In an age of rapidly advancing technology and conflicting economic forces, it is important to guard against overuse of medical treatments and interventions, according to Pieter Cohen, M.D. He was this year’s William Goodson Jr. lecturer.
Cohen, an associate professor of medicine at Harvard Medical School, spoke Nov. 3 about “Slow Medicine,” the approach he and others promote at slowmedupdates.com. Cohen described Slow Medicine as thoughtful practice that involves patients, relies on the best evidence available and is “applied to help decrease excessive and potentially harmful interventions.”
Relatively high use of medical resources and procedures does not produce better results in many areas, Cohen said. For example, research indicates that 30 percent of U.S. knee replacement surgeries are not appropriate. That’s 200,000 major surgeries a year that should have been avoided, he said, resulting in 14,000 people needlessly suffering serious complications and side effects.
Similarly, aggressively ordering lots of CT scans and other tests can result in other overtreatments, not to mention increased anxiety and other side effects, he said, especially when tests produce false positive results.
Cohen cited research in 1973 by John Wennberg, M.D., author of “Tracking Medicine,” who identified the two main drivers of medical overuse. One is supply, so that adding physicians, specialists and hospital beds to an area will increase its use of medicine. The other is the style of medical practice prevalent in an area.
When Wennberg did his research, it was rejected by the Journal of the American Medical Association. But Dartmouth University then financed Wennberg’s work and started the Atlas Project, which examined patterns of medical use and resource intensity in the U.S.
According to Cohen, Wennberg’s conclusions have been proven correct, and Slow Medicine “digs deeper into the style issue to figure out what we can do better.” By involving patients, fully looking at options and not quickly reaching for a specific diagnosis and treatment, he said, Slow Medicine can improve care.
Economic pressures from pharmaceutical companies and medical device makers can promote overuse of some treatments, while cost pressures can curb others than might be beneficial. Slow Medicine tries to put the focus back on what’s best for the patient, which can end up saving money, but for the right reasons. It also keeps physicians from doing things mainly to make themselves feel better, and can prevent extending a treatment that works for some types of patients to others for whom it really wouldn’t be beneficial.
Cohen said Slow Medicine also can take more effort, to fully explain possible risks and rewards of different treatment choices, so that patients have more information and can know that there’s a good case to be made for more than one treatment option. In the end, more thoughtful, appropriate and caring practice can result.
Slow Medicine also is “about letting go of a specific, certain diagnosis” in favor of a more general assessment and then watchful waiting for signs of a particular ailment or for a clearer indication that treatment is needed. The slower approach often provides time for healing without intervention, he said, or provides the data needed to take the best treatment approach possible.
Cohen was the 31st speaker in the William B. Goodson Jr., M.D., Memorial Lectureship, which was established in 1987 by a group of families, patients, colleagues and friends to honor Goodson’s many contributions to medicine.
The challenge of finding the right dosage of medicines for young patients is complex and requires fresh thinking, J. Steven Leeder, Pharm.D., Ph.D., told the audience for the latest installment of the Health Sciences Deans’ Seminar Series.
Leeder, a professor of pediatrics and pharmacology at the UMKC School of Medicine, spoke Oct. 25 in the Health Sciences Building on Hospital Hill on “Exploring Inter-Individual Variability in Drug Response: Moving Beyond the Dose-Exposure Relationship.”
Leeder, who leads the pediatric clinical pharmacology group at Children’s Mercy Hospital, noted that many drugs are initially developed for adults and tested on them, making dosage calculations for children more difficult. On top of that, he said, the typical differences in how people respond to a drug can be magnified in children, given great differences in patient weight and in how rapidly different biological mechanisms in children can change during growth and development.
The maturation of the brain, Leeder said, implies that receptors and transporters affecting drugs’ effectiveness may be changing in children and adolescents, but there’s relatively little research knowledge of these changes.
Given those challenges, he said, it makes sense to invert the usual sequence of “dose-exposure-response”: administering a standard dosage of a drug and then seeing how much of that dosage is present in a patient’s body and how much the patient’s condition responded to the drug. Instead, he favors looking at “response-exposure-dose”: identifying the desired response or therapeutic outcome, and determining the amount of drug that needs to be in the body – the “exposure” — to achieve the desired response. Given that knowledge, he said, then a dosage can be tailored to the patient.
Leader, who practices at Children’s Mercy Hospital, noted that many drugs are initially developed for adults and tested on them, making dosage calculations for children more difficult. On top of that, he said, the typical differences in how people respond to a drug can be magnified in children, given great differences in patient weight and in how rapidly different biological mechanisms in children can change.
The maturation of the brain, Leeder said, means receptors and transporters that affect drugs’ effectiveness must be changing in children and adolescents, but there’s relatively little research knowledge of these changes.
Given those challenges, he said, it makes sense to invert the usual sequence of administering a standard dosage of a drug and then seeing how much of that dosage was used by a patient, and how much the patient’s condition responded to the drug. Instead, he favors looking at the response or outcome that’s desired, and then trying to gauge how well an individual patient’s system will use a drug. Given that knowledge, he said, then a dosage can be tailored to the patient.
Such an approach, he said, might best use the “more information on everyone” being provided by the increase in genomics, bioinformatics and population-wide data from electronic health records.
Leeder holds the Marion Merrell Dow Endowed Chair in Pediatric Clinical Pharmacology and is division director for clinical pharmacology and therapeutic innovations. He earned his pharmacy degree at the University of Minnesota and his doctorate at the University of Toronto. He completed a fellowship in clinical pharmacology at the Hospital for Sick Children in Toronto.
The School of Medicine is accepting nominations for three upcoming faculty, staff and student awards in the areas of diversity and health equity, mentoring and medical education research.
The Excellence in Diversity and Health Equity in Medicine Awards recognizes an individual or organization that has demonstrated sustained and impactful contribution to diversity, inclusion and cultural competency or health equity. The award is given to a student or student organization, and to faculty, staff, resident and/or organization/department.
Nominees should be those who have made consistent contributions to diversity, inclusion, cultural competency or health equity through one or more of the following:
Recruiting and/or retaining a diverse student or faculty body;
Facilitating an inclusive environment for success of all;
Working to promote health equity and the elimination of health disparities;
Strengthening efforts to develop or implement cultural competency strategies that improve health-care delivery.
Nomination materials should be sent to the attention of Cynthia Ginn in the Office of Diversity and Inclusion at email@example.com.
Two Betty M. Drees, M.D., Excellence in Mentoring Awards are presented each year. The Lifetime Achievement in Mentoring Award is for a faculty member with the rank of professor. The Excellence in Mentoring Award goes to a faculty member who is either an associate or assistant professor.
The awards recognize the significant contributions mentors make to enhance and develop the careers of our faculty and trainees. Characteristics of successful mentoring include generosity, listening, objectivity, and constructive feedback regarding career and professional/personal development.
The UMKC School of Medicine is the 5K sponsor of the 2017 Hospital Hill Run – one of the most storied races in Missouri history. Originally created by SOM Founder Grey E. Dimond, the race attracts thousands to participate or volunteer in the family friendly UMKC School of Medicine 5K, as well as the 5K rerun, 10K or half marathon.
As the named sponsor of the UMKC School of Medicine 5K on Friday, June 2, at 7 p.m. – where strollers are welcome and families of all sizes are encouraged to take part – all UMKC staff, faculty, students and alumni may register at a discounted rate.
Participating UMKC staff and faculty also may earn points toward their wellness incentive programs by racing or volunteering. When registering for the Friday night or Saturday morning race events, use the code DISCUMKC for 20 percent savings.
In addition to improving your health and wellness, your participation in the Hospital Hill Run supports many local charities.
There are many ways to get involved in this year’s Hospital Hill Run. Volunteers are needed for all events: to help unwrap medals; pack post-race food packets; sort, stack, and pass out t-shirts; distribute bibs; set up and staff aid stations; cheer and steer participants on course; award medals; give wet towels, food, and hydration at the finish line; and race clean up.
The School of Medicine’s Missouri Delta Chapter of the Alpha Omega Alpha Honor Medical Society welcomed its 2017 class of inductees during an annual celebration at Diastole.
Induction to the society is an honor that recognizes one’s excellence in academic scholarship and adherence to the highest ideals of professionalism in medicine. New AOA members are selected based on their character and values such as honesty, honorable conduct, morality, virtue, unselfishness, ethical ideals, dedication to serving others and leadership.
This year’s inductees included 12 new junior and senior students, residents and fellows, alumni and faculty.
Student inductees include: Junior AOA members Danielle Cunningham, Sanju Eswaran, Carlee Oakley and Vishal Thumar; and senior members Mohammed Alam, Jeffrey Klott and Reid Waldman. Resident and fellow inductees were Mouhanna Abu Ghanimeh, M.D., Katrina Lee Weaver, M.D., and Stephane L. Desouches, D.O.
Sajid Khan, M.D., ’05, was the alumni inductee and Dev Maulik, M.D., chairman of obstetrics and gynecology and senior associate dean for women’s health, was this year’s faculty inductee.
Twelve senior inductees were also selected last fall, including: Himachandana Atluri, Kayla Briggs, Molly Carnahan, Kevin Gibas, Neil Kapil, Susamita Kesh, Deborah Levy, Sean Mark, Luke Nayak, Amina Qayum, Dayne Voelker and Zara Wadood.
Richard Isaacson, M.D., ’01, delivered the annual AOA Lecture on May 5. Isaacson serves as director of the Alzheimer’s Prevention Clinic and Weill Cornell Memory Disorders Program at Weill Cornell Medical College/New York-Presbyterian Hospital. He spoke on advances in the management of Alzheimer’s treatment and prevention.
The UMKC School of Medicine Community and Family Residency Program has announced that Chadwick Byle, M.D., and Kevin Munger, D.O., M.S., will take on leadership roles as the program’s chief residents for 2017-18.
Byle received his medical degree from the University of Missorui-Columbia. Munger is a graduate of the Des Moines University College of of Osteopathic Medicine.
As chief residents, Byle and Munger will serve as liaisons between program residents and faculty, representing the interests and serving as spokesmen for residents. They also serve as a role model, providing oversight and educational leadership.
Primary care specialties are facing an uphill battle for survival, said John Goodson, M.D., a primary care advocate.
Goodson, an associate professor of medicine at Harvard Medical School and primary care internist at Massachusetts General Hospital, delivered the UMKC School of Medicine’s annual William H. Goodson, Jr., M.D., Lectureship on Oct. 28. John Goodson is the son of William Goodson, who practiced internal medicine in the Kansas City area for more than 45 years.
“I’m really dedicated to the care of my patients,” Goodson said. “That’s what keeps me going in life. The balance of my life is patient care and I will do all that I can to save primary care. That’s why I have become an advocate.”
In 2015, John Goodson established the Cognitive Care Alliance to encourage improved compensation for generalist physicians and to help ensure a highly talented primary care work force for the nation’s future. The alliance has since grown to a force of nearly 109,000 physicians covering the spectrum of primary care specialties, Goodson said.
Goodson said three issues are key to maintaining a strong primary care workforce: training medical students who enter primary care specialties; practice reform, including such things as infrastructure, support, team building and health information technology; and, ultimately, attaining parity of compensation for primary care physicians.
“The healthcare economy is not a free economy by any stretch of the imagination,” Goodson said. “We spend $3 trillion on health care. It’s a huge jobs program and there are many problems. Our job is to ensure that our work is appropriately compensated within this gigantic environment.”
While the complexity of the primary care specialties has increased, he noted that interest in primary care has decreased throughout the years. Goodson said he isn’t sure anyone has the perfect answer, but that the problem is understandable when one compares the compensation for primary care physicians to other specialists who earn much higher salaries.
He called for changes in the way service codes used for billing and reimbursement are defined and valued. Goodson said the playing field is tilted with too few primary care specialists included on the panel of health care professionals that determine those service codes and their values.
“We need to defend the cognitive capabilities of our professions,” Goodson said.
This was the 30th year of the annual lectureship. A group of family, patients, colleagues and friends established the William H. Goodson, Jr., M.D., Lectureship in 1987 to honor his many contributions to the field of medicine in the community. Each year, noted speakers offer scholarly perspectives and information related to internal medicine to current and future practitioners.
The School of Medicine Missouri Delta chapter of Alpha Omega Alpha recently selected 12 new student members who will be inducted into the medical honor society next May.
Selection to the organization is considered an honor recognizing one’s dedication to the profession and art of healing. It is based on character and values such as honesty, honorable conduct, morality, virtue, unselfishness, ethical ideals, dedication to serving others, and leadership. Membership also recognizes excellence in academic scholarship.
Each May, the School of Medicine AOA chapter also welcomes fifth-year students, alumni, residents and faculty inductees who are announced in the spring.
This year’s senior students selected for next May’s induction into the AOA include Himachandana Atluri, Kayla Briggs, Molly Carnahan, Kevin Gibas, Neil Kapil, Susamita Kesh, Deborah Levy, Sean Mark, Luke Nayak, Amina Qayum, Dayne Voelker and Zara Wadood. Two additional sixth-year students will be selected to join the 2017 Class prior to the induction ceremony in the spring.
New members of the organization are invited to participate in an induction celebration that takes place at Diastole.
Two students received awards for their research posters at the Missouri chapter of the American College of Physicians annual meetings at Osage Beach. The meetings took place Sept. 15-18.
Fifth-year student Gaurav Anand captured the first prize and Danielle Cunningham, also a fifth-year student, placed third in the student poster presentations.
Anand conducted his research at the Vision Research Center with Peter Koulen, Ph.D., Director of Basic Research and Felix and Carmen Sabates Missouri Endowed Chair in Vision Research, and Christa Montgomery, Ph.D., Research Scientist at the Vision Research Center. He titled his winning poster, Pharmacological control of oxidative stress-mediated effects on endocannabinoid signaling pathways.
“I was interested in the field of neuroscience and ophthalmology,” Anand said. “I wanted to start conducting basic science research in order to further explore my interest in these areas before attempting to conduct clinical research.”
With his first place award, Anand is now eligible to take part in the poster competition at the national ACP meeting next March in San Diego.
“Working alongside two outstanding mentors, Dr. Koulen and Dr. Montgomery, I have gained an immense amount of experience and have learned everything from performing basic science techniques to using complex imaging and data analysis programs,” Anand said. “I have also become familiar with the process of compiling data, graphs, and other information in order to create a presentable research poster. All in all, the experience I have gained will be very beneficial for the research projects I conduct in the future.”
Cunningham placed third with her poster, Neuroradiologic characteristics of astrobastoma and systemic review of the literature: 2 new cases and 125 cases reported in 59 publications.
At the meeting, five students and 13 residents from the School of Medicine presented posters. The Missouri ACP competition drew 20 student posters and 80 posters from residents of medical schools throughout the state.
Orthopedic surgeon Eric Sides initially laughed off Reggie Cook’s idea. Too crazy.
“I don’t understand why you can’t take my left elbow off and put it on my right side,” said the 37-year-old Cook, who lost use of his arms seven years ago after a car accident.
But then Sides thought about the suggestion, and it actually made sense. Cook’s left arm was paralyzed by nerve damage, but the joint was undamaged. The right arm had movement, but the elbow joint had been shattered beyond repair in the accident.
Sides’ thoughts then went to his friend, Lisa Lattanza, considered one of the world’s leading elbow experts. Training together at the University of Missouri-Kansas City School of Medicine led to their close kinship and prominent surgical careers.
Though their orthopedic residencies ended two decades ago and Lattanza is in California and Sides is in Texas, the two remained close. Sides talked to Lattanza about Cook’s unusual request and they came to a conclusion: Why can’t we do this?
They recently joined forces in what’s thought to be the world’s first elbow-to-elbow transplant. The groundbreaking surgery offers a new hope for Cook to live an independent life.
A desperate request
Cook approached Sides, one of the most sought-after orthopedic surgeons in El Paso, Texas, when no other doctor offered options.
In January 2009 after a long night at work, Cook fell asleep at the wheel and crashed. He was in a coma for months. He suffered brain trauma, broke 14 bones in his neck and was left practically a quadriplegic.
Cook’s legs are partially paralyzed and he uses a wheelchair to get around. But his biggest challenge was the loss of mobility in both arms. A nurse came to his house each day to help him change, shower, use the restroom, make him something to eat, brush his teeth. Cook lives with his sister and her family. He credits her, his daughter and dark humor for keeping his spirit lifted.
There have been glimmers of hope before. His left arm is permanently nerve damaged and paralyzed, but an attempt to rebuild his shattered right arm showed promise. In 2013, an artificial joint made of metal and plastic gave him his right arm back —for a few weeks. The delicate joint ripped, a blood clot formed and became infected.
So doctors removed the joint to treat the infection, then reinstalled it. Another infection. Each time the joint was taken out, doctors had to scrape away part of the bone to get rid of the infection, until he had only a few inches of bone in the upper arm, and not much more of the bones in his forearm.
Doctors told him the artificial joint wouldn’t work. They didn’t know what else to do. That’s what led to Cook’s unusual request of Sides that brought in Lattanza, chief of hand, elbow and upper extremity surgery at the University of California, San Francisco.
UMKC School of Medicine Residency
Residents, then and now, divide their time among Children’s Mercy, Saint Luke’s Hospital and Truman Medical Center.
“Through UMKC, the surgeons we worked with were incredible,” said Lattanza, who completed her residency in 1998. “That’s where I learned how to perform surgery. Now I teach residents.”
She and Sides, who was two years ahead of her, were members of a tightknit group. The four-year program had three residents annually.
“We built such a close camaraderie as trainees because it could be so stressful at times,” Lattanza said. “We did battle together.”
“She’s like a sister to me,” said Sides, who completed his residency in 1996. “We would do anything for each other.”
Lattanza and Sides share a similar approach: they love surgery but detest bureaucracy. That the prospect of this surgery was completely out of the ordinary did not deter them.
“We’re doctors and we really want to help other people,” Lattanza said.
Sides accompanied Cook to San Francisco for an array of consultations and for the surgery on April 15 of this year.
A novel surgery
Planning the 12-hour surgery took more than six months. While it might seem like Cook had nothing to lose from the surgery, Lattanza said the surgery actually could have made things even worse for him. He could have lost his right arm. He could have lost the use of his right hand.
On the plus side: a transplant of Cook’s tissue meant no risk of the rejection that might occur with a donor elbow. And actual bone would hold up better than an artificial joint.
On the challenging side: elbows are among the most complicated joints in the body. Knees, shoulders and hips have only one connection where bones meet; elbows have three. And all of the nerves and blood vessels that serve the hand run over the elbow.
Another major complication in this surgery: Moving Cook’s own elbow from the left to right is the mirror image – or reverse – of the one it would replace.
Planning included simulated 3D computer surgery. They then practiced on cadavers to figure out the obstacles when moving the elbow from left to right.
“A big issue was making sure that we did not injure any nerves, which would have altered his hand function and made him worse,” Lattanza said. “Everything was very scarred from his first four surgeries.”
Lattanza compared the surgery and its preparation to choreographing a complex ballet where everyone had precise moves to execute at specific points in time. The troupe was a team of more than a dozen surgeons, nurses and medical technicians. Surgeons performed simultaneously on both sides of Cook.
Due to state licensing restrictions, Sides did not get to scrub in to the surgery, but he participated.
“It was great to be in the operating room again with Eric again,” Lattanza said. “Everyone on the team performed flawlessly and I don’t think I have ever used all my skill and brainpower to this extent. It was exhilarating.”
Although there will have to be a follow-up surgery to reconstruct ligaments, the elbow transplant is so far a success. Cook remains in San Francisco with Lattanza examining him routinely and Sides checks in by phone.
As planned, Cook’s left arm was amputated during the procedure and he nicknamed the stump “Mighty.”
“He’s doing quite well,” Lattanza said. “After 10 days, he bent his arm and he hadn’t done that in seven years. He was quite emotional.”
“We are cautiously optimistic, but he has a long way to go. If the elbow heals and works, he definitely will be better off than when we started.”
Sides, who specializes in adult reconstructive surgery and sports medicine, hopes to team up with Lattanza again.
If Cook’s transplant is successful, it could be a useful example for other patients. Sides said similar procedures could be used on legs or other parts of the body. One application might be a war-wounded veteran.
News of Cook’s unusual surgery has received national media attention. UMKC School of Medicine faculty and their former residency colleagues have celebrated the medical advance.
“It makes me and all of us very proud, because this really is a first,” said Mark Bernhardt, chair of the UMKC School of Medicine Department of Orthopaedic Surgery. “I worked closely with each of them each during their four years, and they were both bright, inquisitive, talented, committed residents.
“Look what teamwork did here. It proved it is a crucial part of patient care.”
Bernhardt announced that Lattanza will be the annual Dr. Rex L. Diveley visiting professor in April 2017 at the UMKC School of Medicine. She will interact and lecture with students and faculty for two days.
In an email, Lattanza wrote to Bernhardt and other UMKC faculty and colleagues.
“Every one of you was there in the operating room with us. We could not have even dreamed or attempted this without the fabulous training and confidence that you all gave us during residency.”