Bridges to Equity Summer Externship

I will be spending six weeks exploring cancer epidemiology at Karmanos Cancer Institute in Detroit, MI as part of a program aimed at bridging the gap between medicine and public health.

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Takeaways

My goal going into this externship was to explore ways in which I can incorporate public health endeavors into my practice as a physician, and I am glad to say that that goal was achieved. The past month and a half has had its challenges, but it provided me with excellent insight into the research realm of the public health world. In particular, I was able to learn about cancer epidemiology, specifically, prostate cancer epidemiology.

The importance of tying together epidemiological research and clinical practice, for me, is so that neither the individual nor the population’s health is overlooked. This particular study that I was working on, entitled Treatment Options for Prostate Cancer Study, was looking at the broader population of men with prostate cancer and how they decided on a treatment. Although this question may have arose in clinic during an individual office visit, the findings from the study can be applied on a much larger scale and may help many men achieve a better quality of life.

Additionally, an individual’s decision to go ahead with surgery or chemo may be influenced by socioeconomic status or race. These are important considerations to take into account when making recommendations regarding prostate cancer treatment for the general male population and when speaking with a patient one-on-one in the office. I was fortunate enough to have had the opportunity to witness firsthand how physicians are able to individualize recommendations for prostate cancer treatment. In addition, I was able to see how patients can influence the approval of research proposals, and just how crucial it is for them to be able to do so.

Aside from learning the broad scope of how physicians can combine public health research and clinical practice, I also learned about the nitty gritty details of the cancer registry and how to carry out large-scale studies. For example, eligible patients are identified through the Surveillance, Epidemiology, and End Results Program which contains lab results and diagnostic information. The physicians of these patients are then contacted and if they agree that the patient can participate in the study then we contact the patient. All of this information, and the survey data if the patient chooses to participant, is tracked in a large database. Although this sounds simple, the amount of detail and manpower that goes into keeping track of thousands of surveys is astounding.

Overall, I have a better idea of how I want to integrate medicine with public health. Working on the TOPCS study helped me understand how much detail goes into this kind of project, and how to incorporate the information gained from this study into clinical practice.

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Work-Life Balance: A Public Health Issue

This particular post is going to be a bit off topic from the prostate cancer study I have been working on. Thankfully, another research assistant started last week and we have been able to complete the TOPCS study tasks much quicker. As such, I was able to reflect on my experience on the cancer epidemiology floor of the Mid-Med building. Right off the bat I noticed that the floor was dominated by women. Which shouldn’t have been surprising, but it was.

For some context, my background in research is very lab bench orientated. I worked for two years in a pharmacology lab at the University of Michigan and while there were some women that worked in research, I found that the majority was men. I can recall my supervisor at U of M, who was female, and a mom, and pregnant at the time, describing to me what maternity leave entails. A quick google search of U of M’s maternity leave policy summarizes what she had described: “Employees unable to work due to pregnancy and delivery will use sick-time pay to cover any time they are medically unable to work related to their pregnancy or delivery.” The site then states that extended sick time pay can occur up to 8 weeks after delivery.(1) This doesn’t sound so horrible, and it may be better than most women get at some companies. But is having a child really comparable to an illness? If we look to Sweden, the country that seems to be the poster child of public health endeavors, we find that parents receive 480 days of leave per child (60 days allocated specifically to the father) during which time they receive 80% of their wages.(2) Now the “maternity leave” that U of M employees receive seems quite subpar.

Taking this back full circle to my colleagues in the Mid-Med building, who are majority women and majority moms, the work environment seems quite different from my previous research experience. Many of these women are able to work from home, and therefore, can spend more time with their family. In addition, they are able to leave early some days to pick up their kids from daycare or camp. My supervisor at U of M was at work every single day and had to coordinate with her husband or her parents to pick up her child from daycare. Needless to say she ended up going to another lab group. Granted I have only been on the epidemiology floor for a few weeks, but overall, everyone that I have worked with seems happy in their position and much less stressed than some of the women I observed in the pharmacology lab.

Parental leave has been a public health issue particularly in the United States for some time, but it seems like there haven’t been many initiatives to improve this issue. Often times spending time with your newborn child means not getting paid, which places stress on parents. To the same effect, working all day and not spending time with your newborn child is also stressful. This stress can build and could cost companies more in terms sick leave or disability later on. I hope that as the work-life balance discussion continues that more companies/institutions recognize the importance of having longer paid maternity leave (not just “sick leave”).

https://hr.umich.edu/working-u-m/my-employment/leaves-absence-toolkit/leaves-absence-associated-pregnancy-maternity

http://www.npr.org/sections/babyproject/2011/08/09/139121410/parental-leave-the-swedes-are-the-most-generous

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Connecting Population Studies and Individual Patients

The past week I had the opportunity to attend a meeting for prostate cancer advocates, the focus of which was grants and the grant review process. This was a great experience because 1) it helped me better understand the whole grant writing and reviewing process and 2) it helped me connect a face and a purpose with the daily tasks of the Treatment Options in Prostate Cancer Study (TOPCS). The advocates are individuals who have been personally affected by prostate cancer, and who are able to review grants themselves to determine the practicality of a research proposal in the context of the patient’s perspective. Too often it is easy to get caught up in the bubble of academia, but having input from patients who have gone through clinical studies and various treatments offers a refreshing and invaluable perspective.

Later in the week, I was lucky enough to shadow a few physicians in clinic including Dr. Heath, a genitourinary oncologist who treats many patients with prostate cancer and Dr. Xu, the principal investigator of TOPCS and a family physician. Again, this was a great experience to connect different aspects of TOPCS with actual patients in the clinic. For example, this study is investigating how and to what extent physicians influence patients’ decision to proceed with one type of treatment over another. Another question that comes into consideration when deciding on treatment is what co-morbidities patients have. I was able to see how both patient and doctor are able to balance these considerations in deciding on the best course of action for maintaining quality of life and managing cancer. Overall, the experiences of this past week helped me bridge the gap between broad-scale population studies and individual patient considerations in the clinical setting.

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It’s all in the details

Over the past few weeks I have come to appreciate the incredible amount of detail that goes into this study. The goal is to receive about 2,000 initial surveys from men recently diagnosed with prostate cancer. About 18 months after this initial survey, these same men then receive another survey which differs depending on whether they chose to have surgery or radiation therapy vs active surveillance. Thankfully, Microsoft Access makes keeping track of these surveys much easier, however, there are still some challenges. For example, some surveys are returned with some questions missing answers, some surveys are not able to be delivered to certain patients, some patients may be ineligible, etc. Then there is the added challenge of trying to contact patients via phone if there is missing information or if they have not returned a survey yet. Aside from this, reports must be generated showing the overall number of surveys that have been sent out, how many have returned, how many consent letters we have sent to physicians and patients, and much more. The difficulty with these reports is ensuring that no patient has slipped through the cracks and that we are calculating all of the correct information. To mitigate this, safeguards are in place to certify that all of the data is correct and the tasks for each week are completed. Suffice it to say that I have learned more about Microsoft Access than I had ever hoped to learn.

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Over-Treating Low-Risk Prostate Cancer

After investigating the overarching challenges in our healthcare system, I had to change gears in some aspects as I transitioned into my “actual job”. This past week was spent mostly completing various tasks to keep the prostate cancer study going. The study that I am working on (called Treatment Options for Prostate Cancer Study) is exploring the reasons that men with low-grade (Gleason grade of 6 or below), low-risk cancer decide to have some form of radiation or surgery to remove part or all of their prostate as opposed to active surveillance. I have learned that prostate cancer is different than other types of cancers in that the low-grade version of this cancer is not likely to progress or become life-threatening.  However, even though it is not likely to be life-threatening and there may be complications from radiation or surgery such as incontinence or impotence, majority of men still opt to pursue these treatment options.

This is obviously relevant at the level of individual patients and how they can personalize their treatment, but it is also relevant on a broader public health scale. One in six men are diagnosed with prostate cancer at some point in their life, but only 1 in 36 will die from this cancer. Also, half of men diagnosed with prostate cancer via PSA testing have low-grade, low-risk tumors yet about 90% still opt to have radiation or surgery. Therefore, the number of men receiving unnecessary treatment is vast. Not only is it unnecessary in majority of low-risk cases, but the treatment itself can negatively impact the patient’s physical and mental health. This may lead to even more doctors appointments, hospital visits, medications, etc., which are all attached with a cost. The treatment itself is not cheap, and the follow-up care only tacks on more costs if there are complications. This is a prime example of over-treatment in the United States that hikes up healthcare costs and still does not improve quality of life.

The latest and greatest treatments for cancer are incredibly important and have saved many lives.  However, we must recognize that these treatments still come at a cost, both literally and at the cost of the patient’s quality of life. With regard to prostate cancer specifically, active surveillance is an optimum alternative as the patient will receive frequent testing to ensure the cancer is not progressing. If it is progressing, then treatment is started immediately. This saves the patient money and saves them from stress as a result of possible complications down the road. If this same principle is applied across the spectrum of medical ailments, we may become better at reducing our over-treatment and improve the quality of care for chronic conditions. 

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Changing the Discussion of Healthcare in Detroit: The Comeback City

The majority of this week was spent on reviewing documents and videos to get a general idea of public health in the United States and why we use public health as an avenue to improve our country’s healthcare system. While we are GREAT at having the most innovative (read: expensive) medical technology, we are not so great at actually managing chronic diseases or even preventing these diseases from occurring. Our population is dying from heart disease, cancer, and medical/hospital error. All of these are preventable. While I am hearing more discussion about exercising regularly and eating healthy, not everyone has the luxury of having the gym closeby, a safe park for their children to play in, a grocery store closeby that actually sells fresh produce, or even the time to make a healthy meal.

Forty percent of residents in the Motor City don’t have access to a car. Detroit is a unique city in that it is incredibly spread out, and anyone who knows Detroit’s history knows jobs have been few and far between (although this seems to be changing). Knowing that jobs are hard to find near your home, and knowing that you don’t have access to a car, how would you get to work? How would you get food from the grocery store? How do you prevent the heart disease your physician keeps telling you about without the means to do so?

The video Unnatural Causes demonstrated that poor people are disproportionately at risk for developing a number of preventable diseases. Further, if you are an African American you are more likely to die sooner than your white counterparts, regardless of socioeconomic standing, as a result of the institutionalized racism still present in this country. The number of obstacles Detroiters face simply to stay as healthy as their neighbors in the suburbs is astounding. While I was somewhat disappointed that this video did not seem to offer any solutions to the number of problems they listed, Dr. El-Sayed did, in fact, give some solutions already at play in Detroit and some potential solutions for the future.

With an understanding of the problems in our healthcare system and in Detroit, we can begin to come up with solutions that can turn the Motor City into the Comeback City that many hope it will become, and in some ways has already started to become. The new director of Detroit’s Health Department, Dr. El-Sayed, has already begun to implement projects to improve the health of Detroiters.  For example, water in virtually all schools in Detroit, including daycares and private schools, was able to be tested for lead within weeks. Marathon Petroleum agreed to reduce its sulfur dioxide emissions after pushback from the Health Department, when they originally wanted to increase emissions. There is potential to implement a “baby box” program like that seen in Finland in which every newborn receives a box filled with necessary supplies to prevent infant mortality (an epidemic in Detroit). I think I can speak for most by saying that I am tired of hearing about the issues in Detroit and am eager for solutions. With these tangible programs beginning to improve healthcare in the Comeback City, I am hopeful that we can set a positive precedent for other cities to follow.