The power of photons is amazing. In fact, every day, photons are trapped with sensors and converted to matrices of millions of numbers. By rearranging these matrices and converting them to electrical outputs and, eventually, back to new photons for our eyes to see, these photons can trigger powerful emotions in us—anger, laughter, happiness, even tears of grief. There is a name for this incredible process: filmmaking.

filming-istock-166463571_640During my teenage years, I thought I wanted to become a filmmaker, until I realized that what I was actually passionate about were the engineering aspects of filmmaking. By taking simple shots of the world around me, and then transforming those basic components of light, color and sound, I could touch the hearts of others. Consequently, I decided to study engineering in college because the discipline gave me an opportunity to hone these skills—using tools and knowledge to manipulate the physical world and impact human lives. The discipline also guided my journey to medicine.

It was not until high school when I shadowed our physician neighbor for the first time that I was formally introduced to medicine. I was touched by how the application of the physician’s vast knowledge of biology, physiology and pathology allowed him to ultimately engineer medical lifestyle changes and complex treatment plans. It quickly became clear to me that the field of medicine shared the same fundamentals as engineering—the application of knowledge to the surrounding world.

This theme resurfaced many times, and often in ways I did not anticipate—after a conversation at a medical volunteering opportunity with a man about his young granddaughter diagnosed with terminal leukemia, I felt surprisingly disillusioned and disheartened. Why wasn’t there any solution? According to my developing engineering paradigm of medicine, there was always a solution, and it simply required the correct rearrangement of chemicals to produce a drug or a more intricate understanding of physiology. However, instead of reciprocating the immense disillusionment I felt, the man expressed a deep sense of gratitude toward his granddaughter’s medical team. He discussed how, albeit the terminal diagnosis, the physicians around his granddaughter showed consistent compassion and commitment to providing the best care possible, and that alone provided the family strength. I was struck with the realization of a powerful human dimension of medicine that engineering otherwise did not provide. As my paradigm grew to encompass this understanding, so did my passion for medicine.

I entered medical school because medicine is a unique, intricate combination of engineering and the human connection, and I aspire to use the fundamentals of science from the classroom to eventually transform the world around me through my career. More importantly, beyond scientific transformations, I want to be able to offer empathetic and supportive comfort in hopes of providing the most compassionate care. I train in medicine so that one day, I can be the filmmaker in my patients’ lives, transforming my knowledge of the world around me to connect to their hearts and minds.


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Pranjal Gupta

Pranjal Bodh Gupta is a first-year medical student who arrived at Johns Hopkins from Vanderbilt University where, over the course of four years, he danced in numerous cultural showcases. Throughout these shows, he learned various routines, including a Japanese fisherman dance (“Soran Bushi”), Indian Bollywood dance, Korean pop, Japanese drumming dance (taiko) and Indian Bhangra. As a side hobby, Pranjal made short films and majored in chemical engineering. His latest adventure includes learning medicine and trying to gain social media fame.

In some ways, a hospital is a great equalizer. Once you’re admitted, things like employment status or race no longer matter — unless that happens to be medically relevant. What matters is that you’re sick enough to need a team of health professionals to take care of you. Whether you live in a gated community or public housing, once you shed your clothes and slip on the hospital gown, you’re all the same, entitled to equal respect and medical care. As a medical student seeing inpatients, it is sometimes easy to forget that these patients, while they may appear equal within the walls of the wards, have extremely diverse social experiences once they leave the hospital.

When I was first asked if I was interested in helping out with a pilot study delivering interventions to reduce sugary beverage consumption in Baltimore, I was intrigued. After my third year of medical school, traditionally a clinical year in the hospital, followed by a year of studying obesity, nutrition and the social determinants of health during my master’s degree in public health, I was excited to go into the field to research a topic about which I was passionate. I wanted to see where my patients lived, gain firsthand knowledge of their experiences, and ultimately understand how these factors personally impact a population I have come to know and care for.

Quote: Everyone has a unique home life, and even two public housing developments can have vastly different access to safe exercise spaces, grocery stores and public transportation, all of which make miles of differences in health care.What I didn’t anticipate was the complete culture shock. After several years of living and studying in Baltimore, I was convinced that I knew the nitty-gritty of this ever-evolving city well and that little could surprise me. However, entering a public housing development and recognizing that this was where several of my past patients lived came as a shock. The great equalizer of the hospital gown was instantaneously dropped, and what remained was a stark awareness that upon discharge, my patients were going home to very, very different neighborhoods.

Suddenly, I felt foolish. My advice to patients with heart failure who lived in this area —  encouraging them to limit their sodium intake — seemed ridiculous, given that most of them didn’t have access to a car and the corner store nearby stocked few healthy foods or fresh produce. Was I recommending that they effectively starve in order to comply with a low-sodium diet? Why hadn’t I done more research to figure out what foods were accessible to them? And, with some guilt, I remembered that time I recommended a patient cut back on sugary beverages, thinking to myself that it couldn’t be that difficult. If someone really dislikes the taste of the tap water available to them at home and soda costs less than the bottled water down the street, what did I expect them to choose? I wondered why I hadn’t recommended “zero-calorie” drinks instead — especially after hearing a few individuals in the study expressly state that they hated drinking their home’s tap water.

It is impossible for any health care professional to know all the differing social contexts of every single patient. Everyone has a unique home life, and even two public housing developments can have vastly different access to safe exercise spaces, grocery stores and public transportation, all of which make miles of differences in health care. What is within reach, however, is checking in with patients to see if our advice makes sense by asking them what they believe is achievable. You can be sure that in the future, when I give any medical recommendations, I won’t make that past mistake of forgetting the social foundations of health and will instead make it a point to explicitly ask what challenges my patients may face in following my advice.


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Ruchi Doshi

Ruchi Doshi is a third-year medical student pursuing her M.P.H. She is also an avid cook and baker who loves everything Bollywood.

Digital health is one of the hottest buzzwords in health care. It seems like a new health care app is on the news every day, and big data, we’re told, is on the verge of ushering in an era of personalized, efficient medicine as we’ve never seen before. But what does this mean for the health care provider, the medical student and the patient today?

digital-health-istock-578311388To find out, I recently attended the Connected Health Conference in Washington, D.C., where public-sector and industry leaders on mobile apps, personalized medicine and product development came together to share their work, challenges and vision for the future.

The conference kicked off with a keynote by Patricia Mechael, who talked about the concept of digital health in context to the other terms we keep hearing — for example, “mHealth,” “health IT” and “health informatics.” Digital health includes all of this and more — everything from wireless devices and telemedicine to health information technology and personalized medicine. Connected health, the conference’s namesake, refers to the aspects of digital health without the genetics component.

The Cost of Disconnection

Perhaps unsurprisingly, the countries with the highest percentage of connected health devices in use are China (28 percent), India (26 percent) and the United States (21 percent). The countries with the least percentage of connected health devices are a little less predictable: Japan, Poland, Peru and Russia. What’s even more interesting is the top barriers that were cited by those surveyed: lack of knowledge and cost. For physicians interested in integrating digital health into their practice, this raises an important question. Will reducing cost and spreading awareness about the power of connected health devices be enough to get everyone on board, or are the connected health devices today simply not solving the problems of the average user? According to research done by Ipsos Healthcare, only 49 percent of American patients would use a device or tracker as part of their treatment plan, even if it was recommended by their health insurance company.

Did you know: The countries with the least percentage of connected health devices are a little less predictable: Japan, Poland, Peru and RussiaAs a millennial and Bay Area native, I found this number pretty shocking. Coming from a world where checking your step count is as natural as checking the news, it was hard for me to believe that someone wouldn’t want to try an app or device if his or her doctor said it might help. After all, these technologies allow patients to better track and manage their personal health, potentially reduce the number of visits to health care facilities, and provide a more comprehensive picture of health characteristics.

Research: The Foundation of an Evidence-Based Medical Practice

One solution to increase adoption may be providing more evidence. As a medical student, it has quickly become clear to me how important evidence-based medicine is to medical practice. Not only is research the foundation for physicians’ best practices and protocols, but it also helps patients make informed decisions and empowers them to better understand their diagnosis and treatment. But what does research look like in digital health?

The World Health Organization, in partnership with the Johns Hopkins University Global mHealth Initiative, has been working on a guide to conducting research and assessment in digital health. In addition to this guide, there are a number of other tools used by researchers in this space, including the MAPS (mHealth Assessment and Planning for Scale) Toolkit, a self-assessment tool that helps teams scale up mHealth innovations, and the Digital Health Atlas, a global web platform that curates digital health implementations to map, monitor and foster digital health innovation investments to meet government health goals. A search of these tools performed in one of the conference’s many workshops revealed that currently, the most prioritized interventions are targeted messaging and reminders, on-demand information services, electronic decision support, remote client to provider consultations and digital supply chain tracking/management.

For medical students interested in digital health, a number of institutions offer clinical informatics fellowships, including the University of Arizona, Boston Children’s Hospital, Case Western Reserve, Stanford and the University of California, San Francisco medical system.

Ultimately, the Connected Health Conference offered a glimpse into the possibilities created by digital health while providing key tools to help us create the health care future we want.

About the Author

Lochan Shah

Lochan Shah is a medical student interested in the intersection of medicine, technology and public health. What gets her out of bed in the morning — besides a pair of good running shoes — is the people that make this world move, and she’s on a mission to help them move it.

Medical marijuana, for years a controversial pipe dream throughout the United States, is embroiled in an entirely new debate in 2017. For decades, the discussion over legalized marijuana usage has centered on ethics and morality, conflicting desires between freedom and protection. These arguments are still robust today, but the terms have shifted — from medical usage to complete recreational legalization. In the medical community, the science is well-accepted; marijuana has a variety of ameliorative benefits in health and disease. Now, our discussion revolves around how to best embrace this newly utilizable medicine, including developing research standards and training new and old doctors how to diagnose and prescribe medical marijuana in a manner that best helps their patients.

medical marijuanaIn 1996, California was the first state to pass a functional (nonsymbolic) bill allowing medical marijuana to be prescribed by doctors and utilized by patients for a variety of conditions, including glaucoma (reduces ocular inflammation), cancer (reduces chemotherapy side effects, such as nausea) and chronic pain. Four more states followed suit before the turn of the century, and in 2017, 28 states and the District of Columbia allow medical marijuana to be prescribed for a variety of conditions. In these states, an estimated 2.5 million patients have prescriptions, but statistics on who these prescriptions are coming from are hard to suss out. This opacity highlights the new challenge throughout the United States: how to train and regulate providers in this growing field of medicine.

According to a 2013 poll from The New England Journal of Medicine, more than 76 percent of physicians would prescribe medical marijuana to a patient with deteriorating cancer. The doctors cited the demonstrable effects of cannabis use on nausea, pain amelioration and appetite promotion. They also compared the deleterious effects of marijuana to those of other FDA-approved drugs currently prescribed to treat similar conditions and overwhelmingly found the former less damaging than the latter. These medical opinions are based on evidence from scientific research. More than 60 peer-reviewed papers have examined marijuana’s medical effect on a number of conditions — including Parkinson’s disease, multiple sclerosis and HIV/AIDS — 60 percent of which reported positive effects of the drug, compared to only 5 percent reporting negative effects.

Did you know: according to a 2013 poll from The New England Journal of Medicine, more than 76 perfect of physicians would prescribe medical marijuana to a patient with deteriorating cancerRegardless, marijuana remains Schedule I at the federal level, a classification that specifically defines the substance as having “no medicinal value.” This creates a conflict for doctors and health care systems throughout the country. Physicians risk their federal license by prescribing medical marijuana, and large hospital networks, such as Johns Hopkins, have largely remained uncommitted on the issue. Johns Hopkins is simultaneously conducting research into medical marijuana’s health benefits, as well as commissioning a team of doctors and administrators to explore the risks and rewards of incorporating the growing new field into its health system. Most importantly, this incorporation would require training physicians, both new and old, in prescribing a drug for years vilified in the United States. The sweeping acceptance of medical marijuana is unlikely to reverse directions, and we are poised to see significant changes in the medical community regarding this drug in the very near future.


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Benjamin Bell

Benjamin Bell studies sleep and circadian rhythms in mice and flies, and is fortunate the mice understand his semi-nocturnal work schedule. When not actively in the lab, you can find him thinking about research and science-writing on his motorcycle, on the hiking trails, or at any local concert venue.

It’s often said that it is hard to imagine what life must be like for someone until you have walked a mile in his or her shoes. It took me less than a mile to venture to my local Planned Parenthood. Located right up the street from the Johns Hopkins medical campus in the heart of Baltimore, this massive clinic has done so much for our city. As an Ob/Gyn resident at The Johns Hopkins Hospital, I have had the benefit of being able to work here. This, however, was not my first exposure to Planned Parenthood. My own personal experience began years before, when I fell through the cracks of my health insurance plan and could not find affordable and accessible care anywhere else.

planned-parenthood-baltimore-cropped

Planned Parenthood of Baltimore
Image courtesy Diana Cholakian

In the few months between finishing my undergraduate education and starting medical school, I lost my health insurance. The premium to start a plan in those short months when I had already taken out so many loans to pay for medical school and didn’t have a source of income was more than I could afford. I decided to test my luck and simply try not to get sick for the time being. I failed to remember that I had been receiving monthly birth control pills through my previous insurance plan and was nearing the end of my final pack. A quick search on the internet brought up Planned Parenthood as an alternative option where I could continue to receive my birth control prescription without paying the steep out-of-pocket cost.

It wasn’t until then that I realized how much Planned Parenthood offers. In 2007, Baltimore had the fourth worst infant mortality rate in the nation. Leana Wen, our city’s health commissioner, attributed Baltimore’s recent lowest infant mortality ever to the city’s partnerships with Planned Parenthood, which has worked to improve post-natal care.  This decline in infant mortality parallels a sharp decline in teen pregnancies in Baltimore. While a causal effect cannot be drawn, one cannot help but notice this drop occurred simultaneously. In addition to providing services, Planned Parenthood of Maryland, together with Maryland’s legislature, helped pass the Maryland Contraceptive Equity Act in May 2016. This law, which will go into effect on Jan. 1, 2018, will eliminate copays for birth control, allow women to receive a six-month supply of birth control at one time (making it easier to take it more effectively), lift the requirement for prior authorizations on IUDs and even impact male reproductive health by removing copays for vasectomies!

For residents who don’t have insurance or can’t make it to the clinic, the city’s Planned Parenthood also provides preventive care in the form of routine screening tests, including mammograms and Pap smears. While this law highlights one of the different ways that Planned Parenthood has helped men and women alike in our community, I was surprised as a resident how many women I saw in my clinic who were referred to me from Planned Parenthood because their Pap smears showed precancerous cells. For residents who don’t have insurance or can’t make it to the clinic, the city’s Planned Parenthood also provides preventive care in the form of routine screening tests, including mammograms and Pap smears. Although it is hard to determine how many cases of cervical or breast cancer have been detected by the tests ordered out of Planned Parenthood, we do know that offering these simple screening tests helps to detect specific cancers at their earliest stages and prevent morbidity.

With such a long list of beneficial services offered, it is clear that Planned Parenthood has had a dramatic and positive impact on Baltimore, one that relies on the support, donations and volunteer hours of our community if it is to continue. Appropriately, the Johns Hopkins Medical Student Senate has chosen to donate 100 percent of this year’s proceeds from its annual Monte Carlo night benefit to Planned Parenthood of Maryland. The evening should serve as an important reminder of the opportunities that Johns Hopkins students and staff members have to invest in the health of the community, our patients, our work environment and our city.


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Diana Cholakian

Diana Cholakian is a fourth-year gynecology and obstetrics resident at Johns Hopkins. When she’s not in the OR, she enjoys biking, hiking, and running around the city.

In September 2016, a Nevada woman died of a bacterial infection. The woman, in her 70s, had been hospitalized previously in India due to a fracture of her right leg, which led to bone infections and more subsequent hospitalizations. During these infections, she almost certainly received antibiotics to help her recover, especially given that in India, the guidelines regarding antibiotic use are often not followed or regulated very stringently. This only made the bacteria that managed to survive stronger; remarkably, testing has since revealed that the strain that killed her was resistant to all 26 antibiotics available in the United States. In its recently released report, the Centers for Disease Control and Prevention (CDC) mentions that the mechanism of resistance was not due to the well-studied MCR-1 (mobilized colistin resistance) gene, which resides on a piece of DNA that can be easily passed between bacteria. Additionally, though it was not known at the time, this particular bacterial strain was found to be susceptible to fosfomycin, an antibiotic that is currently not approved for treatment of bacterial infections.

antibiotics put everyone at risk.Antibiotics are widely used in the U.S. and around the world. They can be found in hand soap, animal feed, paint and even in coatings on children’s toys. Because antibiotics are everywhere, the selective pressure for bacteria to evolve resistance to antibiotics is too. When treatment with one antibiotic doesn’t work, another takes its place. Furthermore, relaxed rules and regulations regarding antibiotic use in other countries, including India, appear to be accelerating the pace of the mounting antibiotic resistance crisis worldwide. Since its discovery in 2009, the resistance gene NDM-1 (New Delhi metallo-beta-lactamase) has spread to over 70 countries, demonstrating the alarming rate at which bacteria can swap these dangerous genes. The problem now is that bacteria are evolving as quickly as scientists can synthesize new or modified antibiotics.

five tips for fighting antibiotic resistanceAntibiotic resistance puts everyone at risk. Everyone can help to mitigate that risk by following CDC and World Health Organization guidelines for combating antibiotic resistance. First, only use antibiotics when necessary, such as when prescribed by a health care provider, and be sure to follow the instructions for proper use. Don’t share or use leftover antibiotics. Prevent infections as best you can, especially by washing your hands and getting necessary vaccinations. It’s also important to remember that if you do get sick, you might not need antibiotics! Some infections are caused by viruses, not bacteria, and won’t respond to antibiotics, but without ordering lab cultures, it may be difficult to discern between the two. Don’t be surprised if your doctor asks you to wait an additional week to see if your symptoms subside on their own before writing you a prescription for antibiotics. Health professionals have a crucial role. Limiting prescriptions to when necessary and instructing patients on their proper use may help prevent suboptimal or incorrect use.

The battle against antibiotic resistance will continue for as long as there are antibiotics. Staying one step ahead will require constant vigilance.


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Sarah Robbins

Sarah Robbins is a human genetics Ph.D. student. Her skill at reading recipes has made her able to translate her talents from pies to PCR.

On Jan. 21, 2017, millions of women around the globe marched in solidarity with women in the United States to protest against various forms of social injustices and misogyny they experience on a routine basis. As I listened to the massive crowds chanting various slogans in repudiation of perceived inequities, one message rose above the din of the streets — it was time to dismantle the structural impediments to women’s rights in this country and around the world.

Women's March on Washington

Photo Credit: Maya Thet Oaks

Taken within the context of the gross inequities against marginalized groups — immigrants, individuals with disabilities, people from minority ethnic groups — the rallying cry for justice was a civil rights era message redux. It became self-evident that in spite of decades of progress in breaking down barriers for disadvantaged groups, we were still far from an egalitarian society. In America, we continue to wrestle with various forms of ethnic and gender discrimination, with potentially devastating consequences for our society and institutions. Although much progress has been made since the industrial revolution and the civil rights era, some things remain unchanged.

odonker4

Photo Credit: Maya Thet Oaks

In the 1960s, women working in the science, technology, engineering and math fields had the particularly daunting and unpleasant task of proving their mettle in what were sometimes downright hostile working environments. For women of color in the Jim Crow era, it was double jeopardy dealing with gender and race in the work place. About one week ago, I saw the movie Hidden Figures, which crystallized the issue for me and underscored why the recent women’s march on Washington resonated so powerfully. The movie is adapted from a nonfiction novel, Hidden Figures: The American Dream and the Untold Story of the Black Women Mathematicians Who Helped Win the Space Race by Margot Lee Shetterly. It highlights the true-life story of three inspirational African-American women, Katherine Goble Johnson, Dorothy Vaughn and Mary Jackson, who worked at the NASA computing office in Hampton, Virginia.

At the time, America’s space program was lagging behind that of Russia, which had just launched Sputnik into orbit. Goble Johnson, Vaughn and Jackson were part of the Space Task Group, whose role was to work on computations that would eventually help launch the Friendship 7. In segregationist Virginia, they were forced to work in a prejudicial environment, which restricted them to using “colored-only bathrooms” and “colored computers.” Back then, all computations were done by hand, and “computers” referred to the actual people who carried out the calculations. Johnson’s calculations established the trajectory of America’s first space trip in 1961.

it is undeniable that a society which treats any of its citizenry as second-class individuals only shortchanges itself. Throughout the movie, the futility and ridiculousness of segregationist and discriminatory policies become abundantly clear as the women strive to prove their worth to the program. What happens when we don’t accommodate and encourage diversity of talent? Hidden Figures provides a sober reflection on the potential dangers of discrimination to human progress and the concomitant loss to society when minority groups are denied opportunities for meaningful contributions.

As we celebrate Black History Month, it is only fitting with the recent release of Hidden Figures that we acknowledge the invaluable contributions of disenfranchised groups and realize that our collective progress falls short of its mark without erasure of any kind of discrimination from our society.

It is telling that prior to the release of this movie, very few people, including myself, knew of the extraordinary contributions of these African-American women to the United States’ space program. In fact, it was not until November 2015 that President Obama recognized one of the women, Johnson, with a National Medal of Freedom. In many ways, their struggles as portrayed in Hidden Figures echo those of many women protesting at the march in January. Although women make up about 51 percent of the U.S. population, they held only 24 percent of full-time professorships in science, health and engineering departments across all institutions. So the struggle continues.

As one of the popular signs at the march reminds us, “Girls just want to have fun-damental rights,” and this is something we should support. Reflecting on the lessons from the movie and the weekend march, it is undeniable that a society that treats any of its citizenry as second-class individuals only shortchanges itself. It is therefore high time we push for equal rights for all, working in solidarity to eliminate discrimination against women and all marginalized groups.


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Charles Odonkor

Charles Odonkor is a resident in physiatry (physical medicine and rehabilitation) and an Armstrong Institute fellow. An old soul and a dreamer, he is awed by the sacred and explores the world via the lens of a rich Afropolitan heritage.

Countless big and small tragedies occur in the hospital daily. There is the yearning for fresh air, the tedium of one blood draw after another, the inability to defecate, the removal of an organ, the loss of a child or parent. These are interwoven with beautiful miracles, human triumphs, cures and compassion. It is no wonder that as medical students, we find ourselves drawn into the quilt of it all.

Talking with several of my classmates, I was not surprised to find that each one could recall multiple events they had witnessed in the hospital that broke their hearts. In the same way, the suffering that I have seen firsthand in the hospital is firmly imprinted in my memory.

Strong emotional support networks, outside hobbies and activities, and physical exercise are important outlets for medical students during their clinical years. Sydur Rahman, a fourth-year medical student, vividly recalled his experience of a tragic death in the hospital. As part of the code team in the pediatric Emergency Department, he did chest compressions on a toddler, but ultimately, she passed away from her injuries. “That very night, I met up with some friends because I didn’t want to be alone. It was what I did to cope,” he said. By surrounding himself with friends and family, Rahman found the emotional strength to keep going.

Alison Kraemer, a third-year medical student, discovered that engaging with her team provided another way to reflect on difficult situations. She asks important questions, such as, “How would you break this sort of news to a patient’s loved one?” that have allowed her to grow from these experiences.

Strong emotional support networks, outside hobbies and activities, and physical exercise are important outlets for medical students during their clinical years. Still, making sense of human suffering is a difficult task. Judith Vick, a third-year medical student, finds a way to honor the patients whose suffering she has witnessed “through honoring them as teachers.” When Vick studies pathophysiology, she often recalls certain patients who she has cared for in the hospital. These connections allow her to remember medical knowledge that must be mastered, which “makes meaningful their suffering, in an abstract way, for future patients.”

For me, I find that writing creatively allows me to express myself and honor the suffering I witness. This is a poem I wrote after my first experience with a patient’s death in the hospital.

MED 5B CODE BLUE

I look down at my hands “good compressions” said the machine

see them pressing at the chest

of a man that I had never met

the clock ticking time

“intubate”

His feet bounce in their black Nike sneakers

as I lean my weight into my palms

“we need a fingerstick”

the fem line is dry

“more hands on board”

the whole bed is moving with the noise

of the bottom of a boat “glucose 144”

scraping off a rocky shore

the monitor shows tumbling white globs of chicken

“he’s aspirated”

My hands are shaking

my eyes no longer on his eyes

The fem line quivers out of the thigh

as if to write a message

his lips are agape

still

“rhythm check in 10 seconds”

A breath in, all around, fifteen people packed in a room for one,

a moment of effortful stillness

it is half past two in the morning

nothing

and then the machine

“start chest compressions”

my hands back on his chest again

my eyes on his

staring unblinkingly at the starry sky

beyond the plaster ceiling.


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Stephanie Zuo

Stephanie Zuo is a fourth-year medical student who believes in the healing power of a listening ear.

What do a relatively unknown gene, a well-known signaling pathway and nuclear transport have in common? They’re all part of how diabetes and cancer drug metformin works. Metformin is a widely used type 2 diabetes drug that lowers glucose levels and sensitizes cells to insulin.

Metformin’s mechanism has been long sought after, and studies into how it works have revealed that besides its ability to lower blood sugar, it also slows cancer growth. Previous work has shown that metformin compromises mitochondrial energetics and ultimately inactivates the mTORC1 pathway, a well-studied signaling pathway that plays a key role in regulating cell growth and proliferation. But precisely how this happens has remained a mystery.

petry dish in the labNow, in a study published in the Dec. 15 issue of Cell, the lab of Alexander Soukas at Massachusetts General Hospital in Boston has uncovered a more complete picture of how metformin’s anticancer properties work. The authors discovered that expression of another gene called ACAD10 is important for metformin’s ability to reduce cancer growth. Also involved is the machinery regulating transport of proteins through pores in the nucleus and mTORC1 activation.

How did the Soukas group connect these seemingly disparate players? It relied upon popular model system Caenorhabditis elegans, a roundworm also known as C. elegans, to find out. When metformin was administered to these animals, the researchers found that a gene called ACAD10 had elevated expression levels. ACAD10, or acyl CoA dehydrogenase family member 10, is not well-studied, but genes similar to it are involved in the breakdown of fatty acids in the mitochondria.

Previous work has shown that well-known signaling pathway mTORC1 was involved in metformin’s action, and the Soukas group confirmed that it was related to the increased levels of ACAD10 observed. Next, the group needed to connect these parts together. The group systematically mutated all of C. elegan’s genes and administered metformin. It then screened for mutants that blocked the drug’s effects, which suggests that the normal, nonmutated gene is a possible target. From this work, the researchers found that several genes belonging to the nuclear pore complex were involved in metformin’s mechanism of action. This complex allows proteins and other molecules to access the nucleus by fitting through pores in its membrane.

Now all the pieces of the puzzle can be fit together. The researchers determined that a critical component involved in activating the mTORC1 signaling pathway, RagC, needed to access the nucleus through the nuclear pore complex. Metformin blocks this movement and thus prevents mTORC1 from being activated. This then induces the expression of ACAD10, which ultimately slows cancer growth.

These findings shed light on how metformin, a widely prescribed diabetes drug, can also act to slow cancer growth. Although its anticancer properties were discovered early on, this work provides more mechanistic details of the pathway and gives researchers new pharmacological targets for specifically attacking cancer cells. Similarly, these new insights into mTORC1 signaling offer an interesting example of how inactivating one pathway (mTORC1) can activate a seemingly unrelated gene (ACAD10) with big implications for the overall health of an organism. Much more work is needed to fully understand this phenomenon, but connecting these components is a good start.


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Dawn Hayward

Dawn Hayward loves reading classic books, as most of the main characters enjoy breaking societal norms.

To maintain wellness in the medical profession, wellness must be brought to the forefront as an issue for the medical community. The emphasis on wellness should start early while physicians are still in their training and continue in the workplace.

student wellnessAt the Johns Hopkins University School of Medicine, the Student Wellness Initiative, led by Jenny Wen and Samantha Roman, is seeking to make wellness a part of student life. With events ranging from a speaker series to a wellness retreat, this group works closely with the administration to ensure that medical students are receiving the support they need from the school. However, the group’s leaders have also emphasized the importance of making wellness an integral part of the medical school curriculum and of the culture of medicine nationwide.

As health care providers, we urge others to maintain their own wellness, and yet we fail to follow this same advice when it comes to our own. I have had friends develop severe gastroesophageal reflux disease after surgery rotations when they did not eat for hours on end. Others developed sleeping disorders after a rotation that required them to wake up at 3 a.m. and sleep an average of four hours per night. Still others developed issues such as alopecia and anxiety from the undue stress put upon physicians in training not only from their jobs, but also from the self-imposed, internal pressure to succeed.

This deadly combination of irregular meals, irregular sleep patterns and immense stress is a scourge among medical trainees, but initiatives, like the Student Wellness Initiative (SWI) at the school of medicine, have popped up in medical schools and residency training programs around the country, aiming at helping trainees better care for their own mental and physical health. According to Roman and Wen, Johns Hopkins’ student leaders of SWI, the goal of this organization is to “act as the voice representing student interest in wellness to the school administration and community. SWI aims to share why self-care is important, and provide the space and opportunity to learn how to maintain one’s own wellness. We also provide an opportunity for students to bring their own vision for wellness to the group.”

Throughout the year, SWI hosts the LiveWell workshop series, which brings in speakers to facilitate group discussion and didactics on various wellness topics. SWI has also hosted a variety of other events, including a Healer’s Art wellness course, weekly lunchtime meditation sessions, a petition for a wellness director, a peer counseling program and a monthly newsletter, among other activities.

student wellnessWhile organizations such as SWI are a good start to promoting wellness among medical trainees, we must also begin to incorporate wellness as a part of medical student education. Roman discusses the importance of integrating wellness into the first- and third-year medical curriculum. Both years are incredibly important times of transition for medical students, during which it is critical that students both have an outlet to explore their thoughts and emotions, and learn self-care habits that they can carry into residency.

Furthermore, according to Roman, by integrating wellness into the medical school curriculum, “the university would show both students and the greater medical community that the administration and the school care about wellness.” The issue of physician and trainee well-being has begun to take shape on larger platforms as well. In 2016, it was one of two health care areas targeted by the surgeon general’s office, with Surgeon General Vivek Murthy acknowledging: “The suicide and burnout rate [for physicians] is very high … If health care providers aren’t well, it’s hard for them to heal the people for whom they are they caring.”

Although previously, medicine has been seen as a field requiring great self-sacrifice, that mentality is slowly shifting. According to Wen: “The Accreditation Council for Graduate Medical Education Milestones now highlight wellness as a key component of professionalism, and medical schools, such as UCSF and Vanderbilt, are role models.” At UCSF, students meet regularly with a psychiatrist throughout their medical training to discuss emotional issues, and Vanderbilt has annual wellness retreats built into its curriculum, while also emphasizing wellness issues in classes and seminars throughout the school year. At Johns Hopkins, the administration has been greatly supportive of SWI, and the group reached new milestones last year, including piloting a wellness retreat for second-year medical students and successfully petitioning the school to hire a wellness director, who will focus on coordinating wellness efforts among schools and institutionalizing wellness initiatives.

While great strides have been made in the last decade in making wellness a topic of discussion in the medical community, there is still much room for improvement. As captured by Wen and Roman: “We can no longer ignore the mountains of evidence that health care professionals and trainees have some of the highest levels of depression, mental illness, suicide, burnout and substance abuse of any group of people. The wellness of providers is essential for the wellness of our patients, and when the medical community as a whole embraces this idea and starts to make appropriate changes to training and practice, we will have healthier, happier providers and patients.”


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About the Author

Rabia Karani

Rabia Karani just completed her M.P.H., and is now finishing up her last year of medical school. She is passionate about any topic regarding patient care and public health. An anthropologist at heart, she is an avid reader, a Harry Potter enthusiast, and she hopes to use her love for writing to inspire understanding between different groups of people.