Mike Munger, M.D. ’83, a family physician in Overland Park, Kansas, this month became president of the American Academy of Family Physicians at its annual convention. The academy represents 129,000 physicians and medical students nationwide.
As president, Munger advocates on behalf of family physicians and patients nationwide. The organization fosters education and training, provides other extensive resources for its members, and encourages research and best practices in family medicine to promote health and reduce overall health care costs.
Munger became president-elect a year ago and also has served three years as a director on the AAFP Board.
Munger has been a practicing family physician in the Kansas City metropolitan area for 30 years. He is in practice at Saint Luke’s Physicians Group in Overland Park, where he also serves as vice president of medical affairs for primary care. The group has 105 physician members at 14 different sites, three of which maintain Level 3 medical home designation from the National Committee for Quality Assurance, and 11 of which are participants in the Comprehensive Primary Care Plus Initiative. CPC+ is an outcome of the Center for Medicare and Medicaid Services Innovation Center.
After earning his bachelor of arts and medical degrees from UMKC, Munger completed his family medicine residency at what was then the Goppert Family Practice Residency Program at Baptist Medical Center, also in Kansas City. He is board certified by the American Board of Family Medicine and has the AAFP Degree of Fellow, an earned degree awarded to family physicians for distinguished service and continuing medical education.
A promising therapy to combat brain tumors in children has emerged from a confluence of bold research, scientific insight and luck, a Children’s Mercy research director said Aug. 30 in the latest installment in the UMKC Health Sciences Deans’ Seminar Series.
The research aims to block a pathway that mutant cells often take when forming tumors near the brain stem. The work’s progress and hurdles were detailed by Tom Curran, Ph.D., who is the executive director and chief scientific officer of the Children’s Research Institute and a professor of pediatrics at the UMKC School of Medicine.
His presentation was titled “How mice, sheep, corn lilies and a beer helped children with brain tumors: Targeting the hedgehog pathway in medulloblastoma.”
When he started the hedgehog inhibitor work, Curran already had contributed extensively to the understanding of tumor formation – and knew plenty about mice. He discovered the Fos-Jun tumor-generating complex, and had identified reelin, the gene responsible for reeler, the mutation that makes mice lose muscle control.
Curran wanted to extend his mutation research to the tumors that form during brain development, “so we made the decision that we would take a take a precision medicine approach to medulloblastoma, even though we knew nothing about it at the time.”
He said his team came up with “a very naive concept” for proceeding: to identify molecules involved in tumor formation and then develop inhibitors for them, confirming both the mutations and their inhibition in mouse studies. After cause and prevention were demonstrated in mice, clinical drug trials in humans would follow.
The plan, however naive, has generated significant research success.
“That’s what translational research is about,” he said. “You have to develop a simple model … with milestones that let you know you’re making progress toward the goals.
“The other factor that is really important to this kind of science is luck. You need to be in the right place at the right time.”
The project’s first indication of good timing came quickly.
“Three weeks after we decided we were going to target medulloblastoma, the very first paper came out linking the sonic hedgehog pathway and … these tumors.” (A family of mutant genes with a spiky appearance is called hedgehog genes, and one of those was named after the Sonic Hedgehog computer game a Harvard researcher’s son was fond of.)
Sheep and corn lilies entered the picture when Curran was looking for a hedgehog-path inhibitor to work with and recalled a story about sheep giving birth to one-eyed lambs. What might have been a genetic defect was determined instead to be caused by a chemical in the corn lilies the ewes had eaten. The chemical, named cyclopamine, was found to block the sonic hedgehog path, the effect Curran was looking for. But it also was toxic and eventually seemed unlikely to lead to a suitable drug for humans.
Fortune intervened again when Curran was having a beer with a colleague after a conference in Taos, N.M. The friend was an expert on the sonic hedgehog pathway and referred Curran to another researcher whose team was doing similar work but running out of money for testing. Curran got in touch with the other team and was able to do the testing, which produced good results.
The project also has had its share of challenges to overcome, including recurrence of tumors after initial success in a human trial. That often happens in cancer treatment, Curran said, as drug resistance develops. But a biopsy from that case has provided further information, and trials continue.
Besides his positions at the Children’s Research Institute and UMKC, Curran is the Donald J. Hall Eminent Scholar in Pediatric Research and a professor of cancer biology at the University of Kansas School of Medicine.
Before coming to Kansas City, he led the Translational Brain Tumor Program for a decade at St. Jude Children’s Research Hospital; was deputy scientific director of the Children’s Hospital of Philadelphia Research Institute for another decade; and set up the multi-institution Children’s Brain Tumor Tissue Consortium.
Curran earned his doctorate for studies at the Imperial Cancer Research Fund Laboratories in London. His work has been published in nearly 300 papers and cited more than 50,000 times.
The School of Medicine’s graduate programs have expanded with a residency in neurology and a fellowship in endocrinology, diabetes and metabolism.
The neurology residency started July 1 with two residents, Dr. Ellen Troudt and Dr. Nikita Maniar. Troudt, currently at Truman Medical Center, and Maniar, at Saint Luke’s Hospital, will work for a year in internal medicine and then three years in neurology. Research Medical Center, Children’s Mercy Hospital and the Center for Behavioral Medicine also are affiliates for the residency.
Dr. Charles Donohoe, the Neurology Department chairman and associate professor of neurology, said adding the residency was “integral to sustaining the TMC-UMKC neurology program.”
“Five years ago we had no full-time neurology faculty,” said Donohoe. “Now we have five faculty members in the Neurology Department, and to add a residency in such a short time is quite an achievement. We also think it’s important to have a solid neurology presence at a safety net hospital such as Truman.”
Now that the program is underway, Donohoe said, it will use the match system next year and aim to add three physicians a year, eventually having a dozen residents. Dr. Sean Gratton, who is the program director, said this was “the first new residency program at TMC or UMKC in many years.”
Troudt is from New York and earned her medical degree at the Ross University School in the Caribbean island nation of Dominica. Donohoe said she had recently worked in cutting-edge stroke treatment as part of an ambulance team that had the rare advantage of having a CT scanner in their vehicle.
Maniar is from Florida and also earned her medical degree in the Caribbean, at the St. George’s University School of Medicine in Grenada. She then earned an MBA there and recently was a research fellow at the Brooklyn Hospital Center in New York.
The new endocrinology position is a two-year fellowship held by Dr. Maha Abu Kishk, an internist who earned her medical degree in 2003 and has been a hospitalist with Truman Medical Centers. This fellowship is affiliated with Hellman & Rosen Endocrine Associates, which will be a primary training site along with Truman Medical Center.
“We’re excited to add this fellowship, which helps address the shortage of endocrinologists,” said Dr. Betty Drees, professor of medicine and program director for the fellowship. “As diabetes continues to increase in prevalence, so does the need for endocrinologists.”
Public health systems still are failing to prevent lead poisoning in children, Bruce Lanphear, M.D. ’86, writes in an editorial in the journal Pediatrics.
Lanphear, whose research on lead poisoning put him in the national spotlight when the lead crisis in Flint, Mich., came to light, said children in hundreds of other cities had blood lead levels higher than the children of Flint.
The American Academy of Pediatrics Council on Environmental Health, Lanphear said, “recommends greater emphasis on screening children’s environments to identify lead hazards before a child is poisoned, using tools to sample and test house dust, soil, or water for lead.”
He also said pediatricians could push for lead abatement in older homes and regulations to cut environmental hazards. Testing of chemicals to establish their safety before they can be released into the environment also should be required, Lanphear said, but prospects for such regulation are dim.
The editorial accompanied research by others finding that, as lead levels have declined in many areas, testing labs are having trouble accurately detecting low levels of lead in children’s blood. There appears to be no safe threshold for lead exposure, especially in children, so detection at low levels is still important.
Lanphear also was one of three School of Medicine alumni whose work was reported last year in a UMKC Medicine article.
The addition of a second antibiotic to treat cellulitis skin infections did not result in significantly better cure rates in research recently published in JAMA, the Journal of the American Medical Association.
The study was the latest from an emergency medicine research group that includes Truman Medical Centers and Mark T. Steele, M.D. ’80. Steele is associate dean for TMC Programs at the UMKC School of Medicine and chief medical officer and chief operating officer for Truman Medical Centers.
“I’ve been involved with this group for more than 20 years,” Steele said. “It has 11 sites across the country and studies infectious diseases relevant to emergency medicine. This latest study used five of those sites, including Truman.”
The study involved 500 patients who had cellulitis that was not accompanied by abscess or a wound. Half of those patients were treated with cephalexin, an antibiotic effective against streptococci that typically is used in such cases. The other half got cephalexin plus trimethoprim-sulfamethoxazole, an anti-staph antibiotic that more patients with skin and soft-tissue infections have been receiving “just in case” MRSA — methicillin resistant Staphylococcus aureus — is present.
For the entire group treated, the added antibiotic seemed to help, producing a cure rate of 76.2 percent, versus a 69 percent cure rate for those who received just cephalexin. But that difference was not considered statistically significant. In addition, when the results were narrowed to the patients who were known to have taken at least 75 percent of the recommended doses of their antibiotics, the cure rates were almost identical, 83.5 percent for those who also got the second antibiotic, and 85.5 percent those who received just cephalexin.
MRSA has been showing up as a cause of more severe, abscessed skin infections, which has led to more dual prescribing of the antibiotics. Steele said this study’s results could inform emergency physicians that for cellulitis, absent abscess or a wound, the addition of the second antibiotic wasn’t more effective.
Amy Stubbs, M.D., helped oversee Truman’s portion of the research. She’s an assistant professor of emergency medicine at the School of Medicine and director of the school’s emergency medicine residency program. She completed her residency in emergency medicine at UMKC and was chief resident.
The National Institutes of Health sponsored the study, which Steele said was particularly well constructed to meet the standards of JAMA, the world’s most widely circulated medical journal.
It was the third in a series of published studies by the emergency research group, called the EMERGEncy ID NET. One dealt with treatment of abscesses and was published in the New England Journal of Medicine. Another looked at infected wounds seen by emergency physicians and was published in the journal Clinical Infectious Diseases.
When fourth-year student Jordann Dhuse crossed the finish line at the 2017 UMKC School of Medicine 5K, she wondered what all the fuss was about.
“I was shocked when I realized I had won my division,” said Dhuse, first among the 930 women in the June 2 race.
“I haven’t run all that many races,” said Dhuse, who enjoyed other sports in high school but took up running just a few years ago. “I had won my age group before, but not my division.”
Dhuse runs more “as a way to decompress from studying” than to be competitive, she said. But she does push herself to improve, and her time in this year’s 5K, 23:11, was almost two and a half minutes better than a year ago, when she placed 30th in the women’s division.
“I try to fit in a run most days, three miles if I’m lucky,” she said, and often can be seen running near the school, or walking her dog, Milo.
“He’s a long-haired chihuahua, so he doesn’t run with me,” she said. “But I let him wear my race medal. I think it weighs more than he does.”
It was the fourth year that the 5K took place the Friday evening before the Hospital Hill 10K and Marathon. The move was made to make the shorter race more family friendly, and it draws parents pushing strollers, along with many teams from various workplaces and non-profits.
“I like the atmosphere of this race,” said Dhuse. “You get families, people in town for the weekend, different groups.”
Dhuse is from the Chicago area and came to UMKC after earning a bachelor’s degree in health science at the University of Missouri.
“I followed my brother, Kyle, to Columbia,” she said. “He’s a year older and fell in love with the campus.”
Then Dhuse decided to go on for a medical degree and was happy she was accepted at UMKC.
“I was attracted by the program’s whole approach, especially the docent system,” she said. “I love being on a team.”
Many of her Gold 3 docent mates are different from her in at least one respect: “I’m interested in emergency medicine, and most of them are interested in internal or family medicine. But we support each other.”
Providing health care to refugee populations faces tremendous obstacles, but it can be done, and everyone can help, Nicholas Comninellis, M.D. ’82, told students, faculty and guests on May 16 at the School of Medicine.
Comninellis, UMKC’s Alumnus of the Year in 2015, spoke on “Refugee Care—Displaced But Not Forgotten,” as part of the school’s International Medicine Lecture Series.
He has been on the faculty at the School of Medicine and in 2004 founded INMED, the Institute for International Medicine, which is based in Kansas City and equips health care professionals to provide primary care for refugees and other displaced people.
Using slides and a brief film from UNHCR, the United Nations Refugee Agency, Comninellis homed in on dire refugee situations stemming from ISIS control of regions in Syria and Iraq. He asked audience members to help him list the obstacles to treating refugee populations, and then he went through the four phases of aiding refugees, from pre-emergency and emergency through post-emergency maintenance and repatriation.
The combination of displacement from their homes, violent emotional and sometimes physical trauma, a severe lack of material and medical resources, and lack of infrastructure for sanitary living makes providing even basic medical care difficult, he said.
High stress is also common, often related to worrying about whether there will be enough to eat. And even when a refugee settlement can achieve some stability and sense of safety away from battle areas, boredom and finding meaningful work then can become a big problem, he said.
Comninellis showed many heart-rending, close-up photographs from refugee camps, and then a photo from Jordan showing a vast expanse of thousands of tents in a desert camp where refugees had lived for the past five years.
In calling on his audience to help, Comninellis said the refugee problem one “of biblical proportions,” and he read verses from Leviticus and Deuteronomy admonishing people to care for and love “the foreigner residing among you.” He noted that his father’s father had been a refugee from Greece during World War II, and that many people in the audience probably had some refugee history in their families.
He also noted that his organization, INMED, offered courses, training, fellowships, service learning and diploma programs so that students, residents and other graduates could develop and practice skills in international medicine.
He also encouraged everyone to volunteer with a reputable organization that aids refugees, to help refugees who settled in their communities, to be aware of changing refugee situations in the world, and to encourage elected representatives to pursue policies that help refugees.
Before Comninellis spoke, Steven Waldman, M.D. ’77, J.D., M.B.A., and associate dean of International Programs, said the School of Medicine on Aug. 22 would have a session outlining opportunities for international service learning and research that will be available through Global Health Learning Opportunities. That’s a collaborative of about 140 international programs, through the Association of American Medical Colleges.
Waldman also said an International Medicine Day was in the works for November, during which posters could be presented, much like the school’s annual Quality and Patient Safety Day.
Several trends in health care make the practice of compassionate medicine more difficult, but integrating the humanities into medical education can help produce more-caring physicians, Arno Kumagai, M.D., said at the second annual Noback-Burton Lecture.
“The first question is, What kind of doctors are we trying to create?” Kumagai asked in his April 28 lecture at the UMKC School of Medicine, titled “Ways of Seeing, Ways of Knowing: A Role for the Humanities in Medical Education.”
Kumagai, vice chair for education in the Department of Medicine at the University of Toronto, argued that medical education should be moral education, promoting justice, compassion and “development of the empathic self.”
He said the rising emphasis on patient-centered care was welcome—and needed to counter current challenges and developments including:
Rapid technological change, which despite its possible benefits can be hard to keep up with and disruptive.
Turning medicine into a commodity and patients into customers. Conveyor belt medicine and measures of “productivity” work against the best care, Kumagai said.
The standardization of medical education. Though a wide range of essential skills must be imparted to every student, individuality and fresh and varied ways to see and engage with patients should be nurtured rather than sacrificed.
The ubiquity of electronic medical records, leading to typing into a computer crowding out human interaction, especially during a 15-minute conveyor belt style appointment.
Especially given these developments, Kumagai said, how do medical schools educate future physicians to best provide patient-centered care?
Integrating the humanities into the curriculum is certainly part of the answer, but moreover Kumagai argued for using the many ways that the humanities and art can get people to open their perception and see and know their patients and the world differently.
As an example, he said it had built empathy, and shown students the power of other people’s stories, to match medical students with patients with chronic conditions, and have them really get to know those patients. Valuable lessons come from such “deep listening and dialogue,” Kumagai said, and can keep doctors from seeing patients as their illnesses and not whole people.
“We often forget that at the heart of medicine lies the interaction we have with someone who suffers … a sacred space in which people become different than they are, including ourselves,” Kumagai said. “Medicine is ultimately the opportunity to bear witness to the mystery, tragedy and wonder of being human. And it is our duty as physicians not to look at this as extra. This humanism, humanities, is at the core of medicine. It is not an extra.”
This was the second year for the lecture series, endowed by James Riscoe, M.D. ’75, a member of the school’s third graduating class. Riscoe said he started the event to honor Richardson K. Noback, M.D., the first dean of the School of Medicine, and Jerry Burton, M.D. ’73, a classmate who is recognized as the first graduate of the medical school.
Dayne Voelker and Amanda Fletcher, both set to graduate in May from the School of Medicine, were selected as UMKC Vice Chancellor’s Honor Recipients.
The vice chancellor for student affairs and enrollment management takes nominations from each academic unit to recognize graduating students who have excelled in academic achievement, leadership and service to UMKC and the community.
Voelker, who will head to Rochester, Minnesota, for an internal medicine residency at the Mayo Clinic, was nominated by Gary Salzman, M.D., his docent in the Green 6 unit.
“Dr. Salzman has been even more than a mentor and docent,” said Voelker, of Perryville, Missouri. “He’s really been a second father figure. I have been able to ask him for advice on just about anything.”
Fletcher, whose residency will be in orthopedic surgery at Duke University Medical Center in Durham, North Carolina, was nominated by Marge Weimer, the education team coordinator for her docent unit, Purple 1.
She said Weimer had been “a supportive friend and mother figure I could always look to for guidance.” She also thanked Agostino Molteni, M.D., her research mentor.
Fletcher’s offices and service activities include secretary of the Medical Student Research Interest Group, vice president of the Orthopedic Surgery Interest Group, the Alpha Phi Omega Service Fraternity, Sojourner’s Health Clinic, the Global Medical Brigades medical mission trip to Honduras in 2013 and a surgical mission trip with Project Perfect World in Ecuador.
Many serious health conditions are associated with childhood trauma, and medical schools and health care systems need to do much more to recognize that connection and devise effective treatment, said Nancy Hardt, M.D., the latest speaker in the Dean’s Visiting Professor Series.
Hardt, a University of Florida emerita professor of pathology and obstetrics and gynecology, spoke April 27 at the UMKC School of Medicine on “Adverse Childhood Experiences: The Most Important Public Health Topic Missing from Our Curricula.”
Adverse Childhood Experiences — ACES for short — include sexual and physical abuse, growing up in poverty, divorce, alcoholism and other drug addictions, and crime and neighborhood violence. Hardt drew on research indicating the scope of their connection with disparities in health, including findings that:
— Suffering six or more childhood trauma incidents cuts 20 years off life expectancy.
— More than 14 percent of adults in one study had suffered four or more adverse childhood experiences.
— Of people who have suffered five or more adverse events, 90 percent have some sort of developmental delay.
— Each adverse childhood experience increased the rate of everything from asthma and anxiety to heart disease, stroke and diabetes. ACES also correlated with poverty and unemployment, which further increase the likelihood of serious health problems and difficulty in getting them treated.
Hardt cited the work of Michael Marmot, who wrote “The Health Gap” and said, after studying developed countries around the world, that the United States “had a lot of nerve” allowing one-fourth of its children to grow up in poverty. Marmot also did research among British government workers and found that all up and down the pay scale, more money correlated with better health.
Many social service agencies are trying to address ACES and head off the costly health problems they cause, Hardt said. But medical care has lagged behind, she said, in part because medical schools don’t teach prospective doctors about these connections.
She told of one doctor, Vincent Felitti, whose research established a connection between childhood sexual abuse and obesity later in life. He initially was puzzled about why some patients in a weight loss study couldn’t keep off lost weight — until he learned that adults who had been sexually abused often felt safer, less a target, when excess weight made them unattractive.
“He said, ‘I’ve been a doctor for 25, 30 years, and I never knew that. Why didn’t they teach me this in medical school?’ ” Hardt said.
Felitti then met Rob Anda, a Centers for Disease Control researcher who thought childhood trauma correlated with hypertension in adults. Felitti and Anda then did a large study showing the many health problems linked to ACES.
The good news, Hardt said, is that rsearch also has shown that the effects of traumatic experiences often can be reversed with the right treatments and interventions.
An abused or neglected person’s resilience can be aided by everything from mindfulness practices, meditation and yoga to getting sufficient sleep, nutrition, exercise and daily pleasurable experiences, she said.
Researchers and caregivers also are learning more about what to try, she said. For example, in some cases it has been found that traumatized children who cannot attach to adults can connect with younger children and help them, too.
Hardt said it also was important for medical schools and centers to practice care for their own people, so that students and caregivers weren’t themselves stressed or traumatized and thus less able to provide care that’s responsive to trauma. And it’s important for the medical profession to realize and address the secondary trauma that caregivers can suffer.
Hardt noted further that there’s a sound business case for such treatment and interventions, given the large number of serious later-in-life problems that can be prevented or mitigated.
Good treatment requires a team effort, she said, and that provides opportunities for medical schools to work ACES information and experience into their curriculum. Medical students, for example, could provide the sort of staff help that’s always need by community partners treating traumatized youth.
The Kansas City area already is “rockin’ and rollin’” in this area, Hardt said. The Head Start-Trauma Smart program of Saint Luke’s Crittenton Children’s Center is just one example of an area program doing good work, she said.
“I’ve never seen a place with more opportunity to make this happen,” she said.