Doctors Take on the Status Quo
“When did we become The Man?” asked alumnus Harlan Krumholz, at the 25th Reunion Symposium, titled “1985–2010: A Medical Odyssey (Part I)—Academics and Health Policy.” It might as well have been titled “Question Authority … Even If That Authority Is You.” In a punchy morning session, speaker after speaker shared their efforts to challenge the status quo in U.S. healthcare.
Local alumnus Paul Ridker, the Eugene Braunwald professor of medicine at HMS and Brigham and Women’s Hospital, began with a talk about heart disease. Even though half of all heart attacks and strokes occur among those with average or even low cholesterol, our guidelines for prevention still focus primarily on cholesterol.
It turns out that there is a better marker: inflammation.
Over a decade ago, Ridker showed that elevated levels of a marker for inflammation known as high-sensitivity C-reactive protein (hsCRP) signal an increased likelihood of heart attack or stroke. Since then, the American Heart Association has begun recommending inflammation tests for those with other risk factors. But Ridker, whose group showed that statin drugs lower risk of heart attack and stroke when hsCRP levels are high even when cholesterol levels are normal, suggests a step further. He says that statins could be more widely used as cost-effective preventive measures.
Ridker also added that the inventor of the Chipwich (a chocolate chip–riddled variation of the ice cream sandwich) lived to 67, while a doctor who dedicated his life to combating obesity lived to 71. “Four years more, but probably without a single Chipwich,” he mused. “Which matters more, quality of life or quantity?”
Following Ridker were Elizabeth Stewart, professor of obstetrics and gynecology at the Mayo Medical School, and Lynt Johnson, professor of surgery at Georgetown University Hospital. Both have spent their careers making radical changes in their fields.
Stewart challenged the status quo on treating uterine fibroids, which had seemingly been stuck in the 19th century. “We had only one tool. A hammer,” she said. Until recently, hysterectomy was the only choice for the 40 million U.S. women suffering from fibroids. Now, she is using noninvasive techniques such as MRI-guided ultrasound to treat fibroids and doing genetic studies to determine what causes the disorder.
Johnson’s challenge is the “liver gap,” he said. Every year, thousands of people wait for a liver to become available from a deceased donor. The need for livers led this transplant surgeon to begin performing transplants from live donors, taking a portion of a healthy liver from a healthy donor.
The process challenges medicine at its core. “We are taking a healthy person and making them sick,” said Johnson, who has helped improve the standard consent process for live donors and the guidelines for selecting them. “Donors are dedicated. An emotional bond motivates them,” he said. Many are willing, despite the risk of death.
Because the surgery for live donors is dramatic— it results in a Mercedes-Benz–shaped scar that spans the abdomen—Johnson also has worked to improve surgical techniques. His practice now performs minimally invasive surgery that leaves only a short slash at the top of the abdomen.
Central to the symposium was a talk by Judith Salerno, executive director of the Institute of Medicine. Salerno has been in and out of healthcare policy her entire career. She spoke about the history of health policy in America and said that the recently passed healthcare bill is “chock full of amazing things,” such as support for innovation, preventive services and education.
“This is just the beginning,” she said. “Once we realize that the world isn’t going to end because more people have health insurance, we’ll be able to start making real changes.”
A video of symposium is available online.
Alumni Without BordersTales from the Front Lines of Medicine
“There is no such thing as a boring story about being bitten by a snake,” said alumna Leslie Boyer, HMS ’85, during the afternoon session of the 25th Reunion Symposium. Boyer treats snake bites and scorpion stings at the University of Arizona. She says it is best to get bitten or stung close to a clinic that knows how to deal with these kinds of things.
Unfortunately, though, it is often children who get stung, and they are usually out in the wilds of Arizona, hours from the nearest intensive care unit.
A scorpion sting is frightening, but it does not have to be fatal. Supportive care of the patient involves “enough sedatives to kill a horse,” Boyer explained. This is the only way to stop the involuntary twitching the poison causes as it attacks the peripheral nervous system. Boyer also puts sting victims on a vent until the poison passes to prevent their lungs from filling with fluid.
The biggest challenge is getting the patient to the clinic. It is risky to put a twitching, seizing patient into a helicopter for a three- or four-hour ride, Boyer said, and even riskier to try to intubate them.
The alternative, as seen in old Westerns, is to administer antivenom. Such products do exist, but Arizona used its last dose of scorpion antivenom in 2004, Boyer said. Florida is currently running out of its antivenom for coral snakes. And while cobra bites are increasing in the United States, no cobra antivenom is in development.
Labs in Mexico are working on antivenom drugs, however, and Boyer has been on the front lines of trying to get these compounds tested and approved for use in the United States. The barriers have included many she expected—lack of funds, complicated regulatory issues, language barriers—and some she did not. For instance, importing the white powder drug from Mexico proved difficult. “Cocaine is much easier to bring in,” she said. And given recent new immigration laws in Arizona, “we’re turning away our donors and our scientific colleagues.”
The talks that flanked Boyer’s spanned the globe in this symposium, titled “1985–2010: A Medical Odyssey (Part II)—National and International Health.” Many of Boyer’s classmates have also positioned themselves in far-flung locations to serve neglected populations. The Class of ’85 is in Ghana, Nepal, El Salvador, Ecuador, and Iraq. They also work in their own backyards, from impoverished neighborhoods in Los Angeles to rural areas of New England. Speakers included Janey Wiggs, associate professor of ophthalmology at the Massachusetts Eye and Ear Infirmary, and Robin Avery, professor of medicine at the Cleveland Clinic.
While many of Boyer’s classmates are reaching out to help improve healthcare, Boyer’s talk showed that the street runs both ways. She has received much support from colleagues in Mexico, despite legal barriers, and researchers in North Africa have, in turn, picked up on her work. “We need legal ways to collaborate internationally,” she said.
