The Design of a Medical School Social Justice Curriculum

Well over 100 years have passed since Virchow wrote that “physicians are the natural attorneys of the poor, and social problems fall to a large extent within their jurisdiction.” Since that time, the world’s population has septupled, and billions of people are “trapped in the health conditions of” his era.

As a result, many medical students in the 21st century want to work to decrease health disparities, and increasing numbers of medical graduates indicate they intend to work with people who are often underserved. This groundswell of medical student interest in remedying health disparities joins urgent calls for the integration of specific social justice competencies into medical school curricula and aligns with new considerations and the ranking of the quality of institutions’ “social mission.”

Yet, how can medical students learn about global health and social justice without recapitulating the mistakes of their forebears? 

What skills do they need to be effective in social justice outreach abroad and at home? 

What are physician obligations toward "social justice" if any?

We take on these and additional questions in our new article in Academic Medicine, "The Design of a Medical School Social Justice Curriculum." 

Who should decide: a patient who has been suicidal or her legal guardian?

The team recommended a feeding tube. At first Sasha demurred, pointing to Liz’s refusal. But the psychiatrist clarified that Liz did not have decision-making capacity to refuse the procedure, so we relied upon Sasha. Sasha seemed to understand, and said she didn’t want Liz to starve. She asked what the procedure would entail, and what future steps in Liz’s care would involve. We discussed eventual transfer to a nursing home, and said we doubted Liz would ever care for herself again.

Then the conversation took an unexpected turn. 

Read my whole article at Scientific American guest blogs.

Are churches telling HIV patients to stop treatment?

I asked Bill what his pastor and fellow parishioners thought about his decision to stop HIV treatment. “They totally support me,” he said. “In fact, it was their idea.” His congregation had encouraged him to stay off his HIV medications despite his doubts, to see this revelation through “to the end, whatever may come.”

Bill is not alone in his church’s insistence that welcoming a preventable death is somehow an act of faith, that stoic acceptance of sickness and death are the only road to the conditional love of his Pentecostal brethren. The BBC reported recently that many Pentecostal congregations have advised their parishioners to skip HIV therapy and, like Bill, leave their lives in God’s hands.

Read my full article at The Atlantic - Health.

Great video chat about the story on HuffPost Live with Josh Zepps which was then picked up in HuffPost Religion. Look Ma!

Replace the med school interview with fMRI: a modest proposal

Finding applicants with the potential to have great bedside manners is the real challenge of the admissions process. Many applicants are smart enough to know enough and think clearly enough to become full-fledged physicians. But those academic traits combined with the kind of compassion, resilience and moral reasoning patients need is still rare.

Why not just MRI applicants instead? Check out my guest post at the Scientific American which was republished at The Health Care Blog.

Are families of people in the ICU silenced by the law?

Doctors rushed an ill-fated motorcyclist with severe injuries to the head and chest to the ICU.   

In the difficult weeks that followed, the prognosis was progressively more and more grim. Family members were sure the patient "would not want to live like that" on a mechanical ventilator. 

But the law prevented them from speaking on his behalf.  

Read my full article at Scientific American blogs.

I was also interviewed on NHPR about this story as part of a three piece series on end-of-life decision-making. 

How can mothers with HIV breastfeed safely? Lessons from the saris of Bangladesh

Kids who breastfed for at least six months had higher IQ's in later life, according to a recent article in JAMA Peds.  

But US mothers with HIV are taught not to breastfeed their babies for fear they will transmit HIV. The HIV transmission risk to babies from breastfeeding is ~15%.

That means HIV-infected mothers in the US must choose between higher baby IQ's, and a host of other health benefits of breastfeeding, or safety. 

The breastfeeding choice is even more complicated for mothers with HIV in the developing world. There, in countries with unsafe drinking water, HIV isn't the only threat to babies: diarrheal illness is a major pediatric killer. As a result, feeding babies with formula risks infections that can kill in days instead of years like HIV. 

As a result, breastfeeding recommendations in the US and the developed world are the opposite of those in the developing world:

(1) in the US and the developed world mothers with HIV are taught to use formula and avoid breastfeeding; whereas 

(2) in developing countries mothers breastfeed and hope for HIV therapy to reduce the risk of transmission. In the new consolidated WHO treatment guidelines released 30 June 2013, universal HIV treatment is recommended for pregnant and breastfeeding mothers.

This means that a great way to prevent HIV transmission in the developing world is to make drinking water safer. 

But wait, it gets more complicated. A new UNC study has confirmed that breast milk  actually protects from oral transmission of HIV. That means it is the HIV within breast milk that endangers babies, not the breastmilk itself.

If breast milk protects from oral HIV transmission, and has myriad health benefits, then perhaps we can find a way to remove HIV from breast milk? The solution will need to be low tech since the greatest need is in developing countries - no $83,000 NASA filters, please. 

That's where Rita Colwell comes in. A microbiologist at the University of Maryland, and former head of the National Science Foundation, Colwell studied cholera - a diarrheal disease transmitted by contaminated water - in Bangladesh. She showed that water filtered through a folded sari was far less likely to transmit cholera, meaning families could filter drinking water through a cheap piece of clothing and keep themselves safe.  

Might developing world mothers with HIV use the same trick to protect their babies from HIV? An effective filter for drinking water in the developing world could not only prevent pediatric diarrheal disease, sure, but what if it could prevent HIV transmission. 

What? "Filter breastmilk?" you say. Not so crazy after all -  many investigators are studying creative ways of making breast milk safer by nipple shields and other ingenious ways of filtering HIV out of breast milk.  

Over 1,000 children are infected with HIV every day; let's hope we find an answer soon.

Earlier Is Better

For years now there has been controversy about whether early HIV infection should be treated. Could the immune system be spared the ravages of the HIV virus through early therapy? Or does early therapy just make treatment last longer? The jury has been out, and might still be deliberating, but a new piece of evidence has emerged. 

 Deeks et al have shown that, compared to people treated later in HIV disease, those treated within 6 months of initial infection show less immune system damage over time. This might be a sign that early treatment is good.  

We still lack clear evidence that such benefits of early treatment outweigh the downsides of HIV treatment. The side effects, costs and other risks are real. So, we still await a clear sign. 

When face-to-face with a patient with early HIV infection, I tell them what we know, and what we don't, and we share the decision-making. Does the possibility of ongoing immune damage scare them enough to make taking an HIV pill or two daily worth it? Or  does the prospect of starting decades of therapy freak them out more? We talk through it, and most (but not all) start therapy. 

Someday, let's hope we know more.

Quoted @ MIND/Shift

Holly Korbey has a great new article about the death of lectures in which I was quoted. Okay, maybe not the death of lectures - but definitely their dethroning. 

Teachers are wrong to assume that their role is to only convey information, and that merely saying the magic words will translate into learning for students.

Click here to read Holly Korbey's "Anyone Still Listening? Educators Consider Killing the Lecture" @ MIND/shift