sons that she was a woman of great faith and later heard about her gratitude when the chaplains prayed with her.

After a family meeting and transition to comfort care, I went with our palliative care nurse to check on the patient and her family. The shades were drawn and she was sleeping, her sons keeping watch. I stood quietly at the foot of her bed, trying to blend into the background so as not to draw any attention during my observations. The patient, who had reportedly never complained in life, was determined not to complain even in her decline. She had been refusing pain medication because “she didn’t want to make it a habit.” Her nurses had been trying to help her understand that she was at no risk for addiction to pain medication at this point.

I have never found the idea of death to be scary and this was not death under sad circumstances. This woman felt that she had lived a full life and found relief in the acceptance of her illness. She was surrounded by her family and they only desired to carry out her wishes in her final days. She had no unfinished business or family disputes, no last minute confessions; she was at peace. She was in pain, but also seemingly equipped with an inner strength that allowed her to bear it with dignity.

She awoke during our visit and her family again inquired about her level of discomfort: wouldn’t she please just take something for the pain? She responded, “I don’t need medicine for this pain. I just need my Lord and he is ready for me to come home.” I was surprised to find myself looking out the window for any distraction that could keep my eyes from tearing up. I scolded myself for thinking of my own mother, 30 years in the future with me at her bedside, and prayed that I would have the strength to carry out her wishes and give her dignity in death the way these sons were doing for their mother. How do you say goodbye to your mother? These thoughts took only a few seconds, but as I turned my gaze from the window back to the patient, I noticed one of her sons looking at me. I was instantly embarrassed; worried that it would seem I was not paying attention to my preceptor and to the patient. That’s when he picked up a box of tissues, walked across the room, and said “How are you doing?” At these few words, I took a tissue and began to cry quietly. He hugged me and I willed myself to regain control, horrified at my inability to keep my emotions tucked away.

Later, our nurse explained that seeing emotion in healthcare providers can in itself be cathartic and healing for those we serve; I was busy berating myself for what I saw as a lack of control. Still, I knew that I had just witnessed a profound moment in my education and career. My thoughts remained with that patient for several days as I continued to ruminate on what made this experience so different from others.

Upon reflection, I continue to be amazed at the absolute peace and faith of that patient in her religion and her God. It took several days for me to realize why I had been so profoundly touched by this patient and her family. A man, so evidently in pain and grief over the illness of his mother, had the incredible compassion to recognize grief in, and to reach out to, a young medical student. I know this will not be the last time that I am moved to tears by a patient; I just hope that the next time I will recognize it as a way to connect with patients and families. I will appreciate that ability to empathize as a gift and not as a weakness. Patients place an incredible amount of trust in physicians and nurses when they allow us to guide them on this final journey; it is an invaluable lesson to learn that sometimes in these moments, patients have the capacity to heal us too.

Rosemary C. Bailey-Pridham
University of Cincinnati College of Medicine

 

Emily Guh: Study Patients Make an Impact

August 24, 2011

At the end of her annual follow up session at the Einstein Aging Study, M looks at me through thick-lensed glasses and tells me in a wavering voice that she is always amazed at the things she can remember and the puzzles that she can solve at her age of 90. In particular, she finds the Block Design Test, where she must take blocks that have all white sides, all red sides, and half red-half white sides and arrange them according to a pattern, particularly challenging and enjoyable even though she has done them in previous years. She goes to pick up her complimentary lunch and excitedly remarks that she has changed it up this year and is getting a turkey sandwich instead of ham! She gets in a cab to go home after spending the morning at the study, and she smiles and waves through the window as the car pulls away from the curb. I imagine that she will change into more comfortable clothes once she gets home as I suspect she had worn her “Sunday’s best” to the session, the highlight of her day.

M is a 90 year old caucasian female who lives in the Bronx and has been a participant of the Einstein Aging Study (EAS) for 14 years now. Since 1980, EAS has been enrolling participants as early as the age of 70 and has continued to follow them until death or diagnosis of dementia. Currently, participants undergo annual cognitive and functional tests, physical examination, gait analysis, blood testing, and voluntary genetic analysis and MRI scanning in order to create a database of information used to determine factors that can predict cognitive decline in populations of community-dwelling elderly individuals. For example, data from the EAS has shown that a certain polymorphism of a cholesteryl ester transfer protein may be associated with slower memory decline and lower incidence of dementia and Alzheimer’s disease risk. Researchers at the EAS have also determined that gait speed of an elderly individual in a clinical setting is an accurate measure of their functional status at home. The data gathered at the EAS sheds light on both the process of aging as well as factors that can predict onset of dementia and cognitive decline, information extremely useful in the clinical setting.

It is participants and patients like M that have drawn me into the area of geriatrics. A friend cautioned me that the elderly individuals willing to participate in a research study are most likely the friendlier, healthier, and better-adjusted individuals, which could cause me to have a misperception of the ease of dealing with elderly patients. However, when I have met geriatric patients this past year, even the grumpy and disgruntled ones, I have still enjoyed working with and talking to them. There is something that is gentler about them, and my compassion seems to come a little more easily for them. The changes that they are experiencing—possible mental and physical deterioration at varying rates of progression—can be scary and painful, and all of my interactions with older adults, whether within a medical institution or not, inspire me to research the process of aging in order to better take care of geriatric patients in the future.

Emily Guh
Albert Einstein College of Medicine

 

 

Sydney Harvey: One on One Conversation

August 23, 2011

My days with the MSTAR program have thus far began in the lab, at 8 o’clock sharp. When I enter the lab I invariably find the researcher that I work with most closely, Dr. Sarkar, already engrossed in a scientific journal or news article on his computer. When I come in he quickly finishes and we set about our work, analyzing pre- and post-synaptic ion channel changes related to Alzheimer’s disease, which ties in with the lab’s overall goal of discovering neuroprotective estrogens. The work involves immunochemical assays and western blots, among other things, which take a little bit of time to develop. As we set up our procedure of the day, we begin to talk.

I think the talking is perhaps my favorite part of the whole experience. Doing the science and seeing how it is done gives me insight into what my career might look like in 10 years; the talking reminds me of why I am interested in doing it. I enjoyed my neuro course in first year, but it cannot compare to one-on-one exchanges with a talented researcher in the field of neuroscience. The time between setting up an experiment and letting it run is filled with deeper philosophical discussions about how the brain works, what our experiments mean, and where the field might go in the future.

At midday it’s time for my superwoman act – I only have 45 minutes to do lunch, check my emails and change into business casual clothing suitable for the clinic. Much to my amazement, I have yet to forget my stethoscope in the process! More often than not I am working in the patient care center on campus, with our highly sought-after geriatric clinic. There are so many patients interested in appointments that the clinic is booked up through November.

When I arrive there are so many things going on that it was intimidating at first. There are sometimes other students – fourth year medical students or rotating PA students – working with patients alongside nurses, PA’s and the physician on duty. Initially I was a little unsure about how I could be useful, but soon I got into the habit of checking vitals, reviewing charts, and even taking a history or two. The first time I took a real, live patient history was invigorating. Me, an almost-second year student, given the opportunity to get a taste of real clinical work? How amazing is that?

Aside from actually practicing clinical skills, I have learned a lot from observation. I had an interest in geriatrics to begin with, but I didn’t realize how varied one afternoon could be. Some patients are very healthy, others are fighting multiple comorbidities and social stressors, and still other dementia patients come in with varying degrees of the illness. I saw one Alzheimer’s patient who seemed fine in conversation, yet didn’t know the year; another sat and played the harmonica as the doctor reviewed their medications with the family. The clinicians themselves are attentive, compassionate and thorough. Even with a heavy patient load, they still take as much time as they need to talk with the families, setting up family conferences if further discussion is necessary.

At the end of the day I’m left with two distinctly different experiences linked by one common thread: everyone in the equation, both in the clinic and the lab, is working to better the lives of patients. I have learned so much in the last week and a half about neuroscience, laboratory procedure, academic medicine and clinical skills, and yet it doesn’t really seem like work. I wouldn’t spend my summer any other way.

Sydney Harvey
University of North Texas Health Sciences Center at Fort Worth

 

 

Lori Myers: New Work Experience

August 22, 2011

I have settled into my homey little cubicle here at the Indiana University Center for Aging Research. A sign graces my door/entrance and reads, “Lori Myers, MS2 MSTAR Scholar.” I feel so official. I have a stapler, an office phone, an array of colorful pens, and even my own roll of tape. I have yet to use my tape, but I can see it in my peripheral vision just begging to stick something to something. In the meantime, it contributes to my “official” office experience. I am here every day from about 9-5, 8-4, or even 7:30-3:30 (if I’m feeling really ambitious), attending meetings, working on my project, and reading articles. The people are extremely nice and helpful, and the building is pleasant, well-lit, and usually a perfect temperature (usually). I like the feel of going in to work. I like the normalcy. Being a student at 23 seems to delay entering the “real world,” but I like this grown up feel I’m getting working as a researcher. I’m sure 99.9% of working America would think my contentment with my experience so far is ridiculous or naive, but I beg to differ! Let me explain, and I promise it’s not just about my tape roll.

I began worrying about grades, extracurricular activities, studying, and general over-achieving in the 7th grade. This puts me at about 11 straight years of spending the majority of my time thinking about grades, medical school, whatever. I would not allow myself time for hobbies or recreation, and if I did, I felt guilty. I can’t express how nice it is to go to work, work hard while I’m here, then have the evenings and weekends of my summer open for reading, drawing, working out, spending time with friends, and just getting to know myself all over again. Yes, I’m learning a lot about geriatric research and research processes in general. Yes, I’m excited about my project and think about it often (even when I’m off work). Yes, I have a very intelligent, kind mentor. All of these elements are expected of a great summer experience, and I knew MSTAR would likely exceed my expectations. I did not, however, expect the comfortable and accepting environment that the MSTAR program directors, assistants, and mentors have fostered. For once, I don’t feel like a frazzled medical student with the constant weight of upcoming tests pressing on my shoulders. I feel like a normal working adult, but I’m still accomplishing things. The program means guidance, mentorship, structure, and challenges, but at the same time it incorporates an opportunity to learn and explore interests without stress and pressure.

I consider the opportunity to be a medical student a great, great privilege, but I consider the opportunity to be a student with time and interests outside of school an even greater privilege. I think it is rare to find a program that allows a student to pursue research and build life-long professional relationships and mentorships without seeping into and absorbing his or her free-time. I am enjoying my 9 am-5 pm now. I did sign up to be a doctor, however, and no matter the hours, it’s what I’m meant to do. So when 9 am to 5 pm turns into 5pm to 9 am, I will reflect back on this time fondly, and I will think of my dear roll of tape, wishing it was here to tape my tired eyelids open.

Lori Myers
Indiana University School of Medicine

 

 

Suvi Neukam: Why Geriatrics?

August 18, 2011

“Why geriatrics?” is a question I get a lot. My compassionate side answers with an explanation of the fulfillment that comes with helping the elderly to achieve health or relieve pain. My practical side, however, thinks about the disparity between the aging Baby Boomer population and the shortage of geriatricians. The truth, however, is far more selfish. Why geriatrics? Well that’s easy— the patient’s are entertaining! When I think about some of my favorite pastimes—reading, visiting with friends, watching movies, people watching— common to all of them is their ability to give me a story. Similarly, geriatric patients are unique in the sense that they have three to four times the life experience as other patients and they often greatly enjoy the opportunity to share their stories. Over the past several years I have come to realize this characteristic of elder adults and my appreciation of it through myriad service and personal experiences. After my first day as an MSTAR fellow, I was thrilled to know that this summer would be yet another opportunity.

After my first week in the MSTAR Program, I had a slightly modified explanation for the “Why geriatrics?” question. Sure, there is still the compassionate clinical and practical fulfillment, but also my “selfish” motivation has become less selfish. I used to merely look forward to appointments salted and peppered with personal anecdotes. Now, however, I realize that the opportunity for patient’s to share is just as therapeutic and beneficial to health as any other more conventional treatment. Sharing stories reaffirms purpose, and a strong sense of purpose increases longevity. As an MSTAR-trained physician, I now realize that allowing patients to remember their past will help to enhance their future.

Suvi Neukam
University of New England

 


Tiffany Harris: No Typical Day

August 17, 2011

Today I am starting my fourth week of my MSTAR experience. This puts me at about the half-way mark of my 8 week stint. Thus far I have enjoyed my time and really appreciate this opportunity. Prior to this summer, I had no research exposure or experience. I decided to apply for the MSTAR program because I would be able to be exposed to the research aspect of medicine while further exploring my interests in aging.

At my home campus, I was able to find a physician/researcher who was doing work in two areas I am interested in: aging and neuroscience. We are examining the possible role of inflammatory molecules in the natural aging process that occurs in the brain. Preliminary data is very exciting!

There really is no typical day for me. Depending on what part of the experiment we are running, I arrive at the lab at varying times during the day. Each night last week, I stayed until about 8pm. Even though some days are long, the time flies by quickly. My mentor and his assistant show me all sorts of lab techniques, machines, and gizmos, so I keep plenty busy. Due to my lack of experience, the first week or so was spent being introduced to the lab and some basic techniques. The other couple weeks I was able to trek on my own a little. In addition to my project, I have been shown a couple of the other major projects being done in the lab. I find these very fascinating, and they really open my eyes to what this side of medicine is all about.

The next couple weeks I will be analyzing my samples for the expression of those targeted inflammatory genes. If all goes well, I will then have a couple weeks to sort through and analyze the data we retrieve. So far, I have had a great experience and have learned much. I never thought I would willingly learn more information the summer after my first year of school! I am very grateful for this opportunity and I hope to continue learning throughout the next 4 weeks.

Tiffany Harris
University of Nebraska Medical University

 

 

David Priemer: Using Technology for Falls Research

August 16, 2011

I just finished the first three weeks of the program and it has been nothing but a positive experience thus far. I have helped conduct research as a volunteer in this laboratory before and thus have become reacquainted to many old faces, which is always nice, and have taken a step forward in the laboratory as someone who actually has their own project as opposed to being an aid in others.

I am completing my MSTAR project in a clinical biomechanics laboratory associated with the College of Applied Health Sciences at the University of Illinois at Chicago. The focus of this lab is the study of musculoskeletal aging, using motion technology, much like that used to make 3D games like Madden and movies like Avatar. We strategically place reflective markers on joint surfaces of our subjects and, using motion cameras that emit light and receive reflections off of the markers as information, we are able to record and analyze the movement of our subjects to get a unique look at how they control their movement.

The title of my project is "A comparison of stability during overground and treadmill walking in community-dwelling older adult fallers and non-fallers”. Very basically, I am studying the gait patterns of older adults between the conditions of walking over normal ground and on a treadmill while also comparing two groups of older adults that we’ve characterized as either “non-fallers”(those who report no falls within a year) and “fallers”(those who report multiple falls within a year) specifically looking at variables of step width, step width variability and margin of stability(a calculated measure of dynamic stability). The same protocol has been completed with a published manuscript through this lab using younger adults to study how gait changes between the two conditions. What I am investigating in this project are the differences between young subjects in the previous study and older subjects and also to see if we can differentiate “fallers” from “non-fallers” based on what we find.

During the first week of the program, I spent nearly all my time going through the lab’s contact lists and recruiting subjects, so far I have 19 of the 20 subjects we plan to have scheduled either in this month or the next. During the 2nd week and through to this one, I have mainly been seeing subjects and cleaning the motion data to prepare it for analysis. The protocol for each subject is completed in 1-2 hours, however converting what the motion cameras see as markers into something discernable as a moving body and ready for analysis(a process we call “cleaning”) can take several hours per subject, depending on how smoothly the data collection went. I have seen 9 subjects already and am thus approaching a sizable number of completed subjects with fully cleaned data so that I can begin preliminary analysis of their actual gait events.

Outside from the science for a moment, my experience has been a great one as well. As a primary investigator in this study and one who gets to interact with the subjects, I’ve gotten to meet and briefly get to know a small, but still diverse and interesting group of older adults with rich and active lives. Meeting these people would change anyone’s outlook on what it means to age should it be a negative one. The older adults in my study, whether they’ve been labeled as “fallers” or “non-fallers” have undoubtedly been and will continue be an inspiration to me as I continue this project.

David S. Priemer
Saint Louis University School of Medicine

 

 

Michelle Barlow: No Easy Answer for Pain

August 15, 2011

A few weeks into my summer project, and I officially have a better understanding of the true nature of this process that we call “research.” Unfortunately, my initiation into this world comes with an agonizing wait for that elusive entity known as “IRB approval” to allow my project to proceed beyond background research into the prospective collection of data. However, I cannot complain as this time has afforded me the opportunity to prepare more fully to undertake the data collection as well as increase my knowledge of the topic, geriatric pain management in the ED. As a result, I am in the process of coming into a fuller understanding of what exactly pain means to an elderly patient, what we ought to be doing to treat it, and ways in which the reality of this treatment can be improved. It turns out that just like everything else in geriatrics, and most things in medicine as a whole, pain is anything but simple.

Pain comes in many forms and levels of severity; it is truly as diverse as its population. It has many causes, both chronic and acute, but it also may be the cause of additional problems, such as delirium and depression. In geriatric patients, the true source of pain is often disguised behind dementia or accepted as a natural cause of aging, and its treatment can be just as complex as the diagnosis. Truly, care of the geriatric patient in pain is not for the faint of heart. It requires time and dedication, and often leads to both practical and existential questions. When do the benefits outweigh the risks? When is enough, enough – when is it better to let them rest in peace rather than continuing to do invasive surgeries and procedures? How can I do my best as a physician and still learn how to let go without feeling like a failure? This, of course, is part of the challenge and the charm of geriatrics. There is no easy answer. Many patients require numerous specialist consultations and high levels of teamwork; they take time and effort above and beyond the average UTI or common cold; they must be treated with compassion and gentleness that you didn’t necessarily know you had, but they have so much to offer in return. They can help make you the best that you can be, a doctor with a wide range of knowledge and a big heart.

Unfortunately, many doctors only see their geriatric patients when they’re sick. They’re short of breath and in pain; they’re delirious or demented or depressed; they are tired but alive. But just wait until they’re well again – see their faces light up as they talk about their kids and grandkids, watch them go for walks and play games with their friends, see the sparkle in their eyes and that big sincere smile that makes it seem as if they have discovered the secret to what life is really all about.

Of course, I don’t expect to see this entire transformation take place during my time in the ED. After all, the Emergency Room is a place of practicality, not existentialism. There are simply too many patients and not enough time to really be able to address the multifactorial concerns of a geriatric patient. Perhaps this is why EM physicians struggle to adequately care for their older patients. It can be a harsh environment for everyone involved, but it doesn’t have to be. One step at a time, we can improve the system. And if my one meager research project can promote change just enough so that future physicians get to see one more wizened face light up with sparkling eyes and a knowing smile as they walk out the door, I will be pleased to have been a part of the progress.

Michelle Barlow
Mount Sinai School of Medicine

 

 

Vincent Cheng: Working with Rats

August 12, 2011

My first several weeks in the MSTAR program have been an amazing introduction to the field of geriatrics. On my first day, my mentor at the Johns Hopkins Bayview Care Center, Dr. Jeremy Walston, explained the basic causes of frailty in older individuals and how his lab investigated components leading to this outcome. I appreciated Dr. Walston taking the time out of his busy schedule to explain the reasoning behind the different projects in his lab and how these would help improve our understanding of frailty.

During my first few weeks as an MSTAR student, I learned new lab techniques, such as working with rats for the first time. In a project studying the effects of a rapamycin diet in rats, I worked with other investigators on designing a treadmill training program to test muscle strength. On the first day of training the rats, my fellow investigators and I discovered that many of the rats were reluctant to begin walking on the treadmill. The lab director suggested that the rats disliked walking towards a dark wall and lacked a sense of direction. Thus, we placed a piece of white paper at the distal end of the treadmill and were delighted to find that, following this modification, the rats were much more eager to use the treadmill. It was a wonderful example of how an insightful yet simple intervention could significantly affect the efficiency of an experiment.

Working with rats has been exciting in unpredictable ways as well. During one of the trials in our experiment, one of the rats pushed the glass covering on the treadmill and escaped! My co-investigators and I quickly secured the area or, in layman’s terms, slammed all the exit doors as fast as possible. Despite this sudden twist in our plans, I am happy to report that my colleagues and I were able to retrieve the rat unharmed…and the rat was unscathed as well. I realized that, even in an unexpected event, one can learn important lessons in becoming a skilled researcher. In this case, I learned that there are often unseen challenges in an experiment. My colleagues and I were sure to rectify this minor oversight by weighing down the glass covering in future trials.

Vincent Cheng
University of Kansas School of Medicine

 


James Peairs: Ophthalmology Experience

August 11, 2011

During my first week and a half in my mentor's laboratory and clinic, I have been able to shadow Dr. Zhang in his ophthalmology clinic as he sees patients with age-related macular degeneration and diabetic maculopathy, two diseases that affect the geriatric population. Recent treatment advances target the growth of new blood vessels underneath the retina by blocking the effect of Vascular Endothelial Growth Factor (VEGF). In the last decade, as these anti-VEGF intraocular injections have been studied, clinicians have begun to wonder why certain patients react to treatment with large reversals of their vision loss, while others seem to have a more muted response. In his laboratory, I have participated in experiments to help elucidate if there are genetic determinants that drive these differing responses.  Dr. Zhang has collected blood samples from consenting patients, and they are divided into those patients who respond well to treatment, and those who do not. DNA is collected from the blood, and this DNA is analyzed at certain single nucleotide polymorphisms (SNPs or "snips") that differ in the population to see if there are any SNPs that predict treatment response.

Dr. Zhang believes that within 5-10 years, doctors will be able to access a patient's full genome and select treatments that work best for a patient's genotype. I have only been in his laboratory for a little more than a week, but I already feel like I'm on the cutting edge of medicine that might one day help a person keep their eyesight and their independence.

James Peairs
Boston University School of Medicine

 

 

Victoria Yeh: Stepping into the Lab, Patients' Lives

August 10, 2011

I am currently involved in two different projects – I am collecting and organizing data for a study on the cognitive status of patients with heart failure and their adherence to medications, and doing data analysis for a study on injuries and illnesses that occur in patients with cardiovascular problems. Both research projects aim to answer questions about patients’ ability to adhere to their treatment regimens for heart disease. For some patients this can be very difficult, and one of the important questions I’ll be looking at is whether it is even more difficult for patients as they get older.

To start off my research, I spent some time doing a literature search to see what others have found in studies on adherence to treatment and exercise. I learned a lot about the different factors that make it difficult for patients to take their many medications, as well as the factors that influence a patient’s ability to exercise after a cardiovascular event. I’m beginning to gain a deeper appreciation of the challenges experienced by elderly patients with heart problems - remembering the dosage and timing of numerous medications (including ones that are unrelated to their heart problems), difficulty accessing or obtaining their medications, trying to exercise despite aching muscles, arthritis, and symptoms such as shortness of breath, and having to deal with multiple co-morbidities. I think these are all important factors to keep in mind when I treat my elderly patients in the future, and using this knowledge, I will try my best to help them work around these problems to maximize the effectiveness of their treatments.

I also went on data collection visits with the research team to see patients in their homes. During the visits, the patients were given tests to evaluate their cognitive function and knowledge of heart failure. Since I was new to the study, I mostly observed while the tests were being performed, and counted the patients’ different types of pills to track how many they’ve taken. The patients also have high-tech pill boxes that track the number of times they open the box throughout the day, as well as scales that are used to record their weight. I’m beginning to discover that medication adherence is a very difficult subject to research – it’s hard to account for what happens to each of the numerous pills that patients have in their possession!

I’ve also enjoyed seeing patients at the retirement community where I shadowed my faculty sponsor. When we saw patients who lived in the retirement home apartments, I discovered that you can learn quite a lot about the patients just by stepping into their homes. I could see if the patients had difficulty moving around in their homes, whether they kept important objects within their reach, and photos of family and friends. I’ve also learned a little about important issues that come up when working with older patients, such as evaluating the need for guardianship when patients begin to lose their cognitive abilities. The patients in the retirement community have been very friendly and great to talk to, and I enjoy learning from them every time.

In the next few weeks I look forward to looking through more of the patient data to find patterns and different factors to analyze, and when the data is finally organized I can eventually do a statistical analysis. I think there will be many interesting findings from the data!

Victoria Yeh
Case Western Reserve University School of Medicine

 

 

Sean Wo: Working With a Research Patient

August 9, 2011

I arrived at the lab early on this particular morning, and I was already sweating from the muggy Pittsburgh summer. Although my involvement in the MR HYPER (mister hyper) project mostly involves behind-the-scenes data analysis, I had the opportunity this morning to see for myself how the data is collected.

Today's subject, a middle-aged female, came bustling through the door about 20 minutes late. Being in a hurry didn't help either. MR HYPER compares brain aging in prehypertensive people with normotensives. Measuring blood pressure accurately is crux of the project, meaning that she would have to sit calmly for several minutes before the research assistant could take her BP. Unfortunately, this also meant that the subject, whom I'll call Ms. H, was going to miss her MRI appointment.

After some logistical wrangling, Ms. H finally made it to the MR magnet, but it was not all smooth sailing from there. She suddenly found herself claustrophobic upon entering the scanner bore and had to be taken out. With the help of her significant other, she coaxed herself back into the scanner, but had to be taken out again when the MR images showed that there was something metallic in her hair. Ultimately,

Ms. H completed the scans, which lasted a whole hour. The SO was a real trooper; he sat in the corner of the uncomfortably cold scanner room giving moral support while the rest of us cleared out to the more hospitable control room. Ms. H had a hard time staying still. She squirmed and kicked often, making some of the MR data quite poor. However, as much as I wanted her to keep still, I could understand the difficulty of doing so. Some years earlier, I was a subject in an fMRI study and I remember how unnatural it was to have my head strapped onto a bed lying in the middle of an oversized, noisy magnet.

In the afternoon, I went with my PI to see a statistician who would give us some instruction on doing diffusion tensor imaging (DTI). I had been reading up on various MRI modalities, trying to make sense of the math involved. The statistician explained things in clear terms, but most of the theoretical stuff is over my head. I found myself wishing that I had paid more attention in college during linear algebra class.

I spent the rest of the day trying to set up a way to calculate grey matter thicknesses on the brains of MR HYPER subjects. As it turns out, reconstructing brain surfaces from MRIs takes a lot more computing power than the typical medical student laptop. I found a distributed computing project on campus that I think will help me, but progress for the day was slow because of my inexperience with Linux. I think I'm pretty handy with computers, but I'm no programmer like many of my fellow med students, an illustrious crowd they are. At the end of the day, I reflected on how my aging research calls on all the skills and knowledge that I've accumulated over the years and then some. Coming into the summer, I knew that the studying I put into my med school neuroscience course would pay off, but I never suspected that the times I slept through math in undergrad would come back to haunt me. Although challenging, using neuroimaging to study aging is truly a worthwhile and interesting pursuit.

Sean Wo
University of Pittsburgh School of Medicine

 

 

Jamie Sparling: Neuroimaging Research Focus

August 8, 2013

Hello! I’m Jamie Sparling and I just finished my first year at Boston University School of Medicine (BUSM). This summer, I am completing an MSTAR research project in the lab of Dr. Angela Jefferson of the Boston University Alzheimer’s Disease Center (ADC) and participating in the educational component at Harvard Medical School. I’m wrapping up my third week of the program, so I’ve been able to get settled fairly well here at the ADC. I had participated in the ADC’s PAIRS (Partnering in Alzheimer’s Instruction Research Study) program, where first year medical students are paired with an early stage Alzheimer’s Disease patient, and we meet monthly during the school year. This research experience allows me to continue working with our PAIRS program director, Dr. Jefferson, while experiencing the vital research core of the ADC.

Throughout each week, I attend meetings for our research group, as well as guest speaker presentations and consensus meetings for the HOPE study. The Health Outreach Program for the Elderly (HOPE) study is a long-term study of memory and aging. In the weekly meetings, several other medical students and I observe as a group of neurologists, geriatric psychiatrists, and neuropsychologists review the subjects’ clinical, neuropsychological, and neuroimaging data in order to make a diagnosis. It has been very enlightening to witness these discussions and gain a better understanding for what constitutes normal cognitive aging” vs. mild cognitive impairment (MCI) vs. dementia. Earlier this week, I also went to an orientation for our Geriatrics Section here at BUSM. Our medical school is unique in that we have a required 4th year rotation in Geriatrics, so I will be able to join these students for some of their didactic sections and clinical experiences. The faculty and staff that make up the section are very warm and welcoming, and I look forward to continuing my relationship with them throughout my remaining years at BUSM.

Most of my time, of course, has been devoted to my research project, which uses neuroimaging data from the Alzheimer’s Disease Neuroimaging Initiative (ADNI). I have been studying the literature to better understand the approaches other researchers have taken to quantify and characterize microvascular changes in the brain, as well as their use of Pittsburgh compound B (PiB) to image amyloid. At the same time, I have been working with others in the lab to leverage an automated reconstruction tool to analyze these images. This will allow us to relate these changes in the brain with clinical risk factors and cognitive outcomes based on neuropsychological tests, which is also collected by ADNI.

This past week, I also began the clinical component of my MSTAR experience. I have the opportunity this summer to shadow both geriatricians and neurologists in a number of different settings, including in-patient rounds, clinic, home visits, and a nursing home. In my first session, I shadowed a neurologist specializing in movement disorders. We saw several patients suffering from Parkinson’s Disease, and I learned a great deal about the diagnosis and treatment of this condition. I also witnessed a case of iatrogenic parkinsonism, which reinforced to me the complexity of patients’ medication regimes, particular for older patients, as well as the central role of a primary care physician in managing and coordinating this complexity.

Next week, I begin my Geriatrics shadowing, as well as our didactic sessions for the program. I’m looking forward to meeting the other MSTAR students who are in Boston for the summer. Our first few sessions will cover research methodology topics, as well as an overview of the aging research fields, which we’ll focus on later in the summer. I think that the sessions will be both useful and thought-provoking, and I’m very grateful to have the opportunity to participate in a program that balances the research, clinical, and didactic components of academic medicine.

Jamie Sparling
Boston University School of Medicine

 

 

Lisa Maclean: Seeing Overlaps

August 5, 2011

Last night, I was trying to decide what I should look over before my geriatrics rotation. I made a list of the common medical conditions that I associate with older patients: dementia, arthritis, broken hips, cancer, heart disease. As I looked at this list, I immediately realized that there was no obvious section of my old study guides, class notes, or textbooks that would cover most of these topics. We were introduced to some of the basic principles of cancer in our biochemistry class, broken hips came up in anatomy, we learned a little about arthritis during our radiology unit, and heart disease was a major topic of physiology. Dementia had been a major topic of conversation in our social medicine class, and we’d also discussed it some in our clinical skills class, but we had learned very little about it in our basic science curriculum. My first-year medical school education had introduced me to each of the conditions on my (very subjective) list of common geriatric problems, but none of these topics overlapped in any of my courses.

Like most medical students, I’ve had fairly little clinical exposure. I’ve volunteered in the student-run clinic, and I’ve shadowed doctors in a few specialties. I’ve also had the chance to see patients in an outpatient setting thanks to clinical skills weeks integrated into the first-year curriculum at UNC. But until today, all of my experiences were confined – quite literally – to a fairly small geographic setting. I had always thought that doctors either work in an outpatient clinic or in a hospital, but not in both. Once again, geriatrics is a field where all of these seemingly discrete aspects of medicine overlap. The geriatrician that I worked with today sees patients in three settings. He spends the first part of his morning at an outpatient clinic on the campus of a local retirement community where he sees patients for routine check-ups, follow-up visits, and for treatment of acute illness. After he finishes up with his outpatient visits, he goes to the assisted living floors of the retirement community where he visits with patients who skilled nursing care, either temporarily or permanently. On the skilled nursing floor, his patients that have the same range of illnesses as many of the patients in his outpatient clinic, but their conditions may be more severe or complicated by other health problems. In the afternoon, he leaves the retirement community to visit patients in the hospital. Inpatients may be receiving palliative care, recovering from surgery, or suffering from a severe acute illness.

As I spoke with my preceptor about the variety of clinical settings that he works in, he mentioned that one of the most important aspects of his job is deciding when to transition patients between these settings. Each setting has different advantages and different drawbacks, and you often have to trade a person’s independence and social support for increased medical care. These decisions are complicated further by the patient’s financial status and insurance plan, the involvement of the patient’s family, and the resources that the hospital or skilled nursing floors have available.

During my first day of clinical rotations in geriatrics, I saw patients with all of the conditions that I had thought of last night above and (not surprisingly) I saw a number of conditions that hadn’t made it on to my list. Geriatrics draws on knowledge from every class that I’ve taken in my first year of medical school, and it also exposes me to a wide range of clinical settings. I feel so lucky to be getting this kind of clinical exposure geriatrics so early on in my medical school experience, and I can’t wait to continue.

Lisa MacLean
University of North Carolina School of Medcine

 

 

Seth Levin: Many Firsts

August 4, 2011

I am almost two full weeks into my summer MSTAR at UMass Medical School. I have made great headway on the project, which focuses on the cognitive status and behavior of heart failure patients following acute symptom onset. I am very excited to explore my interests in geriatrics in the domain of epidemiological research. Having recently completed the cardiovascular course block at the end of my first year, I am also eager to apply my clinical and basic science background in heart failure to a study that will enhance the understanding and treatment of this condition.

This summer marks several “firsts” for me. Not only have I completed my first year of medical school, but I am now working on my first clinical research project. Having conducted basic science research in college, I was initially nervous about the transition to the clinical and population sciences. Despite my trepidation, I have found the experience incredibly rich and the atmosphere very welcoming. My research mentors, Dr. Gurwitz and Dr Saczynski have provided me with excellent input and have helped me transition into the research environment.

Working in the geriatrics division of the medical school has been extremely rewarding. Earlier this week and today, I had the opportunity to attend several departmental meetings in which geriatricians from the medical school presented their individual research projects, ranging from investigations of patients with acute coronary syndrome to studies of hospice care. The meetings provided a glimpse into the research atmosphere, where each member brings his/her own expertise to the conference and is eager to provide input. I was also fortunate to learn about the educational development of geriatrics in the medical school curriculum, including the integration of aging topics into my second year coursework. My research mentors have encouraged me to participate in similar meetings over the summer, including a venue to present my research and receive constructive feedback.

I feel privileged to be a part of a community of clinicians and researchers, whose common goal is to enhance healthcare in the aging population. This evening, I will be attending a dinner celebrating the 15th anniversary of the Meyers Primary Care Institute, a collaborative organization among UMASS Medical School, Fallon Clinic and Fallon Health Care, that promotes primary care through education and research projects. I am greatly looking forward to the occasion, where I will meet physicians and fellow researchers with similar passion for geriatrics. In the mean time, my chief concern is what to wear to the event.

Seth Levin
University of Massachusetts Medical School

 

Linda Scheider: First Days in the Geriatric Clinic

August 2, 2011

This is my second week working as an MSTAR student. Fortunately, the only obstacles I have faced so far are administrative. I am almost through the maze of administration required to have an employee ID, access to the office, access to the computers, and access to the chart system. Everyone is the office has been so welcoming and friendly. They truly operate with a team based mentality in every aspect of work, research, and practice. At this point, I am putting the finishing touches on my Access database, which I will be using to take data for my project. I was able to hammer out the parameters I will be collecting in my project in the last few days with my mentors. I have done some preliminary exploring in the chart system with my mentor to make sure I understand how to use the program and I made sure all the parameters I wish to collect can be easily located in the patient’s charts.

This morning I was able to shadow in the Geriatric Clinic. I really enjoyed this experience. As a first year medical student, I was really interested to see so many patients with positive findings. I heard three heart murmurs this morning, and practiced grading them. Two patients were in the clinic with chronic ulcers and I watched the wound care required for these types of injuries. It is very informative to hear many of the patients talk about the bad doctors that they were at before and how much more they appreciate the care they are getting in this clinic. I believe the success is mainly due to the open communication approach taken by the practitioners here. This allows the patients to make informed decisions, feel more comfortable, and confident in their care. These are some of the lessons that I hope will shape the doctor I become.

Linda Scheider
Virginia Commonwealth University School of Medicine

 

 

Elisha Fredman: Starting Early in the Lab

August 2, 2011

I arrived today in the lab at 7:00am. In my undergraduate research, my PI was a PhD researcher who had no preference for what time we arrived to the lab, as long as the work was done. I guess that is one of the differences I have encountered working with this group of doctors, specifically surgeons, who have always started the work day at a significantly earlier hour. Being mentally focused and present this early in the morning has not been easy, but I am growing accustomed to it.


Arriving in the lab, I say good morning to at least eight or nine other doctors and residents, all dedicated to the same goals of solving medical mysteries and coming up with solutions to the quality of life difficulties that come along with aging. Even before I arrive at my work station, a feeling of overwhelming purpose washes over me, as I think about being part of this large and motivated team. In this respect, it has been very powerful conducting research as a part of a large and active lab because it has helped me appreciate the expansiveness of the questions we are trying to answer. Being part of such a large group also gives me hope that the work that I do, supported by the efforts of many others with their unique skills and abilities, can have a true and significant impact on the world of medicine.

Thus far, the research itself has consisted mostly of computer-based data system searches and literature reviews. For my project, I will try and insert siRNA into the inner ear of a mouse model for Meniere’s Disease in order to block the neurodegeneration process that causes the progressive hearing loss characteristic of the disease. Laboratory research, however, is a slow and methodical process. Before any experimentation can be done, I must first carefully examine the available data-bases of siRNA and try to select the most appropriate match for our mouse vector. It would truly be a shame to go ahead with a multi-week protocol to find that the initial product was not the right one. In addition to locating the right substrate, I then must review the relevant literature for instances in which others have previously used it, and what their findings were. While this stage is perhaps not the most riveting, it is an essential part of the process, and keeping my mind on the bigger picture helps me press on.

One of the most rewarding parts of working with this group of medical professionals has been the advice and mentorship that I have received from them. Many of them have taken the initiative to get to know me and my clinical interests, and then offer their own stories and suggestions. As such, in addition to meeting some interesting people and learning ab



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