September 2011 Diary of an MSTAR Student
September 2011 Diary of an MSTAR Student

Francis Felice: Arterial Details

September 29, 2011

After a week of trying different techniques to make our protocol work, I finally collected some usable data today. For my project, I'm using a doppler probe to monitor blood flow in the radial artery; this is a technique that has been successfully applied to mouse models with the equipment I am using, but the technique has been untested in humans, so my mentor and I were becoming skeptical when we weren't getting analyzable results. However, with some trial and error, as well as some irritated skin from having to push the probe pretty deep into my arm to get a signal, I've traced the radial artery up my arm so that I will be able to obtain data from a proximal and distal point of the artery.

The first step, which also happened to be the longest step, was to make sure I could get any kind of consistent doppler signal from my radial artery using equipment that was built for rodents. This was predominantly an effort of trial and error, because even though I could readily palpate my distal radial artery, I couldn't find the blood flow with the probe. As a result, I ended up having to try a lower frequency probe, which gave me a lower quality signal, as well as different angles and depths to finally get a signal from the distal radial artery, but this data was not sharp enough for me to perform any meaningful analysis. Furthermore, at this point, I was only able to get a signal at the distal radial artery and I needed to get signals from two distant points along the radial artery for our experiments.

So the next step was to start using the higher frequency probe to see if I could obtain higher quality data from the distal radial artery. Once I was able to consistently find the distal radial artery with the higher frequency probe, I endeavored to find a more proximal portion of the radial artery with the higher frequency probe. This proved difficult, because while I could readily palpate my distal radial pulse, I had a much more difficult time palpating my proximal radial pulse, so I had a difficult time determining where the probe should be placed to have any chance of finding the artery. So I spent time trying to palpate a proximal portion of the radial artery with the hopes of finding a landmark I could use to find the artery on other people. This caused some more pain from probing deep into the arm to try to find the artery, but after some time, I was able to find the proximal radial artery consistently and since it essentially runs along with the distal cephalic vein, I was able to use the cephalic vein as a landmark to find the artery in other people.

Once I was able to find both sections of the artery consistently, my goal was to get a signal that was clean enough to analyze with our software. This took some more time and pain, but I'm now able to get clean signals from both proximal and distal sections of the radial artery independently. Since my protocol requires that I capture signals from both locations simultaneously, my next step is to determine how to capture both signals consistently and in a way that can be applied to other people. So this turned out to be a good week with success following initial frustration. As I have experienced during previous research opportunities, I cannot expect everything to go smoothly and this experience has been no different so far, but that's part of the challenge.

Francis Felice
Baylor College of Medicine

 

 

Elisha Fredman: Dealing with Data

September 28, 2011

Viewing some of my tissue samples under fluorescent light, it looks like there may be a detectable difference between my experimental and control groups, which is rewarding to see. It is especially exciting because, as this is a bench research project and not a clinical study, just treating the samples and then preparing them to be viewed has taken a number of weeks. After all of that work, it feels good to have a positive outcome. At the same time, however, whenever we try and prove something in science, it most often requires multiple avenues through which to confirm that the results are accurate and precise. As such, I know that I am still a few steps away from making any real conclusions.

I shared my findings with the head of the lab, who liked what he saw and asked me to present to the lab at the weekly meeting, so I had my first opportunity to put a slide show together of my work thus far and present it to the group of experienced researchers. It was beneficial to hear their impressions and suggestions on what I have done and what I can do to move forward, which I know will help shape my next steps. In addition to this lab meeting presentation, the medical resident who had begun the project some months ago was asked to present at the department-wide research meeting, at which he also used my slide show and mentioned my contribution to the study. This was also exciting as it gave me some recognition in the department as a whole. In these times of limited residency spots and competitive matches, it is beneficial to receive that recognition and to have the opportunity to meet other senior members of the department.

I don’t want to give the false perception that everything always works out nicely and results are always as expected and satisfying. Some of my data has returned quite peculiar, and as I move on, I will have to give attention to that in addition to the positive results. It is tempting to brush aside conflicting results when positive ones are also present, but this is where one of the core aspects of good scientific research comes in. To be a good and successful researcher, one must carry a sincere and unfaltering sense of honesty. To me, making sure that this attitude remains pure is largely dependent on not losing sight of the reason for which one entered the arena of research, namely true discovery, and not be blinded by alternative motives.

Elisha Fredman
Case Western Reserve University School of Medicine

 

 

Sheila Rustgi: Working with Patients & Teachers

September 27, 2011

Today was a busy day for the MSTAR students at Mt. Sinai. In addition to time dedicated to our research projects, the nine of us come together weekly for a research seminar and didactic sessions as well as to practice our clinical skills in Mt. Sinai’s Geriatric Outpatient clinic, the Martha Stewart Center for Living. Having only recently learned history taking and physical exam skills, I am excited about the opportunity to keep practicing over the summer.

First we heard from Dr. Helen Fernandez, a geriatrician who also runs the Geriatrics Fellowship program at Mt. Sinai, about how and when to perform a geriatric assessment. She taught us some straightforward tests, such as the mini mental state exam and the clock drawing tests, and also provided us with evidence from the literature of their specificity and sensitivity. The session was interactive and we discussed a recent case of Dr. Fernandez. Even though the patient lived alone, Dr. Fernandez had done a very thorough history and found a number of potential issues in the patient’s life. In just a few visits, she was able to create a long-term plan of action as well.

After the seminar, I met with Dr. Melissa Carlson, my project mentor, for our weekly one-on-one meeting. My project is an analysis of inappropriately short and long stays in hospice by cancer patients. I’m using the SEER-Medicare dataset, a registry of deceased Medicare beneficiaries diagnosed with cancer. Dr. Carlson answered some of my questions about SAS and we reviewed the table I had made. After identifying some variables of interest, we created a work plan for the next week.

Following this meeting, I grabbed a quick lunch and reported to the geriatric outpatient clinic. Last week I had shadowed the Chief Fellow, but this week was a bit different. I reported to the Special Medical Office Assistant, Willy, who takes the patients’ vitals and draws blood. As I watched him chat and joke with patients, I was impressed by how quickly he put them at ease. The second patient we saw was a former nurse. She was very talkative and asked me about myself and medical school. She also remarked that Willy is a good teacher as he showed me what he was doing as he drew her blood. After watching Willy draw blood from a few more patients, he took me into a room and announced that I was now going to draw his blood. Having done this only once before, my pulse began to quicken. I asked which arm I should use and he just shrugged. Despite my anxiety, I successfully stuck a vein and Willy didn’t even (visibly) flinch. Then he told me that once he found an appropriate patient with “big juicy veins,” I would draw blood from that patient as well. If I wasn’t sweating before, I certainly was then.

The patient he chose was a very nice man. He sat quietly while I gathered the gloves, gauze and alcohol prep pad. His vein was so large that Willy said he wasn’t even going to stand over me. Although I did have some difficulty, the patient never complained and was kind enough to tell me it didn’t hurt. That was when Willy told me why I should go into geriatrics. The geriatrics patients, he said, were the nicest. Many of them love to chat, like the nurse I had met earlier. Even when he had difficulty drawing blood, the patients just told him to try again without complaining. As I continue to practice and refine my history-taking and physical exam skills, it is encouraging to work with both patients and teachers who are kind, patient and have faith in you.

Sheila Rustgi
Mount Sinai School of Medicine

 

 

Sean Wo: Filling in the Gaps

September 23, 2011

This Tuesday was a particularly long one because of the weekly noontime meeting. Every week, I meet with a group of other students doing summer research in geriatrics or gerontology. This gives us an opportunity to present our work and receive feedback on our project designs as well as presentation skills that’ll be useful at a poster conference. Each of these sessions is hosted by Drs. Stephanie Studenski and CF Reynolds III, esteemed geriatricians at Pitt Med.

Before this meeting, however, I worked on getting an automated brain stripping technique to work. In addition to measuring brain cortical thickness, I’m also working on getting the volumes of various brain regions measured automatically. The trickiest part of this process has turned out to be finding a way to select the parts of an MRI that contain only brain parenchyma and nothing else. Now, this is a long and tedious job for a human to do, but a computer can do a reasonable job in a few minutes. That is, if I can find the right algorithms to do so. After much trial and error, I found a way that stripped skulls from 61 of my 62 brains well, but failed badly on one, leaving behind the entire left eye and a large chunk of occipital bone. It took more than 3 hours of computation time, but I’d say 61 out of 62 half-decent strips ain’t bad at all. Suffice it to say that no paper written on the subject of automated skull stripping concludes that it’s a solved problem.

As ever, the projects presented today at the noontime meeting were very interesting. The first dealt with the neurotoxic side effects of adjuvant chemotherapy on balance, while the second aimed to explore psychiatric predictors of lower back surgery outcomes. Both had samples drawn from older populations, and both were in their early stages. Nevertheless, both addressed fascinating research questions very relevant to current clinical practice.

After this hour-long meeting, however, was a much longer one dealing with using statistical software. Two professional statisticians gave us a crash course on all of statistics, covering everything from types of variables to types of regression. Fortunately, I have some background in using the more common statistical tools. After that, they showed us how to use SPSS to test various hypotheses on a sample data set. I can’t say I got much out of the 2 and a half hour ordeal, but I did learn how to quickly inspect my data for normality using a P-P plot.

I spent the rest of the day reading up on reviews of brain aging. I was hoping I could find one big, up-to-date review that would summarize everything worth knowing about the aging brain, but alas, no such perfect review exists. I can’t complain. Science is democratic in that the people complaining about gaps in the literature ought to consider filling in those gaps themselves.

Sean Wo
University of Pittsburgh School of Medicine

 

 

Kelley Saunders: Alzheimer's in the Lab & Clinic

September 22, 2011

So far, my experience with the MSTAR program has been fantastic. I am doing research at the Banner Alzheimer’s Institute (BAI) in Phoenix, AZ. My project is working with the Arizona Alzheimer’s Registry, a database designed to appropriately match people with research projects currently conducted at sites in the Arizona Alzheimer’s Consortium. At this point, I am still extracting data from the registry for statistical analysis and every step of the process has been a learning experience. As a newcomer to scholarly inquiry and manuscript writing, I have a lot to learn and luckily have tremendous mentors that are excited to teach.

Every week BAI and its clinic staff hold a case conference that is attended by Geriatric fellows, psychiatry residents, nurses, PAs, social workers, students, and other physicians. The cases presented at these conferences are selected for a variety of reasons: the complexity of the presenting illness, difficulty managing medications, challenging family dynamics, or atypical scenarios. Each conference has increased my knowledge about different types of dementias and how they are managed clinically. This is one of my favorite activities of the week.

Although I truly enjoy the research that I am doing, there is nothing more rewarding than working directly with patients. I have been asked to complete cognitive testing on a few patients at their clinic visits. Working with dementia patients one-on-one reminds me of why it is that I chose to go into medicine in the first place. To see the devastation that this disease can have on a patient and their loved ones is heart breaking. However, it is comforting to see that we can help these families navigate this illness both medically and non-pharmacologically. It is possible to have a positive impact on their lives by providing comprehensive care—something I hope to continue throughout my training and future career in medicine.

Kelley T. Saunders
University of Arizona College of Medicine, Phoenix

 

 

Sydney Harvey: A Changing Experience

September 21, 2011

I can’t believe it’s been 4 weeks since the summer began, and I am midway through the MSTAR experience. I’ve learned so much in four weeks, yet I’m left with a sense of amazement in how much more there is to know. The mentoring I’ve received has been fantastic.

In the lab, I have been given increasing amounts of responsibility. In the first week, my mentor was a little uneasy about totally handing off his experiment to a young med student he didn’t know very well. Four weeks later, he is giving me directions and letting me do the experiments basically on my own. In a week he will be attending a conference in Paris, leaving his “precious proteins” from human subjects in my hands until his return. Knowing that he trusts me to work independently gives me a great sense of accomplishment. The next week in the lab will be full of questions and brainstorming as I prepare to start writing my research paper and drawing up a presentation which I will be giving to the students, fellows and researchers in the neuroscience department. Things are starting to really come together for me on the research front.

The clinical experience has continued to be an exciting process. My clinical mentor has exposed me to many different sites including nursing homes and assisted living; as we see patients, words I learned in first year take on new meaning. I intellectually recognized the terms “purpura,” “ectropion” and “lipoma,” but when I saw them on patients it was very different. Though the words did not leap to my tongue when I was asked to identify them, after seeing these phenomena in person I will never forget what they look like.

This summer has also been full of firsts; my first one-on-one patient interview, the first time I heard a heart murmur, my first time consoling a dementia patient (she was convinced she owed me money). In the beginning I was terrified to help write notes or review medications; what if I messed something up? What if I was wrong? I realized quickly that it was okay to be wrong, and it was okay to try new things on my own. My mentor was always there to make sure things were going well. Yesterday I was given the task of getting updates and reviewing the labs on nursing home patients, and I suddenly felt like this medicine thing is something I can do. The patients are amazing, the cases are interesting, and there is always more to learn.

I went into this summer with an idea of what I wanted to do as a career and what I thought geriatrics would be like. I wasn’t exactly wrong about either of these things; I’m still strongly drawn to academic psychiatry, and geriatrics is as complex and interesting as I thought it would be. I wasn’t aware of how much the MSTAR would make me ponder where I would practice, what I would do in academic medicine, and what kinds of patients I want to see. The geriatric population is intensely diverse and rich in history. These patients have so much wisdom to offer, so much life to share. It’s a privilege to take care of them.

 

 

Andrea Vo: Endocrinoology Research Skills

September 20, 2011

After two weeks already in the MSTAR program, I feel like I have been granted a deeply personal and exciting look at clinical research and endocrinology/geriatrics. I am currently working with Dr. Jill Crandall, an endocrinologist, in a study about resveratrol, which is a natural substance found in red grapes and wine and believed to increase longevity. The purpose of the study is to see if resveratrol would lower blood sugar levels in pre-diabetics aged 50 to 80 and therefore prevent diabetes. As simple as the hypothesis may seem, there are so many facets to the clinical research study itself to deal with on a daily basis, and I am thrilled to be a part of it.

Although I cannot conduct physical examinations or perform certain procedures such as muscle biopsies, I am able to sit with the research associates and fellows as they perform the necessary tests. Realizing that this experience is as hands-on as I can make it, I request to train in as many procedures as possible. For example, I now know how to do a bio-impedance assay to measure percentage body fat and EKG, which is something that I learned about in theory in cardiology class but have never practiced. Understanding the study, and the science behind it, makes medicine much more real and intimate. It made research engaging and (dare I say it) fun!

Working with many different research subjects has encouraged me toward the geriatric field as well. Because I have recently trained to handle phone questionnaires, I have spoken to several elderly people who called to find out more about research studies. These are usually people concerned about their health or who simply want to help the medical field by graciously volunteering.

Furthermore, I thoroughly enjoyed working with the research team. My PI, Dr. Crandall, and the research fellows have all been extremely welcoming and encouraging to all my questions. I am hoping to begin shadowing them at their respective clinics and obtain some further experience about different medical specialties outside of the research, such as endocrinology and geriatrics. I am excited to see where the research study leads and what I can learn from it!

Andrea Vo
Albert Einstein College of Medicine

 

 

Victoria Yeh: Many Lessons Learned

September 19, 2011

During the past few weeks, I’ve been looking through many patient exercise diary entries to record the illnesses and injuries they experienced during the time that they were monitored. Throughout this process, I’ve learned a lot about the challenges of data collection in clinical research. One of the most important lessons I’ve learned is that the wording of survey questions is very important – for example, if you ask patients whether an injury interfered with their exercise this week, they might say that their broken foot prevented them from running. However, they might have actually broken their foot a few weeks ago, and meant that the pain from the foot was still bothering them. In addition to this, sometimes patients reported the same injury or hospital visit multiple times, but described the event in two different ways so that it was difficult to tell if they were talking about the same incident. I’ve also discovered that there’s a lot of variability in the patients’ journaling styles – some of them left most of the pages blank unless something very serious happened, while others seemed to feel obligated to record a sentence or two in the journal every day. I think this leads to some bias in our reporting of illness/injury incidents, but it’s a problem that’s hard to avoid.

Sorting out the data has been difficult at times, but I’m almost finished with this step and I’m eager to start the statistical analysis to look for interesting patterns. So far, I’ve been very surprised by the data I’ve seen, though I knew that these were patients with a history of cardiovascular problems, they had far more hospitalizations and emergency room visits than I would have expected, and a lot of minor illnesses (cold, flu, allergies, stomach problems, etc.) as well. I think that as a future physician, this is something I should definitely keep in mind, since these problems could definitely interfere with the patients’ treatment plans and their overall health.

By shadowing my faculty sponsor, I’ve learned that observational skills are absolutely necessary when caring for elderly patients, as some patients are very weak and even basic physical exam procedures can be difficult to perform on them. For example, a few of the patients wouldn’t open their eyes for a long period of time because of the light, or had difficulty opening their mouths. Observational skills were also very important when patients couldn’t response verbally to questions. Last week I saw a patient who only spoke a few words the whole time we were there, and when I saw the patient’s charts I noticed that it said he’d been depressed. I was very puzzled because I wondered how you would know someone was depressed if they never said anything – don’t people usually ask the patients screening questions? My faculty sponsor explained that they figured it out from changes in his behavior and eating habits. I started thinking about how the physical diagnosis skills that I’d been taught were so heavily dependent on asking our patients questions, and realized that although I’d had a lot of practice asking past medical history and review of systems questions, I’d be totally lost if the patient couldn’t talk to me! Hopefully I’ll be more observant as I gain more experience, and become less reliant on asking questions.

I’ve also been seeing a bit more of the retirement community’s facilities in the past couple of weeks – for example, I stopped by the physical therapy center and watched some of the therapists working with the residents on different exercises that were tailored to their needs. I also met an occupational therapist who explained how she helped patients with activities of daily living, such as going to the restroom and moving about their apartments on their own, and a speech therapist who worked with patients on both their verbal and cognitive abilities. It has been great to see how the whole team of doctors, nurses, and therapists work together to improve the patients’ health.

Victoria Yeh
Case Western Reserve University School of Medicine

 

 

Linda Scheider: Reading Charts

September 16, 2011

This is about the midpoint of my time here working for the Geriatrics department under MSTAR. I have truly enjoyed my experience so far. As of the beginning of this week, I finished going through my list of 500 charts for the chart review. This was somewhat dull work but I got faster and faster at it. Some of the patients are very interesting and the more charts I read, the more familiar with Geriatric medicine I became. Now I know some of the common problems that Geriatric patients face after a trauma or surgery and what things can be done to combat them. I am in the process of analyzing the data which I pulled out of the charts for some initial trends. I have another set of data which is monstrous, 200,000 + patients. This data set will be used for my control patients and to provide some more demographic data for the chart reviewed patients. I am focusing on looking at all the parameters I have been given in this large set to see what analysis my team wants to complete. I will hopeful be running analysis and statistics on all the data in the next few weeks to create some summaries and conclusions for the project.

To break up my days of chart reviewing, I have been attending the Geriatric consult service rounds for inpatients. This has been a very rewarding experience especially after reading so many similar charts. I actually knew more than the new residents who came in because I have been reading the charts. I am much more able to keep up with the discussions of care now than when I first started the program. Part of this program that might get taken for granted is simply the experience of just working in a hospital everyday and starting to understand the flow and organization involved. I believe this experience will make my transition into third year much easier.

Linda Scheider
Virginia Commonwealth University School of Medicine

 

 

Sharon Ostfeld-Johns: Creating a New Tool

September 15, 2011

When I first went to shadow a geriatrician this summer, it wasn’t the clinical aspects of my experience that were the most memorable. I did witness an excellent clinician balancing a myriad of concerns for the patients that made up his afternoon appointments. I saw his kindness and openness, and how important it was to the patients to tell me how wonderful he was, and about the health problems he had helped them with or seen them through. But the most memorable part was witnessing a situation in which the research aspect of my MSTAR program could help solve a problem. Another geriatrician in the practice was having an email exchange with a physician in another specialty over a conflict that arose due to the recent institution of electronic medical records in the hospital. Apparently, an expensive diagnostic test was required according to the electronic system if a certain set of criteria were entered in a patient’s record. The geriatrician argued that often, in his patient population – older, frail, with multiple comorbid diseases – the results of the diagnostic test would not result in a change in his management of their problems, and therefore, he wanted additional options that would allow him to use his clinical judgment and not be cited for “failing” to provide required care.

The goal of my summer research project is to design, from a database of information on outpatient geriatric patients, a tool that would improve the predictive validity of the widely used Charlson comorbidity tool. Using an input of health status (a number of diseases and conditions), self-report of health status (poor/fair, good/excellent), functional status (number of independent activities of daily living and instrumental activities of daily living, gait status), and geriatric syndromes (falls, dysphagia), the tool will generate a prognostic value – it would predict the probability of several outcomes within a number of years. The outcomes include death, nursing home admission, fall, hip fracture, and hospitalization. A simple prognosticator with accurate and helpful information would enable good use of available input, and allow excellent medical decision-making, hospital administration, quality control and research, and preventive medicine. Updating the Charlson comorbidity tool to encompass characteristics other than diseases both improves its predictive validity, making it a more useful tool, but it also incorporates factors of medicine that have long been recognized by geriatricians to be much more predictive than disease diagnosis alone.

I realized in the clinical office a perfect application for the comorbidity tool that had been to me, until that moment, only a spreadsheet full of data.

Sharon Ostfeld-Johns
University of Rochester School of Medicine

 

 

Maria Brown: Witnessing Memory Loss

September 13, 2011

Twenty-first birthday, wedding day, the birth of one’s first-born child, these are moments we all hope we will never forget. Unfortunately and sadly, some do.

I arrived in Baltimore for the MSTAR program not knowing exactly what to expect. I had previously been exposed to geriatrics, though only in a small way. I came with most of my clinical experience in pediatrics and family practice, but still very open to expanding my interests to geriatrics and care of the older population. My first clinical experience was today, working with a doctor in the memory clinic. The day’s events were not what I was expecting. I was able to see multiple patients each along the spectrum of memory loss. The first patient was a younger woman in her mid 40’s; she came with her mother, whom she believed was beginning to show signs of dementia and was afraid she herself was suffering from early-onset Alzheimer’s disease. Fortunately, the daughter’s memory troubles were most likely associated with her use of dicyclomine, an antimuscarinic prescription drug used to treat her irritable bowel syndrome. One of the side effects of the drug is short-term memory loss and her symptoms were not typical for dementia. She was clearly relieved. Her mother, however, was displaying classical early symptoms of dementia, which the doctor believed to be caused by Alzheimer’s disease. She was in her late 60’s and presented with certain memory lapses: she was forgetting conversations with her daughter, she forgot to pay bills, and she had to set reminders for all of her prescription drugs or she would forget she had medicine to take. The mother was oblivious to the fact that she had a problem with her memory. Today she began a new chapter in life, coming to grips with the reality of her condition.

The last patient, an older man in his late 70’s, came in with his wife, who was also responsible for the care of her mother who was suffering from Alzheimer’s disease. When given the Mini-Mental State Examination to screen for dementia, he failed to correctly answer many questions testing his arithmetic, memory and orientation. When asked to draw a clock, he could not correctly place the numbers on the face of the clock or draw the minute and hour hands correctly. He was very frustrated and apologetic, stating that he knew he was drawing it incorrectly but did not know the correct way to do it. His wife then told the doctor that her husband had been doing their taxes for the past nine years, however this previous tax season he could not prepare the taxes, and did not even remember doing them in the past. He then told us with frustration and tears in his eyes, “I don’t remember, I just don’t remember. She says I’ve done them before. I didn’t believe her. So she took out the tax returns from the last couple of years and showed me. I saw my handwriting, I know it was my handwriting, but I just don’t remember doing it. I just don’t remember.” The room was silent. It was in that moment that I realized geriatrics is not just taking care of “old people”. It is caring for a vulnerable population that was once you and I. They were once young and vibrant and told jokes and were, and many still are, the life of the party. They are that same amazing soul, just in an older body. The older gentleman and his wife left with a prescription that may have an impact on slowing the progression of Alzheimer’s disease. I left with a new sense of what it meant to be a geriatrician.

Maria D. Brown
The Ohio State University College of Medicine

 

 

Irina Perjar: Osteoarthritis Research Experiences

September 12, 2011

My primary focus this summer is the relationship between hand osteoarthritis (OA) and certain serum and urine biomarkers that might prove useful in predicting, diagnosing, and monitoring OA. As an MSTAR scholar, I am currently working with Dr. Joanne M. Jordan and Dr. Amanda E. Nelson of the Thurston Arthritis Research Center at the University of North Carolina, Chapel Hill. The current gold standard in determining the state of an individual’s joints is radiographs, which are sometimes not particularly sensitive and can only detect joint damage after it has occurred. Biomarkers would be a welcome addition to a physician’s toolkit in OA management because they may allow us to identify those individuals at higher risk for OA, or give greater flexibility in monitoring the course or disease or success of treatment. Although OA is not exclusively a disease of old age, the burden of the joint disorder disproportionately falls on the geriatric population. I chose to work on this project because it provides a perfect intersection of my current interests in medicine: geriatrics, radiology, and now rheumatology. On a more personal note, I have a family history of OA and am excited to contribute new knowledge to a field that is close to heart.

The past few weeks of working on my project have consisted of reading, reading, and more reading about OA and related rheumatologic disorders. My ultimate goal this summer is to turn my project into a publication, and I am fortunate to have support from my PIs, colleagues, as well as a very knowledgeable statistician. One of the first lessons I have learned while working on this project is that data management is critical. The data I will analyze is already collected, but defining the proper data sets and variables can prove tricky.

Some of my favorite experiences this summer have come in the clinic. I am shadowing my preceptor and other physicians in rheumatology clinic, which has drastically improved my interview and musculoskeletal exam skills. Another bonus of this experience is my increasing familiarity with a specific field in medicine, and I’ve realized that I like knowing a topic thoroughly rather than knowing bits and pieces of many topics. Our MSTAR coordinator has also arranged for me to shadow in UNC’s Gero-Psychiatric unit, and my first day in Gero-Psych was very different from any clinical experience I’ve had before. It was eye-opening to realize how intertwined physical malaise and emotional/psychiatric health can be, especially in those who become disabled or can no longer care for themselves.

One of the best components of the MSTAR program is that the UNC site has a few out-of-state students in addition to many UNC medical students. I have enjoyed stepping out of the UNC bubble (although I do love my classmates!) and getting to know these students. Here’s to hoping that the rest of the summer is as good as the first half was!

Irina Perjar
University of North Carolina, Chapel Hill

 


Caitlin Biedron: Multidisciplinary Teams

September 9, 2011

As an MSTAR scholar working at Detroit Medical Center, I have had the opportunity to shadow geriatric fellows and attending physicians during their morning rounds this summer. This first-hand exposure to geriatric medicine has provided me with a much better understanding of the difficulties facing elderly patients, as well as the multidisciplinary approach that is needed to effectively address them. The following three examples highlight some of these complex issues, including functional status, delirium and dementia, and elder abuse.

While rounding in the Acute Care for Elders (ACE) unit at Detroit Receiving Hospital, I saw an elderly patient that was being assisted by a physical therapist and a nurse, as they attempted to have him walk a short distance in an effort to reduce the loss of function and mobility that often occurs while patients are bedridden in the hospital. Unfortunately the patient experienced orthostatic hypotension while in the hallway, and another nurse had to rush to get a chair, as the patient nearly collapsed on the floor. Fortunately a fall was averted, but the combination of factors facing elderly patients was clearly illustrated by this particular situation. While encouraging exercise and physical rehabilitation for patients is crucial (as functional status – and particularly disability in performing ADLs - is the strongest predictor of perceived quality of life), their ability to perform such tasks must also be re-evaluated on a frequent basis to ensure that falls and injuries are avoided. However, reaching this proper balance can be difficult, even when physical therapists are assisting with the patient’s recovery.

During morning rounds we visited another patient, who had been fairly responsive earlier in the day, and able to answer most questions and appeared fairly well-oriented to time and place. However, when the geriatric team visited this patient later in the morning, she began describing visions of smoke coming from the wall and other vivid images. Furthermore, she had great difficulty answering simple questions about where she was, who assisted her at home, and what her daily routine consisted of without delving into a detailed account of an unrelated event. The attending physician suspected that the patient was experiencing delirium because of the sudden onset. But when he asked her to repeat back a sequence of numbers, she was able to do so fairly well, showing that she could remain attentive and focused, which is not usually observed in a patient with delirium. Therefore, it was decided that a psychiatric consultation was needed, in order to determine if this was a case of delirium (in which case it may be necessary to determine whether it was being caused by an infection) or dementia (in which case certain medications would need to be prescribed and her discharge instructions/destination may be very different). This example once again illustrates the importance of a multi-disciplinary team and approach to geriatric care.

Another situation that was encountered with many patients was their lack of control over banking and financial issues, with the potential for elder abuse to occur. In two cases, elderly patients explained how either a relative or friend was picking up their social security checks, and paying the rent and other bills for them after depositing the check. However, neither patient would likely have the capacity to reliably calculate the exact amount that should remain after all of the bills were accounted for, and it was possible that not all of the remaining funds were being returned to the patient. The attending physician on call mentioned his concerns about both situations, and was especially worried about a patient who had a niece and nephew living with him, who could have been covering their living expenses at his expense. Although these were merely observations, the attending physician seemed very concerned about the situation. I am not sure how he planned to proceed, but his mention of elder abuse was surprising to me, and made me look at the situation much differently than I would have otherwise.

Caitlin Biedron
Wayne State University School of Medicine

 

 

Suvi Neukam: Enabling Healthy Behaviors

September 6, 2011

With mere seconds left on the red-flashing-hand, I arrived to the other side of La Jolla Village Drive. From the safety of the curb I turned around and saw the rest of my group in mid-cross walk. Not equipped with the gait speed of an active 26 year old, the elder adults I was with struggled to make it across the six-lane road in the 30 seconds that the signal allowed. Exacerbating the observation was the fact that this was a group of participants in our walking study—this means that the elder adults were “physically fit”. While the critical mass of our group greatly decreased the risk of an accident, the reality of the situation was that often times, the participants in our study and older adults in general tend to walk alone and certainly not with 8 other people. In good conscience, to continue promoting increased physical activity amongst elder adults, something had to be done about improving neighborhood walkability.

The study I am working with is called MIPARC: Multi-level intervention for physical activity in retirement communities. The primary purpose is to increase physical activity in older adults, primarily through walking, and then assess the benefit to physical health, cognitive function, and quality of life. At each intervention site, peer leaders are selected from the group of participants. The function of the peer leaders are to help recruit for and plan events, continue promoting walking for the last 6 months of the study, and to serve as liaisons for the group voice throughout. Critical to all three of these aspects is ensuring that what we are asking the participants to do is actually possible—are they able to walk? Answering this question and finding solutions is the second purpose of the study.

It was in this spirit that we walked across La Jolla Village Drive that afternoon. Our group consisted of my colleagues, the peer leaders from our intervention site, and two representatives from Walk San Diego, an advocacy group that promotes walkable communities. Prior conversations with the peer leaders made us aware of this formidable cross walk and we were now taking action to make change. Working with Walk San Diego to increase the length of the “walk signal” at this intersection was one of many changes we discussed that day. Also on the list were: filling in several pot holes (apparently there is a phone app where you can take a picture and the coordinates are sent immediately to the city roads department!), cleaning up a commonly used pedestrian bridge, painting more visible crosswalks, and remodeling curbs to be ADA accessible.

Participating in this event was inspiring. We enabled elder adults to recognize the importance of their own voice in the community. We took steps towards making daily physical activity a reality for more people than just the participants in our study. But the greatest inspiration for me was in realizing that as a physician my role was more than just prescribing healthy behavior, it could also be helping to make that behavior possible.

Suvi Neukam
University of New England

 

 

Lisa MacLean: New Research Skills

September 2, 2011

I’m now one month into my summer research, and I’m pleased to report that I’ve finished a draft of one paper, and I’m beginning to work on the statistical analysis of another paper. Of course, the first paper that I’ve completed still isn’t ready for publication and the data analysis for the second paper doesn’t predict any groundbreaking medical news. Everything is taking me longer than I think it should, and my results are not as robust as I’d like them to be. But this, I am learning, is what research entails. I knew that spending a summer conducting geriatric research would be intellectually demanding, but I didn’t have a clear sense of the skillset that I’d need.

At this point, I can identify three skills that have been particularly important for my research: paying close attention to detail, patience and being receptive to criticism. Good medical research requires that no stone is left unturned – all the previous literature needs to be examined, every aspect of a clinical study should be controlled, and each sentence I write should be supported by a documented finding. Patience is important in many aspects of research. Research is not conducted in isolation, and I’ve needed to send drafts and questions to many other researches, none of whom can answer instantly. PubMed searches, data entry, and running numerous statistical tests can be tedious tasks. Lastly, I’ve learned that it’s important not only to be receptive to feedback, but that I should actively seek out the comments of my coworkers and mentors. Indeed, each suggested correction helps me to refine the goals of my research, express myself clearly, and improved my understanding of my research topic.

Throughout the course of the summer, I’ve improved and will continue to improve in each of these areas. Every doctor needs to pay close attention to detail, to be patient, and to be open to learning from her mistakes. As a student, the attention to detail will be absolutely essential as I move forward with my studying. Patience will help me in small group work, in patient interviews, and in understanding my own limitations. Being open to criticism will be essential as I continue to conduct supervised physical exams and history-taking, not to mention surviving clinical rounds in my third year.

I may be particularly lucky that the skills I have gained are so applicable to my immediate future, but I expect that’s not the case. There are so many skills that are required for good scientific research, that I imagine that any student with a summer research job will return more prepared than ever for medical school and the career that follows.

Lisa MacLean
University of North Carolina School of Medcine



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