Mental Health How we foster wellness within
Musings Lessons from children’s literature
In-School Care Partnering to nurture children’s mental health in Washington, D.C. schools
14 More Than Kind 16 Flourishing on Campus
Understanding the neurobiology of altruism
Making changes that matter to support student mental health
Facing the Impostor Confidence and humility in medical training
22 Physician Wellness 26 Building Mental Resilience 28 Global View Beyond the burnout
One doctor’s journey to recovery
How culture shapes mental health
10 3 34 36 38
Check up News & Research
issues in Bioethics Physicians and gun violence
On Campus Alumni Connections
On the cover: Child and Adolescent Psychiatrist Emily Aron (M’08) and her children enjoy the Woodland Trail in Rock Creek Park. Photo by Lisa Helfert.
Check out your brain The library is offering more than books these days. At Georgetown’s Maker Hub in the basement of Lauinger Library, a team of students in the Interdisciplinary Program in Neuroscience set about to create a unique thank-you gift for children who participated in their research study: personalized 3D prints of their brains. Guinevere Eden is the principal investigator in the Center for the Study of Learning project, which looks at the brain bases of reading and math difficulty. PhD student Cameron McKay (pictured here) spearheaded the 3D brain initiative, along with assistance from Georgetown undergraduate research assistant Ryan Mannion (C’20) and Don Undeen, manager of the Maker Hub.
R EA DE R F E ED B AC K
A publication for alumni and friends of the schools and programs of Georgetown University Medical Center
CARE OF THE WORLD In these days of apparent national retrenchment, it was inspirational to read about the global reach of Georgetown medicine in nearly every article of the volume. Georgetown’s institutional commitment to the improvement of worldwide health is on impressive display, and the personal stories of so many Georgetown alums whose lives are dedicated to these sublime goals are humbling and uplifting in equal measure.
Editor Jane Varner Malhotra
This is the ultimate expression of cura personalis, where the care is being extended to the world itself. I am proud to be a small part of this exemplary community. William J. Oetgen, MD (MBA’96) Alexandria, Virginia
Fall/Winter 2018 Georgetown Medicine magazine
Omar Abubars Chelsea Burwell (G’16) Kate Colwell Giuliana Cortese (C’13) Jeff Donahoe Jupiter El-Asmar (F’17) Camille Scarborough Seren Snow Karen Teber Kat Zambon Erica Zamoranos
Design Director Robin Lazarus-Berlin Lazarus Design
AMBASSADORS OF HEALTH Thank you for publishing the most recent issue on global migration and making us all more aware of the health exigencies created in its wake. The worldwide immigrant and refugee crisis is a consequence of so many different dimensions, with individuals and families fleeing from political unrest, religious persecution, climate change, and economic hardship. Through your alumni stories and in-depth review of health care in Rwanda, Kenya, Tanzania, and elsewhere around the world, you are helping us understand the crucial part that Georgetown physicians are playing in bridging cultures, preparing for pandemics and administering cross-border medical care. I was proud to read how Georgetown is using an interconnected multi-disciplinary approach through many of its graduate and undergraduate schools—Medicine, Law, NHS, Foreign Service, Public Policy, etc.—to educate its students on how to effect meaningful positive change in this humanitarian crisis. This issue gives an excellent understanding of how Georgetown’s innovative medical programs are keeping pace with technology, communications, methods, and delivery of health care, both at home and abroad. While the news may be grim, the message that comes through your articles is one of hope and optimism. Through their compassion, courage, and commitment, our best ambassadors of world peace are often those administering health care to underserved people at home and abroad. Nancy Ripp Clark, MD (C’77, M’81) Potomac, Maryland
University Photographers Phil Humnicky Paul Jones
Executive Vice President for Health Sciences and Executive Dean Edward B. Healton, MD, MPH
Dean for Medical Education Stephen Ray Mitchell (W’86), MD, MBA
Georgetown Medicine is published by the Georgetown University Office of Advancement Communications. Visit the magazine online at https://alumni.georgetown.edu/medicinemagazine. The magazine welcomes inquiries, opinions, and comments from its readers. Address correspondence to firstname.lastname@example.org or: Jane Varner Malhotra, Editor Georgetown Medicine Office of Advancement P.O. Box 571253 Washington, DC 20057-1253 For address changes contact alumni records email@example.com or 202-687-1994. For up-to-date information on Georgetown events and alumni news on campus and around the world, visit Georgetown Alumni Online: alumni.georgetown.edu. © 2019 Georgetown University
We are gathering alumni perspectives for a future article on Georgetown and HIV/AIDS—history, research, education, and patient care. If you have a story to share, contact the editor: Jane.Malhotra@georgetown.edu.
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NEWS & RESEARCH
Honored to Make D.C. Better
Top photo courtesy of Washingtonian/Bottom photo iStock
n n Lucile Adams-Campbell, professor of oncology and senior associate dean for community outreach and engagement, was named a 2018 Washingtonian of the Year. The Washingtonian magazine annual honor is bestowed on individuals who have made significant, measurable contributions to the city’s health, welfare, community service, and cultural richness. Adams-Campbell was selected for her exceptional outreach work in the community to address a critical need: health disparities affecting minorities. The District of Columbia has one of the highest cancer mortality rates in the U.S., and African-Americans are at the greatest risk. This is unacceptable, says Adams-Campbell, a D.C. native and the first African American woman in the country to earn a PhD in epidemiology. Through Georgetown Lombardi’s Office of Minority Health (OMH) and Capital Breast Care Center (CBCC), she addresses gaps in cancer prevention, diagnosis, and treatment among minority populations. The greatest health disparities exist in southeast D.C., where the population is approximately 90 percent African-American. Led by Adams-Campbell, the OMH and CBCC offices there are staffed by nurse practitioners and community health educators who are experts in cancer epidemiology, health communications, exercise physiology, and nutrition. They promote evidencebased nutrition and physical activity interventions to reduce the impact of health disparities. Part of the OMH, the CBCC has provided over 16,000 women throughout the Washington, D.C., area with cancer screenings since 2004. The CBCC also offers culturally sensitive patient navigation and health education, empowering minority women—often grossly underrepresented in research studies—to make more informed decisions about their health. “It has been an honor and privilege to work on behalf of D.C. residents through a leading institution and with dedicated colleagues who truly embody our commitment to justice,” Adams-Campbell says. “As long as health disparities continue to impact populations in this city, we have more work to do.” n
DNA Test Kit? Think Twice! A new video from Georgetown Lombardi Comprehensive Cancer Center’s director of cancer genetic counseling Beth N. Peshkin offers advice on Direct-to-Consumer (DTC) DNA testing, including concerns around privacy, accuracy, and new-found relatives. “It sounds less exciting, but talking with your family members about their health history and then sharing it with your doctor can have a more positive effect on your health than a DTC test,” says Peshkin.
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n n The immunotherapy that is revolutionizing treatment of many cancers appears to offer similar benefit to cancer patients living with HIV, say researchers at Georgetown Lombardi Comprehensive Cancer Center. Their study, published in JAMA Oncology, focused on whether checkpoint inhibitor drugs are safe and effective in patients with advanced cancer who also live with HIV. Because checkpoint inhibitors manipulate the immune system, the concern has been that these therapies might have adverse effects such as virus reactivation in patients with HIV infection. Checkpoint inhibitors work by removing the “brakes” that cancer puts on a natural immune response against tumors. Antiretroviral drugs target and block different stages of the virus’ life cycle, preventing it from replicating. Investigators searched the
medical literature to find 73 HIV patients whose cancer had been treated with checkpoint inhibitors. Only a fraction of patients came from a clinical trial; the rest were mostly case reports and case series from oncologists who treated cancer-HIV patients with the new cancer drugs. “Cancer patients with HIV and their oncologists have found themselves in a real conundrum,” says the study’s lead investigator, Chul Kim, an assistant professor at Georgetown Lombardi. “Because of their HIV infection, they are at higher risk of developing cancer than people who are not infected. In fact, cancer has become one of the leading causes of death in patients with HIV.” He says that conventional chemotherapies can reverse HIV suppression, and that these patients also are widely excluded from clinical studies that test the next generation of cancer treatments.
“We hope our finding will lead to increased study of checkpoint inhibitors in patients with HIV and cancer,” says Kim, also an attending
whose immune system is exhausted by its long fight with HIV,” he says. “We will be able to look at what effects checkpoint
physician at MedStar Georgetown University Hospital and MedStar Washington Hospital Center. He adds that the checkpoint inhibitors might not just keep cancer in check. “There are signals in this analysis and other studies that suggest these new cancer drugs may restore an immune response against HIV in patients
inhibitor therapy has on both the cancer and the infection,” Kim says. Kim’s work on this study was supported by a Norman Rales Young Investigator Award from the American Society of Clinical Oncology Conquer Cancer Foundation and a Stanley and Linda Sher research grant from Georgetown. n
“Contemporary science is a globalized enterprise and can’t be regulated merely by enacting a patchwork of national laws. International ethical standards have become a necessity.” — Georgetown medical ethicist Daniel Sulmasy on World Health Organization’s announcement in December that it would examine global science and ethics questions around human gene editing. The announcement came in response to a Chinese scientist’s claim that he performed genetic editing to create twin girls who are resistant to HIV— the first known case of humans undergoing genetic editing before birth.
Top photo Getty Images/Bottom photo Alamy
Cancer Patients With HIV Benefit From Immunotherapy
Top photo Mitch Lensink/Bottom photo Blend Images
A New Look at Native Health Justice n n The health of American Indian and Alaska Natives (AI/AN) is disproportionately affected by criminal justice disparities in the United States, notes School of Nursing & Health Studies professor Bette Jacobs and others in a recent study published in Belmont Law Review. A majority of tribal jails run by the Bureau of Indian Affairs on reservations do not provide health services for inmates, the study states, which would be considered unconstitutional if they were not on tribal land. The study surveys many aspects of life for the AI/AN communities, telling “a story of poverty and relatively low life expectancy, proportionately high incidences of disease, high rates of incarceration, and prolific alcohol and substance abuse. AI/ANs are incarcerated at a higher rate proportionately than their white counterparts. They experience harsher sentences, due in part to jurisdictional laws, and they are the racial group most likely to be killed by law enforcement.” One section looks at diet, noting that a majority of native communities are on or near reservations and in remote areas
with limited access to healthy foods. The population’s high consumption of processed meats, for example, leads to obesity and contributes to high rates of chronic diseases including cardiovascular conditions, diabetes, and cancer. Jacobs, an enrolled member of Cherokee Nation, is a distinguished scholar at the O’Neill Institute for National and Global Health Law. n
Maternal Mortality in D.C. Raises Concern n n Close scrutiny has been placed on Washington, D.C.’s maternal health services for marginalized populations, with the recent closures of two maternity wards in underserved communities. The nation’s capital also has one of the highest maternal mortality rates in the country, and the incidents disproportionately impact women of color. “These closings created a deeper void for patients from already underserved communities,” says Christina Marea (F’02), certified nurse midwife
and instructor at the School of Nursing & Health Studies. “It’s very apparent in the availability and accessibility of hospital services, for example, when there are four maternity wards in northwest and just one in northeast.” Marea says social factors, such as high public transportation costs and finding reliable childcare during appointments, impede women’s ability to seek health care in the District. “Women want to take good care of themselves and their bodies, but when it
becomes a choice between an immediate urgent need of tending to a child in front of you and spending a six-hour day to get an ultrasound, the immediate urgent needs often take priority.” Marea serves on the D.C. Council’s recently established maternal mortality review pane, along with her NHS colleague Ebony Marcelle. Both Marcelle and Marea are working with the D.C. Mayor’s Office to examine this issue of pregnancyrelated death. n
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NHS Collaborates With Jesuit Clinic in Liberia n n
With funding from the Office of the Vice President for Global Engagement, a team from Georgetown’s School of Nursing & Health Studies (NHS) conducted a three-day workshop for local midwives and health care workers in Caldwell, Liberia. Still rebounding to rehabilitate its health infrastructure after a civil war and Ebola epidemic, Liberia has one of the highest maternal mortality rates in the world, and fewer than 200 trained midwives for more than 4 million people, according to the World Health Organization. “I have been a midwife for a long time, and I always felt I had been working in a way that was communityfocused,” said Debora Dole, vice chair and associate professor in the department of advanced nursing practice and one of the workshop leaders. “But this experience has changed my view of what help looks like.”
Professor of Human Science Rosemary Sokas initiated the workshop, which was hosted by Holy Family Health Center, a clinic run by Liberia’s only Jesuit parish. Thirty local midwives and health care workers attended. The program included sessions on health care worker safety and health, and handson midwifery training using low-tech simulators, which
were then given to partners in Liberia. The Georgetown team focused on gauging the community’s needs, and learned about the challenges that midwives and health care workers face in caring for childbearing women and their newborns and infants when staff and resources are severely limited. They also met with stakeholders to
assess opportunities for ongoing collaboration and support. “It was an incredibly profound experience that opened up a world of need and challenge, but also of joy,” Sokas said. “By virtue of being able to physically be there, we opened a door that was impossible to open before.” n
A Georgetown-led study has contributed to the recent FDA approval of a drug for small cell lung cancer (SCLC)—the first in decades to improve survival. “With the addition of atezolizumab to chemotherapy, we have finally moved the needle in SCLC,” says Stephen V. Liu, a lung cancer specialist at Georgetown Lombardi Comprehensive Cancer Center who co-led the clinical trial. “It is now our charge to build upon these results and ensure that the next major advance is not another 20 years away.”
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Bottom: Yale Rosen
Lung Cancer Progress
What’s the Big Deal About Big Data? Q&A with Subha madhavan, georgetown’s chief data scientist and founding director of the innovation Center for Biomedical informatics. What makes big data so powerful? Every day the world creates 2.5 quintillion bytes of data— 25 followed by 17 zeros. Of this data, 30 percent is generated in health care, from laboratories and electronic medical record data to health apps on smartphones and wearable technologies. To go from terabytes of data on each patient to something actionable for clinicians and patients, we use methods such as machine learning and natural language processing. Almost 90 percent of a data science project involves data acquisition, pre-processing, cleaning, and getting it ready for analysis, visualization, and interpretation. My team has become an integral part of how physicians, researchers, and administrators collect and process data. Our goal is to augment their workflow to make better decisions.
Center, we are analyzing molecular data from patients with advanced metastatic colorectal cancers in pursuit of precision diagnostics, to avoid trial and error with treatments. In partnership with our colleagues at MedStar Health, we conducted an eye-tracking experiment to study what’s most useful for physicians in a lab test report and understand their cognitive workflows.
How can big data transform health care? Currently, health care expenses in the U.S. account for around 18 percent of GDP, totaling about $600 billion. Such high costs are unsustainable and laws are being enacted to reduce the burden, most notably the Affordable Care Act. As a result, more health systems are collecting and analyzing big data to improve performance and efficiency, and ultimately achieve better outcomes for patients. In life sciences, biomedical researchers can analyze the correlations between thousands of diseases and biological and behavioral variables to uncover new connections between illnesses and their associated risk factors, leading to better screening, earlier detection of disease, and better preventative care and treatments.
How is georgetown contributing to the field of informatics? At Georgetown, it’s important for us to apply the latest digital health technologies for the common good. We are developing ways to extract useful knowledge from data and apply the tools across basic, translational, and clinical science, working with clinicians and researchers at Georgetown, federal agencies, and industry partners. Recent projects include building an immuno-oncology registry that allows clinicians to ask questions about toxicity in patients receiving these novel cancer drugs. With the Ruesch Center for the Cure of Gastrointestinal Cancers at Georgetown Lombardi Comprehensive Cancer
What’s next? We’re working with the MedStar Georgetown University Hospital on a number of projects, including one with OB/GYN to identify patterns related to postpartum hemorrhage. With the National Domestic Violence Hotline, Department of Veterans Affairs, the Massive Data Institute at the McCourt School of Public Policy, and the Department of Psychiatry, we are developing machine learning models on voice recordings from patients to predict who is at risk for suicide ideation and intimate partner violence. This fall we are launching a master’s program in health informatics and data science, and we’re hosting our 8th annual Big Data in Biomedicine symposium. n —Interview by Kate Colwell
MENTAL HEALTH How we foster wellness within
here to begin on mental health, a topic that truly touches everyone? Children’s literature offers an avenue. As a child I enjoyed the lilting poetry of A. A. Milne, who covered important subjects like curiosity, disobedience, and playing in puddles. Today I wonder how Winnie the Pooh and friends would fare in our world. It’s not hard to imagine the disorders we would assign them. The gloomy donkey Eeyore seems to suffer from depression. In direct contrast, the bouncing Tigger offers a textbook example of attention deficit hyperactivity disorder. Rabbit exhibits some serious compulsive tendencies. And there’s Pooh himself, described as “a bear of little brain.” How would we help these beloved but imperfect characters navigate school and society? Recess with Tigger would be a lot of fun, but he might be disruptive during storytime. Would mindfulness work, or is medication the answer? According to the CDC, one out of six children ages 2-8 have a diagnosed mental, behavioral, or developmental disorder. What does a healthy mental state even look like? The extreme ends are clear, but how are we defining “normal” today? Is that range too narrow? Does social media make it even narrower, towards a perfection that no one can achieve? In researching for this magazine over the past few months, I’ve had a few shrinks on my calendar, as one of them jokingly described it. I know from both professional and personal experience how deeply they care about the well-being of individuals and of society at large. I see how they reach out, particularly to the most vulnerable, those who suffer at the margins. The children we don’t see at the playground, faces on the streets we try to ignore, the incarcerated, the isolated. In this issue, we bring you just a tiny slice of Georgetown’s work in the sphere of mental health. What we don’t mention can fill a library. Consider this the first part in an ongoing series as we take a look at physician wellness and burnout, student mental health, the neurobiology of altruism, and global cultural approaches to human well-being. The good news is that each day is new, and as Eeyore says, the rain stops eventually. The community of friends in The Hundred Acre Wood accept and support one another, despite their differences. Our relationships matter, we are all imperfect and in formation, and wellness is within reach as we turn both inward and to each other—to something that transcends and connects us all—in hope.
Jane Varner Malhotra
Jane Varner Malhotra Editor
In-School Care Georgetown partners to nurture children’s mental health in Washington, D.C. schools By Jeff Donahoe
Childhood is supposed to be happy and secure, but there’s an increasing understanding that it isn’t always that way. It’s not just parents, teachers, and doctors who see this; the Centers for Disease Control and Prevention has documented that diagnoses of childhood depression and anxiety have steadily increased over the past 15 years to more than 10 percent of the population. And that’s just children who’ve been diagnosed. “There’s a national crisis in children’s mental health in every city, state, sector, and demographic,” says Georgetown’s Matthew Biel, MD, MSc, whose expertise includes treating children and adolescents with anxiety, stress disorders, and trauma-related conditions. Biel sees these conditions every day as chief of the division of child and adolescent psychiatry at MedStar Georgetown University Hospital and associate professor of clinical psychiatry and pediatrics at Georgetown University School of Medicine. Over the last 20 years, there’s been an increased acknowledgement that nurturing and safe homes, schools, and childcare in early childhood are the biggest predictors for mental and physical health and academic achievement into adulthood. This knowledge grows from the groundbreaking Adverse Childhood Experiences (ACE) study, published by CDC-Kaiser Permanente in 1998. The ten original ACEs are in three groups: abuse, neglect, and household dysfunction. Ongoing ACEs research has widened to study the impact of bullying, death of a loved one, deportation and migration, violence in the community, and racism. Adversity is a common experience for many children growing up in D.C., where almost 25 percent of children have two or more ACEs; the most commonly occurring adverse experience is extreme economic hardship. In the last decade, Georgetown University Medical Center as a whole has elevated research, education, and outreach efforts to address health disparities. These efforts have focused on community-based activities, especially in the chronically underserved Wards 7 and 8, east of the Anacostia River. These predominantly African-American communities have long been passed over by D.C.’s overall economic prosperity. City health data indicate that residents of these wards experience poorer overall physical and mental health, witness more violence, have less household income, and have reduced life expectancy compared with residents in other parts of the city.
Georgetown’s Division of Child Psychiatry has been helping a wider population of children and young adults and their families by deepening its engagement with the city. “There’s momentum around innovative mental health care strategies and integrating these approaches into schools, childcare, and primary care,” Biel says. He and others at Georgetown and other health care providers are bringing mental health programs into the community, including schools. “The best way for us to reach kids and families is to design services that are accessible and effective, and to deliver these services in community settings,” Biel says.
A city in need Biel co-directs the Early Childhood Innovation Network (ECIN), which was launched in 2016 with a $6 million, fiveyear commitment from the J. Willard and Alice S. Marriott Foundation. Biel’s co-director is Lee Beers, MD, at Children’s National Health System. The network is a citywide effort to improve developmental outcomes for children and families living in underserved D.C. communities with an aim of eliminating or decreasing the impacts of extreme, toxic stressors on young children from birth to age 5. These services include interventions and programs to promote parent and child mental health, deliver training for pediatricians and other primary providers to recognize and treat stress in children, and work with schools and community-based health clinics to build expertise and capacity. “Integrating mental health services into primary care is a great potential vehicle for improving access to care,” Biel says, “but many pediatricians have very limited training in mental health.” One Georgetown Child Psychiatry innovation is to provide pediatricians real-time access to consultations from child psychiatrists during patient appointments. The phone
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Trauma survivors Karimah Ware, PsyD, assistant professor of clinical psychiatry and director of clinical training for the WISE Center, has a traditional child psychiatry practice one day a week at Georgetown-MedStar Health. The rest of the week, under the aegis of the division of child psychiatry, you will find her doing school-based psychology in nine KIPP public charter schools in D.C.’s Wards 5, 7, and 8. Ware’s role in the schools has two purposes. Most of her day is spent working with teachers and school administration teams—principals, guidance counselors, and social workers—to help identify students who need assistance and build sustainable
Clinical Psychologist and D.C. native Karimah Ware works primarily on-site in the city’s public schools to facilitate sustainable mental health support for students, teachers, and staff.
Top photo Shutterstock/Bottom photo Lisa Helfert
consultations are provided in partnership with Children’s National Health System. Biel is also part of WISE, the center for Wellbeing in School Environments, a cross- and multi-disciplinary team at MedStar Georgetown that brings evidence-based mental health interventions to D.C.’s public school students, from early childhood through high school, to improve mental health outcomes and enhance learning opportunities for youth. WISE’s innovations include consultations on student needs; evaluation and treatment of student mental health concerns on-site at schools; training for educators about development and mental health of students; increasing trauma sensitivity and mindfulness in classrooms; and helping prevent or reduce teacher burnout. WISE’s focus is on prevention, early intervention, and support. Each school’s needs are different, and Georgetown tailors the formulation to the school. “Our intention is to say to each school, ‘How can we best partner with you?’” Biel says.
capacity within the schools. As the school day winds down, Ware’s clinical work begins as she leads individual and group therapy with children, and other programs that offer social support and foster resilience. “By and large, many students with whom I work have experienced some kind of stressor or trauma,” such as witnessing or being the victim of a violent crime, says Ware, whose expertise includes childhood depression and anxiety, grief, and trauma. It’s tough to learn—and to teach—in many of D.C.’s public schools. “Schools are asked to do an awful lot,” says Katharine Landfield, who for more than 20 years was a social worker in high-need schools in D.C. and Virginia. “They are the container for child development for all of society.” Schools provide everything from education to meals and mental health support. Many of the students Landfield has seen are in families facing food, housing, and economic instability, underscoring the need for improved economic circumstances for parents to reduce stress overall, she adds. “How can we help children with all that’s going on in their families’ lives?” Landfield asks. In the past decade, after a rash of gun violence affecting children in the crossfire, the city has invested new resources to address kids’ mental health, like having an on-site dedicated social worker for every school. Schools either have a psychologist or share one with another school.
“We are trying to address the effects of chronically stressful environments,” Dutton says. “These are toxic environments. We’re dealing with everyday trauma of racism and poverty.”
normalizing treatment Dutton is concerned about identifying trauma, but not stigmatizing it. Dutton, Ware, and Biel agree that stigmas associated with seeking treatment for mental health and behavior issues still exists, “but it’s tremendously better than it used to be,” Ware says.
Community-focused research Children don’t exist alone—and healthier adults and families mean healthier children. The Department of Psychiatry has a broad portfolio of research, much of it about trauma. “Georgetown’s research standout is focusing on the community,” says Mary Ann Dutton, professor and vice chair for research. The Department of Psychiatry is not a new player in the field; it has historically been focused on trauma, toxic stressors, and interventions research. More than 30 years ago, Georgetown was an early leader in the identification, study, and treatment of PTSD in veterans and populations affected by natural disasters. Dutton’s own research is dedicated to interpersonal trauma and how to address it. “In many communities, accessing care for trauma is challenging,” she says. Her colleague Elizabeth Hoge, MD, leads a populationbased study which looks at mindfulness for reducing anxiety disorders. If mindfulness can be demonstrated to be as effective as medication, it could possibly become eligible for insurance coverage. Additional benefits include fewer negative side effects than medication, plus a wide range of health and wellness improvements. Other research looks at interventions to depression in prenatal and postpartum care; preventing teen violence; the impact of mindfulness in parenting skills; and the efficacy of school-based interventions.
In March, the School of Medicine’s health justice scholars went to Capitol Hill to express their support for legislation to provide school-based mental health services in grades K-12. The Health Justice longitudinal four-year academic track empowers student physicians to become advocates for justice, going beyond the exam room to improve patients’ lives.
“Talking about seeking help is becoming part of the norm in kid-to-kid conversation,” Ware says. “By the time they are teenagers, many kids are very informed about therapy and are supportive of each other seeking therapy services.” Providing and improving care in schools, and educating students dealing with extreme stress takes a high level of dedication. It’s a passion for Ware, who is a D.C. native. “I love this work,” she says. “I want children who are underserved to have the same opportunities for social, spiritual, and economic growth as any other child in the city,” she says. It’s a steep climb, but not impossible. “The solutions involve energy and expertise,” Biel says. “Georgetown has both.” n
M ENTAL HEALTH
Understanding the neurobiology of altruism By Jane Varner Malhotra
n the middle of the night, a young woman was driving down the highway in Tacoma, Washington when suddenly a dog ran in front of her car. She swerved to avoid it and spun out, ending up in the fast lane, facing the wrong way, with a dead engine. Another driver pulled over, ran across four lanes to restart her car, drove her back to the shoulder, made sure she was okay, and then left. “Why did a stranger risk his life to save mine?” wonders Georgetown psychology professor Abigail Marsh. Since that fateful night, the question has inspired her pursuit to understand the brain mechanisms of altruism. Measuring altruism in the lab is a challenge, she says. “People don’t self-report accurately because altruism is a socially desirable behavior.” So she adopted the medical model approach. Building from the deficit end, she studied psychopathic children. “Psychopaths have true deficits in care for other people. Working with children with these traits, it is clearly a mental illness. You can’t blame people for lack of compassion in a clinical sense. It’s a complicated stew but nobody asks to end up that way.” And from there she began studying the opposite extreme: altruistic kidney donors.
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She spent the last nine years interviewing and studying donors, including some who donated at the transplant center at MedStar Georgetown University Hospital. She sought to understand what motivated them to donate a kidney to a stranger. “As a group they definitely have more compassion and care than the average person,” she says. Based on a small sample of structural MRI scans (20 controls and 19 altruistic kidney donors), results revealed visible differences in the brain structure of people who are unusually altruistic. In other words, maybe that person with a big heart also has a big amygdala. The amygdala is an important brain region for social and emotional processes. They chose to look at that region because in people with very low levels of compassion, the amygdala often has characteristic changes like smaller volume. In people who donate their kidneys to strangers, they found the amygdala is larger than average. And in functional MRIs they found that altruists’ amygdalae are more responsive to other people’s fear—versus psychopaths at the opposite extreme. A desire to care for the vulnerable can fluctuate, which is related to hormone activity, says Marsh. “Every part of the brain has the potential for plasticity. We know for example
that populations of receptors in the amygdala change during pregnancy and childbirth. It’s a time of changing hormones. And partly in response you see proliferations of receptors in the amygdala for things like oxytocin—a very strong care-related hormone. One possibility is that what we’re seeing is higher densities of neurons that respond to oxytocin, which promotes care for the vulnerable.” The brain is not completely plastic, she adds, and genetics play a significant role too. “The heritability of the size of the amygdala is about .5, so about half the variation is due to genetics. Probably the experience of caring for others is a big promoter in becoming more caring. The body has all these interesting feedback systems that cause us to find care inherently rewarding and make us want to do it again. That feedback could reflect changes in the amygdala, and changes in other areas in the brain like the striatum. We don’t know. There’s every reason to believe that this is not a fixed structure.” In addition to structural and functional MRIs, Marsh and her team use diffusion tensor imaging (DTI) to track the structure of the white matter that connects regions of the brain. “Very few things happen in isolation,” she notes. “It’s the result of lots of structures conversing.” Studying brain structures will help us better understand emotions, Marsh believes. “Our emotions can feel so intrinsic to who we are that it’s easy to forget that they’re the result of physical and chemical structures in our brain popping little messages to each other,” Marsh says. “And if something happens to those structures like they don’t get built well, it changes your emotional profile. And to some extent, it changes who you are.” Stroke victims offer further insight into the mechanisms of altruism and emotional response. Although right-hemisphere strokes don’t affect language or the use of the typically dominant right hand, people
tend to fare worse than after lefthemisphere strokes, Marsh says. The reason may be that right-hemisphere strokes impair emotional processing— the ability to respond emotionally to other people in social situations and to interpret their emotions. “As a result you can lose all the subtle back and forth of emotional communication, including the ability to build rapport, the basis of strong social relationships.” Social relationships today are often sustained at some level through electronic devices. While some signs indicate that we are struggling with this relatively new communication tool, the long-term impact remains to be seen, says Marsh. “There are certainly kinds of social communications that just don’t work via social media,” she notes. “It could explain why you see viral storms of outrage on platforms where people are communicating in a way that is emotionally disembodied. You don’t get to see the cues that signal that somebody means well or they’re just kidding or they’re sad.” Of course it’s not the first time humanity has worked around communication challenges, she points out. “The great art of letter writing didn’t destroy social communication and that’s just as disembodied.” But our brains were not built to communicate like this, Marsh says. “We are meant to communicate with our whole body. Anytime you strip those cues away things will suffer. That’s what emojis are for—to help add color back into communication.” “Colorful” communication may not always be the ideal, but emotional understanding is critical in relationships, Marsh says. It’s link to altruism may offer important insight for health professionals, who care for the stranger on a daily basis. “Being able to read other people’s emotions and respond appropriately is the foundation of strong social relationships,” Marsh says. “It’s one of the most important ingredients in our mental health, and in our lives.” n
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Flourishing on Campus Georgetown is making changes that matter to support student mental health By Giuliana Cortese (C’13)
n the process of learning, it is natural for students to struggle, whether they are in middle school, or medical school. By definition, learning new things requires mental development, an exercise for the mind, an expansion of thought. But for young adults in university, the demands on time combined with academic rigor and competition can be especially overwhelming. Which begs the question: When does the pressure to perform shift from an academic challenge to a mental health concern? Universities across the country are working to answer this question both at the undergraduate and graduate level, as they face a rising demand for mental health services on campus. In a 2017 survey by the American College Health Association (ACHA), U.S. students reported that anxiety and depression are among the biggest factors that negatively affect their academic performance. Nearly 40 percent reported feeling so depressed in the past year that it was difficult to function, while over 60 percent reported feeling lonely. At Georgetown, several initiatives are underway to support student well-being, including programs for those in medicine. The programs—launched in part due to President John J. DeGioia’s involvement in national student wellness efforts— aim to respond to both the challenges facing Georgetown students and the opportunities that new research is making possible. Engaging with organizations such as the American College Health Association, The Steve Fund, JED, and the American Council on Education, the university efforts are built around the fundamental question: How can we enhance our support for the personal formation of our students and their own capacities for flourishing? These broader initiatives complement the work of Carol Day, director of health education services and adjunct assistant
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professor in human science at Georgetown University. Along with a team of researchers from universities across the country, she has tracked mental health among college students since 2009 and has seen a significant increase in the number of students reporting mental health concerns. “It used to be that students would come to the counseling center because they were dealing with loneliness or homesickness, a relationship break-up or something that felt more developmental,” says Day. “Now, they’re coming in with anxiety, a history of depression. Maybe they’ve also experienced assault in high school or they’ve had a family tragedy.” While reporting these issues is a sign that students feel comfortable asking for help, the demand for mental health and wellness services on campuses is becoming more urgent.
Flourishing through academic interventions To address the rising demand, Day along with Sarah Stiles, professor of sociology at Georgetown University, developed a new course for first-year undergraduates. “Flourishing: College & Community” aims to teach students resilience techniques and evidence-based wellness practices, such as keeping a sleep journal, meditation, and practicing gratitude to cultivate a meaningful life. “We give students scientific research to demonstrate that these well-being practices work, and can help them optimize, build resilience, and cope with difficult stressors in life,” says Day. They have found that graduates of the course are dealing with fewer mental health challenges, have fewer sleep problems and are more able to cope with whatever comes their way as compared to their peers. “I learned that I need to take more risks,” says one student after taking the course. “Life is all about getting involved and
meeting new people. Studying is good, but learning how to balance academics and friends is even more important in living a healthy life.â€? This program is not the first of its kind at Georgetown. In 2005 the university launched a similar classroom model, now known as the Engelhard Project for Connecting Life and Learning, to destigmatize mental health-related topics, and infuse academic learning with themes of well-being and compassion. In one course, for example, students explore the mental health impact of sleep deprivation as part of a neuroscience class in synaptic transmission. They study abnormal psychology, and observe and catalog their own patterns of negative thinking. Then they learn how to reframe these ideas using positive thought formulation techniques. Since it began, the Engelhard Project has offered nearly 500 courses taught by over 100 trained faculty members. Serving as a model for Jesuit education and the Ignatian principle of cura personalis, or care for the whole person, the project encourages students to reflect on their own attitudes and behaviors while fostering connections both in and out of the classroom.
Helping our future healers heal Along with the expanding efforts in the undergraduate sphere, the School of Medicine is also putting a renewed emphasis on student well-being and asking important questions about how to make changes that matter. Georgetown joins medical schools across the country in an effort to address the unique challenges facing students who are pursuing careers in medicine. A 2016 study in JAMA found the prevalence of depression among medical students at 27 percent, three times greater than non-medical students of the same age.
biofeedback, journal writing, intuitive drawing, and movement. Starting with a group of 30 students, the program has grown to 80 students total, with 70 medical students and 10 students from the School of Nursing & Health Studies (NHS). Harazduk has seen a marked difference in students who participate in the program. When they start out, she says, they feel a great deal of anxiety and stress. However, when they connect with each other and share their vulnerabilities or fears with the group, she has seen that stress decrease. “I’ve seen a huge shift. They come in worried, worried, worried. As time goes on, they’re not as anxious,” she says. Hannah Day (M’22), a student in the Mind-Body Medical students Jose Alejandro Almario (M’22) and Victoria Angelucci (M’19) try out “the best medicine.” Medicine program, empha“It’s hard for us to let go of our old habits, especially in sizes the importance of the program in fostering community medicine,” he says. “We hold on to our customs and rituals. For among students. example, we think having a long or difficult anatomy lab is a “It’s easy for medical students to feel isolated, and there’s staple of medical education, but maybe it’s not.” this need for a deeper connection,” she says. “I think the most The medical school grading system is something impactful and important function of the program is helping Georgetown has altered in recent years to help improve student students feel that they are not alone—neither in the demands well-being. In a grassroots effort, a group of students made a of getting through school, nor in their psychological and convincing, evidence-based case for a pass/fail grading system, emotional experiences of trying to meet those demands.” which the administration implemented shortly thereafter. The literature aligns with her experience. According to a Stephen Ray Mitchell, MD, MBA, dean for medical 2019 survey in Academic Medicine, mindfulness-based stress education, recalls the group of students that petitioned for this management training, adaptive coping skills, and social support change, presenting their case to several faculty subcommittees. help reduce the risk of anxiety, stress, and depressive symptoms “They probably did that presentation twelve times, and in medical students specifically—all of which the Mind-Body finally getting there took a cultural shift,” Mitchell says. “But Medicine program incorporates. they presented the data thoroughly, and when faculty had quesEmily Aron (M’08), child and adolescent psychiatrist at tions they went back and found the answers to those questions. MedStar Georgetown University Hospital, recently completed That is leadership.” the three-day Mind-Body Medicine program facilitator train“Some of this requires us to think innovatively about ing run by Harazduk, which has had a profound impact on her how we’re going to approach medical education,” Marchalik personally and professionally. adds. “The feeling of connection carries forward,” she shares. “For One of these innovative approaches began in 2002. Followphysicians, nurses and anyone in the health care field, you can ing in the Jesuit tradition of cura personalis, Nancy Harazduk, start to feel isolated in your experience because it’s a patientassociate professor at Georgetown University School of centered universe. It was great to foster that closer connection Medicine, launched the Mind-Body Medicine program to with others, and I can see how this would be extremely valuable teach students how to better take care of themselves and others. to learn as a medical student early on.” “The first objective of the course is to introduce self-awareCura personalis in action ness to students so that they can affect change. The second objective is to introduce them to various mind-body practices Steeped in a rich spiritual tradition, Georgetown University has that will help them deal with stresses of medical school and of found several ways to integrate spiritual practices into the fabric life, really,” Harazduk says. of student wellness. The program trains students in a span of wellness practices, Practices that encourage reflection and daily contemplation such as meditation, guided imagery, autogenic training, directly align with Georgetown’s Jesuit tradition. Rev. Mark
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“What is our responsibility as an institution to ensure that the environment we create is conducive to wellness?” asks Daniel Marchalik, MD (G’16), assistant professor of urology at the School of Medicine and medical director of physician well-being at MedStar Health, Georgetown’s clinical partner. The issue of burnout is largely systemic, he says, and solutions may emerge from taking a close look at the academic culture or climate.
Bosco, S.J., vice president for Mission & Ministry, emphasizes the Jesuit principle of contemplation in action as a way to help bring more intentionality into one’s life. This principle, along with tools such as the Daily Examen, will be shared at a new retreat for medical students in the spring. “It’s the idea of sitting, breathing, disengaging, thinking, feeling, bringing that to God, and bringing that back to the world. That’s one way in which Ignatian spirituality can be part of daily life for a person,” he says. To encourage student reflection through daily meditation, the John Main Center for Meditation and Interreligious Dialogue was founded in 2005 as a partnership between Georgetown and the World Community for Christian Meditation. The center hosts daily, non-discursive meditations and spiritual programming with leaders from various faith traditions. In addition, it offers lectures on meditation, mental health, well-being, and topics related to spiritual growth and resilience. “We feel a responsibility at Georgetown to present meditation as a discipline, as a deep practice that is open to Mystery or the Divine, while also helping students with self-integration and self-understanding,” says Tony Mazurkiewicz, director of the center. Georgetown’s commitment to reflection has become a framework for programs campus-wide. Dustyn Wright, director of student learning, and pediatrician Maria Marquez, associate dean for reflection and professional development, are co-directors of the professional identity formation curriculum at the School of Medicine. The effort helps incorporate the practice of intentional reflection and development around physician identity formation within medical student education. Through the Cura Personalis Fellowship, a formal faculty development program, faculty clinician coaches are paired with medical students and their associated academic family. The program, taking place throughout the entirety of a student’s medical education, is structured through the use of an e-Portfolio, in-person group sessions, and individual check-ins. Clinician-mentors serve as personal identity formation coaches for students and meet with them regularly to discuss various topics related to well-being, such as impostor syndrome or perfectionism. Aron, who is also a professional identity coach and co-director of the program this year, sees immense value in the work. “You get to watch the students figure out how to utilize resources, their own inner resources,” she says. “They start to understand that each one of them is on their own path and don’t need to compare. It’s been amazing to see that light bulb go on.” “Introspection is an important component of resilience,” says Marchalik, who also directs the Literature and Medicine track at the School of Medicine. “It gives you a chance to make sense
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of your own experience, what you’re going through, and I think that’s the key to thriving.”
The future of medical education
As the School of Medicine’s first in-house psychologist, Simoné Jalon is dedicated to serving the mental health needs of medical students.
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Colleagues Carol Day and Sarah Stiles offer an undergraduate course for first-year students about flourishing in college and beyond.
In response to rising mental health needs among students, Georgetown Counseling and Psychiatric Services recently hired a psychologist, Simoné M. Jalon, PsyD, to serve the School of Medicine. With an emphasis on emotional regulation, sleep health, high-risk suicidality, anxiety, depression, and other related issues, Jalon has experience working with mental health issues that typically arise in high-pressure environments such as medical school. “I was attracted to this position because I see a need for it. There doesn’t seem to be a huge focus on self-care and wellbeing in this field in general, and I can see how a lot of the work that I’ve done can dovetail nicely to help medical students,” Jalon shares. She began receiving appointment requests from students within her first few days at Georgetown in March, and offers evening appointments to meet with third and fourth-year students on clinical rotations. She encourages students to reach out to her and hopes to dismantle the stigma that may be associated with therapy. “I’ve worked with people in the health care field and, in these roles, they’re often the helper,” she shares. “It’s easy to focus on everyone else. But how can you be effective in taking care of your patients, if you’re not taking care of yourself?” Efforts to improve student wellness will be a continuing priority at Georgetown. For Marchalik, merely drawing awareness to the issue marks an important shift. “The fact that we’re having this conversation, that there are student wellness committees, and that I have a job monitoring physician well-being, are all signs that things are moving in the right direction.” n
Nancy Harazduk sees hope in the changing landscape of medical education. Since the start of the Mind-Body Medicine program in 2002, the training has expanded its reach beyond Georgetown. “We’re seeing medical schools from across the country now incorporate this into their curriculum,” she shares. Supporting well-being for students in graduate and undergraduate communities will take continued institutional change, says Carol Day. “We need more accommodating systems, more recognition and awareness. If students are constantly stressed and not sleeping, that greatly diminishes their capacity to learn. We need some systemic changes, which take time and continued support from leadership to prioritize student well-being.” To address some of these cultural and institutional changes, medical students at Georgetown have taken a grassroots approach to student wellness. In the last year, they have introduced student-led yoga sessions, healthier food options on the medical campus, and conducted a school-wide mental health survey. “The culture at Georgetown fosters a supportive environment among students,” says Hannah Day, who is also the firstyear representative on the newly formed Committee on Medical Student Wellbeing (COMSW). “If you’re a student who has an idea that’s going to benefit the student body and it makes sense, you’ll be heard.” “We listen to the students,” echoes Mitchell. “It would be foolish not to because they make the school better. They pay it forward.”
STUD ENT POINT OF VIEW
Seeking the balance of confidence and humility in medical training
Facing the Impostor By John Guzzi (M’19)
he passage of time in medical school is defined by a stream of grades, feedback, and board scores that spell out and quantify our success. When we see a “pass” or an “honors,” we are supposed to be reassured that our knowledge and training is adequate, or even superior to our expected level of development. But how often do those descriptors attached to our grades align with who we see ourselves to be? As a brand new clinical student who didn’t even know how to get around the hospital, how could I have possibly possessed the following: “Outstanding ability to develop logical plan of care. Includes sophisticated plans for treatment and diagnosis. Outstanding clarity, superior organization, excellent summary of history, physical, assessment, and plan. Consistently complete and accurate physical examination. Superior team member. Superior respect for opinions of others. Highly sensitive to others’ needs. Appropriately assertive.” Those words come from the honors section of our grading rubric, and that’s exactly what appeared on one of my first feedback reports. Did they miss the times I rifled through notes during rounds? Did they overlook the questions I whiffed on? I began to doubt that anyone was reading the rubric boxes they were checking off on each grading descriptor. Earning grades of honors, high pass, or pass could feel more like a favor from an attending physician than a mark of merit. At times I felt like a warm body filling a seat: like anybody else could be in my position, put in the time, and become a physician. I now know that those feelings—quiet negativity, a sense that achievements can be chalked up to luck, and the idea that classmates are better—are the tell-tale signs of impostor
syndrome. Impostor syndrome is rampant in higher education, and especially within medicine. Right here at Georgetown, data from our annual Build & Belong wellness survey shows that 85 percent of medical students struggle with at least moderate symptoms of impostorism. And remarkably, the feelings increase each year. Unlike most problems in medicine, a cure for impostor syndrome is right in front of us: recognize it, talk, and be honest. Describing those feelings and simply giving them a name—impostor syndrome—is enough to improve the symptoms. Medical training is a long and demanding apprenticeship that comes full-circle, from trainee to trainer. Grades are an inevitability of education, but physician formation demands face-to-face feedback and discussion about what it means to be in the midst of training. It is important that our role models speak honestly with us. In a world dominated by competition, it is easy to avoid vulnerability and feign self-confidence to mask feelings we all share. Here at Georgetown, we are surrounded by faculty who encourage the growth of a person, not just the education of a physician, but we can still do better. What would medical education look like if we talked more about the tests we struggled with and less about the ones we aced? Why do we feel like hiding the criticism we receive? Better yet, why don’t we share the criticism that we levy on ourselves? Whether as trainees, classmates, educators, or friends, we have a responsibility to be honest with these thoughts and each other. n John Guzzi, a fourth year medical student, founded the Arts & Medicine initiative at Georgetown.
Beyond the Burnout
Medical assistant Ja’Mia Anthony works with physician Emily Zucker to review patient scheduling at a community health clinic in Northeast D.C.
It was a bitter cold January morning when family medicine physician Emily Zucker (M’15) arrived at the community health center clinic for work. She thought some of her patients might be deterred by the deep freeze, but despite the frigid 9 degree temperature, the waiting room was full, and Zucker was busy. On her schedule that day was a new patient, a 13-year-old boy brought in by his grandma, his main caregiver. She was worried because her grandson was struggling in school and increasingly depressed. He had been on medications for attention deficit hyperactivity disorder in the past, and so she brought him in to Zucker for a refill. In the short confines of a 15-minute visit, without any of his medical records, Zucker didn’t feel like it was safe to re-start the medications. She examined him, made sure he was up-to-date on his vaccines, and listened to their concerns. But when she explained that she’d need more information—like a formal
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ADHD assessment from his teacher—before she could consider a new prescription, the grandmother became frustrated. They left that day, Zucker says, upset with her and with the health care system in which she works: one with impossibly short appointments for complicated problems, and an electronic medical record that can’t access what his doctor at another clinic wrote. Visits like that, she says, always make her wish she could do more. “What did I really do for him today?” she asks. “It wasn’t sufficient.” But when she can’t do more—limited by the structure of primary care or by problems beyond the scope of medicine— she tries to take it all in stride. I caught up with her after her clinic session ended that evening to learn more about her philosophy as a clinician. As a fellow in Georgetown’s Department of Family Medicine, I also see patients at the same community health center. Since we began working together last year, I’ve been impressed with her positive attitude and sense of calm in the midst of our often chaotic clinic days. As we talked in our windowless workroom on that chilly January day, I started to understand more about how Zucker approaches the challenges of being a primary care doctor in the 21st century. She is a 2015 graduate from Georgetown University School of Medicine, and a 2018 graduate of the Georgetown Family Medicine Residency Program. Like her fellow Georgetown medical school graduates— from recent alumni like herself to experienced physicians who have practiced for decades—her choices exemplify the balancing game that modern clinicians must play. We must consider many competing demands: our patients, our bosses, electronic medical records, insurance companies, and our own lives outside of work. Lurking in the background of our busy days is the specter of burnout, stories of physicians so fed up with the grind that they leave medicine altogether.
By Mara Gordon, MD
Zucker reads the headlines about physician burnout, and she understands why it’s in the news. She sees about 22 patients a day, and she estimates she spends about an hour and a half finishing up her patient notes on the electronic medical record every day. She sees mostly Medicaid and Medicare patients, and insurance-related red tape abounds: prescription coverage denials, prior authorizations. But she’s made deliberate choices about her career that she hopes will be protective. To stay inspired, Zucker turns to the memory of her grandfather, a family doctor in her hometown of Pittsburgh. He was the kind of doctor who exemplified the “good old days” of medicine, doing home visits and serving as a fixture at his patients’ birthday parties, weddings, and funerals. “I think he would be proud that I’m a family doc,” Zucker says. “I feel like my work is very valuable and my patients need me.” She also takes intentional steps to make her working life easier: she lives a 10-minute drive away from her clinic, she doesn’t multi-task when she’s finishing her notes, and she strives to maintain a good working relationship with the clinic staff, which eases the hand-off of non-physician tasks. She has a group text with her friends from residency where they compare notes, ask questions, and occasionally vent about their new roles as attendings. And when it comes to patient care, knowing her limitations is key. “I think I have a pretty good outlook, making sure that I don’t feel responsible for everything. Almost all problems can
Dan Marchalik leads the literature and medicine track at the School of Medicine, designed to improve narrative competency and communication skills in medical students, leading to greater comfort deciphering patient stories. In addition, the program aims to improve students’ quality of life.
be taken on incrementally,” she says. “And I try not to take on someone else’s problems as my own.” But Zucker is a new attending, and by her own admission, she worries that her low-stress approach to work and home might change when she has kids or more responsibilities outside of work. She loves her job, but she does sometimes wonder: In the current system, is physician burnout inevitable? nnnnnnnnn
Daniel Marchalik, MD (G’16), doesn’t think so. He’s an assistant professor at the medical school and a urologist, and he’s charged with preventing burnout amongst MedStar Health’s 2,500 employed physicians and 1,150 trainees. His title, medical director of physician well-being, didn’t exist until he took the job in 2017. But the work he’s doing, he says, has been a long time coming. “Our profession is transforming,” Marchalik says. “We’re not keeping up.” MedStar is unique in appointing a faculty member to examine physician burnout, Marchalik says. It’s one of the few organizations in the country to devote real resources and time to the issue. The Maslach Burnout Inventory is usually how academics measure burnout, which is defined as a self-reported job-related syndrome. The MBI is a psychological questionnaire that asks respondents to rate their answers to statements like “I feel used up at the end of the workday,” or “I have accomplished many worthwhile things in this job.” Although a recent JAMA systematic review found that many researchers fail to use a standard definition of burnout, Marchalik cites a 2012 JAMA Internal Medicine paper in which he says the evidence is clear on one essential point: “We know that physician burnout rates are higher than any other profession.” Experts tend to group burnout symptoms into three major categories. The first is moral distress, a kind of psychological trauma clinicians experience after witnessing the suffering of many patients over time. The second is fatigue and frustration from administrative tasks related to insurance companies or the electronic medical record. The third is simply working too much: when the scales of work-life balance tip too far towards late nights at the office and away from time with family, friends, and even time spent alone. Since each problem is so different, each requires unique solutions. Marchalik got interested in the issue of physician well-being —which he defines broadly as keeping doctors happy, healthy, and engaged in their work—while he was a urology resident at MedStar Georgetown University Hospital. As a lifelong lover of literature, Marchalik decided to take advantage of the courses that the university had to offer, and he
got a master’s degree in literature during the final years of his residency. A literature and medicine track for Georgetown medical students is now Marchalik’s passion project. He devotes an evening every month to discussing a contemporary novel with the students, a practice which he finds personally protective against burnout. Research shows, he says, that reading books is one of the best ways to help doctors stay happy. “If you can’t keep your docs happy, the hospital can’t thrive,” Marchalik says. While he can’t guarantee that doctors will always get to leave work on time, he is committed to exploring how the institution can do a better job supporting them. To Marchalik, that doesn’t mean lunchtime yoga classes or mandatory meditation sessions. “Putting people in the line of fire and asking them to take deeper breaths doesn’t make any sense,” Marchalik says. “Physicians are really late to the ballgame in terms of advocating for themselves.” Instead, Marchalik wants to focus on making concrete policy changes that make it easier to be a doctor at MedStar. He recently introduced a program for house staff that gives them access to free emergency child care, for example. He’s also working on a long-term project to “optimize” the electronic health record, digging down into the nitty-gritty of how clinicians use it and how changing it might save them time. Although he’s optimistic about the work, he also knows he and his colleagues have a long way to go—and need to do a better job studying whether or not their interventions are effective. “We’re all learning all the time,” he says. nnnnnnnnn
Across the country, other Georgetown medical alumni are also grappling with questions of how to thrive at work. Take Luella Toni Lewis (C’93, M’04), a family physician and
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geriatrician in Brooklyn, New York. For Lewis, health equity and social justice activism allows her to stay connected to a larger community and mission. Having a thoughtful wellness strategy has been key to her resilience—in medical school, residency, fellowship, and in her life now as a physician and consultant. She first became involved as the president of the residents’ union and as a community activist during her residency and fellowship training at St. Vincent’s Catholic Medical Center in Queens, New York. After residency, it was a natural transition to a role as the chair for health care at the Service Employees International Union (SEIU), where she advocated for the rights of doctors, nurses, and other health professionals. There, she worked on both political and policy strategy, and was often asked to share her tools for wellness with union members and staff. These grew into formal workshops for health care workers, and when she left SEIU in 2017, she started Liberation Health Strategies. She now spends her time as an advocate for health equity, both as a practicing physician and as an activist. Her work is about “shifting culture and centering wellness as a strategy for both day-to-day protection from burnout, and creating a space to imagine an equitable health present and future,” she says. For Lewis, her advocacy work for the rights of health care workers and marginalized communities goes hand-in-hand with teaching self-care to her workshop attendees. Her workshops teach both wellness routines and strategies for institutional change. Tools like yoga, exercise, and aromatherapy, she says, complement the work of fighting for improved working conditions. “Sometimes it’s just providing the space to think about what’s going on,” she says.
“In addition to being a family doc and geriatrician, I am an internationally certified Kemetic Yoga Instructor and Licensed Femme! Instructor,” notes Luella Toni Lewis, pictured here at a Femme! event in New York.
When Jacksonville, Florida, cardiologist Thomas Hilton (M’81), started to feel burned out, he took a different approach: he cut his working time in half and devoted his energy to CardioStart International, a nonprofit organization that provides free cardiac care in developing countries. He took his first trip to rural Peru about 10 years ago, where he saw patients with advanced cardiac disease. Nobody on his team seemed to be worried about money, status, or litigation —concerns that had plagued him back in Florida. It was a refreshing change. “There’s almost a kind of reverse burnout,” he says. “Those cases are extremely rewarding.” Deciding to work part-time in Florida took courage, Hilton says, and a step back from the lifestyle to which he was accustomed. But the global health work made him feel so invigorated, he says, it was well worth it. Now, he goes on several trips a year, and trains echocardiography technicians in Nepal. One reason the work is rewarding, Hilton says, is because the CardioStart teams are so collegial and friendly. Having breakfast with his colleagues and discussing the cases for the day makes the work more purposeful. Back in Florida, he says, the doctors in his office are so busy that they work through lunch and often seem too stressed to talk to each other about their patients or making the practice better. All-staff meetings, he says, are sparsely attended affairs. “This isn’t lonely,” he says of his global health work. “This is meaningful. And I feel like I’m good at it. This was one of the most important decisions I ever made in my life.”
In a Nepal village two hours north of Kathmandu, Tom Hilton and Sara Singh conduct a cardiac sonogram with one of 100 schoolchildren screened for rheumatic valve disease. They also worked with a hospital in Bahktapur to develop their open-heart surgical program.
As he nears the end of his career, Hilton is focusing on increasing his global reach. And at the beginning of hers, Terrika Jones (M’17)—now a Georgetown obstetrics and gynecology resident—is thinking about how staying close to home might be the right move for her. The demands of residency have forced Jones to take a serious look at what she values. “We often forget about ourselves,” she says. “You miss out on a lot of things: big events in family members’ and friends’ lives because you’re trying to uphold the obligation that you’ve made to so many other people who are dependent on you.” As she thinks about her post-residency plans, a return to family—most of whom are in the Columbus, Mississippi area—is Jones’ planned strategy for staying happy and healthy. “I want to be able to be prepared for whatever may come my way, but I also want to be able to share that with my family, and to have a family,” Jones says. “I want to still have a life despite being in this stressful field.” Her time at Georgetown taught her to devote her energy to the positive aspects of caring for patients. She hopes to focus on high-risk obstetrics and reproductive health for teens. “Georgetown prides itself on cura personalis—care of the whole person—and has taught me a sense of community,” Jones says. “It is so rewarding to bring joy into others’ lives.” nnnnnnnnn
On Valentine’s Day at the community health center where Emily Zucker and I practice, our physician workroom was a smorgasbord of treats. Medical assistants, nurses, and front desk staff all breezed through to chat and sample the desserts. It was one of those days where we really felt like a team. Zucker’s contribution was homemade brownies from a family recipe, and the batch was almost completely devoured by mid-morning. As we continued our conversation about the big questions facing our profession—about how to take care of ourselves as we take care of our patients—I was reminded that sometimes, good food is one of the simplest ways to bring colleagues together. As she looks to what she hopes will be a long career in primary care, Zucker often thinks of her training at Georgetown. Her formative experiences as a student and resident helped ground her in the type of medicine she wants to practice for years to come. “Georgetown has a very strong family medicine department, and they emphasize the value of primary care,” she says. “The cura personalis motto reminds you why you are going into the practice of medicine in the first place.” n Mara Gordon is a family physician in Washington, D.C., and a health and media fellow at the School of Medicine and NPR.
M ENTAL HEALTH
A LUMN I POINT OF VIEW
Building Mental Resilience By Michael M. Karch, MD (M’95, R’02)
was a warm spring day. I was in a calm rhythm, on my bike again, the first ride of 2018. When I heard the deepthroated diesel Cummins engine from behind, I stayed far right and tucked in, waiting for him to pass. In 35 years of riding, I had been passed by thousands of trucks, but this one would be different. When that diesel made impact, it felt like a hurricane. I was hit, bounced, run over, and crushed by a driver who was texting while driving 6700 pounds of metal. A helicopter ride and a few surgeries later I was alive, but physically broken, with 13 fractures. The only thing that remained strong was my head. Fighting against a whirlwind of confusion, pain, disappointment, and loss, I made a strategic plan for recovery. I thought about 9/11 and other casualty zones where I had worked, lessons I gleaned from studying how our military creates resilience against mental adversity. The practice of mental discipline had to be applied immediately. Yes, the mind is a complex thing, but if trained and organized, the human brain can be a powerful tool for regrowth and healing. I had studied Martin Seligman’s positive psychology research which is used to prepare U.S. troops for deployment. He notes that the human response to adversity can be plotted out on a normal distribution curve. When subjected to adversity, most individuals initially suffer typical traumatic stress symptoms. Approximately 15 percent of these individuals are unable to unlock the fear mechanism, falling into a chronic, dysfunctional state characterized by negativity, depression, substance abuse, and even suicide. They become emotionally destructive. The majority of individuals fall into the emotionally resilient middle, resolving symptoms early and returning to normal life. In a few individuals, however, something extraordinary and transformative happens. From a mental, physical, and spiritual standpoint, they not only grow, they blossom. These emotionally productive individuals find a higher-order purpose in life. How can those of us in high-pressure medical work foster that emotionally productive behavior in response to adversity in our lives? Seligman collaborated on a project with the U.S. Army to develop the Comprehensive Soldier Fitness Program, which identifies five factors for a more productive outcome: positivity, healthy lifestyles, work purpose, social interactions, and higherorder purpose. I add one more: gratefulness.
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Gratefulness allows us to put a traumatic event in perspective. Lying on the road, I immediately felt profound disappointment and loss, as I thought my time on Earth was over. There was more to do. This was followed by immense gratefulness, for simple things like breathing, for my wife and my children, for the helicopter crew, for my occupation, for my education, for all of my life experiences. And gratefulness for additional time. Next is positivity. I would focus on joy despite how bad things hurt. No blaming or victimization. Negative thoughts are like cancer, metastasizing and destroying everything that is close. After years of watching others deal with illness, I knew that staying positive was the most efficient path between injury and recovery. Also essential to building mental resilience is a healthy lifestyle. Healthy people are more resistant to both physical and mental trauma. We physicians often martyr ourselves and minimize the importance of taking care of our health in lieu of taking care of others. But we need to be healthy to take care of those who are not. Choosing a salad over a burger takes discipline. Going out for a run when it is cold and dark takes dedication. The rigors of medical training prepare us well for these challenges. I identify as a fitness junkie. Probably, that healthy lifestyle saved my life. But entirely losing my fitness base and starting over was difficult and painful. It’s embarrassing to go to the gym when your injuries prevent you from lifting even the lightest weight. But to get back to taking care of others, I needed strength and endurance. My plan was simple: discontinue opioids fast, and no alcohol. These two things can be dangerous when vulnerable—why flirt with them now? I gave myself one year and kept meticulous records with realistic milestones. I was fueled by a clean diet, water, and a strong desire to be healthy again. Another key to maintaining mental resilience is work purpose. In medicine we have an innate drive for it. After a traumatic event, it helps to return to work even if only for a few hours a day. Focusing on someone else, being responsible to an alarm clock and a morning shower, opening the blinds, getting dressed for work, and engaging socially provides motivation to get better. Your efforts will inspire others, and in turn, others will re-inspire you. My first day back in surgery was terrifying. I had not been this intimidated by the operating room since medical school. I had 23 years of operating experience, but I had developed a tremor after the accident and had worked diligently with chopsticks to improve it. Would my team notice? Would I harm someone? Would I have to give up this skill which I had worked so hard to achieve? Going back to work takes both mental and physical effort but the rewards are exponential. Getting over my fears and successfully operating again was a massive recharge. Early return to work, in some limited capacity, fuels the recovery
process. Taking care of others is where we find purpose, and it’s positively contagious. Don’t neglect social interaction. Studies show that relationships promote mental wellness. Often we are tempted to not let others see us in our state of weakness. Foregoing humility for the sake of ego is a critical mistake often made by us first-time patients. A few weeks after the accident, some close friends asked me to meet for dinner. I had just had another surgery on my leg and I was a hot mess. I still had tubes and drains with body fluid for all to see, a clam shell back brace, crutches, a walker boot, and my entire left side was wrapped in gauze dressings. I had lost a lot of weight and blood, and was white as a ghost. My ego immediately told me to say no. I am so glad that I knew better and didn’t listen. With close friends, I laughed for the first time in a month. I desperately needed that, it was therapeutic. I felt appreciated. I felt taken care of. And for the first time, in a very, very long time, I felt it was okay to ask for help. Creating a spiritual or higher-order purpose out of personal tragedy offers enormous mental strength and motivation. It’s finding meaning that is bigger than ourselves. I now speak out about the dangers of distracted driving. While almost everyone checks their cell phones while driving, after the accident I tell everyone: Don’t do this. It may cost you your life or worse yet, someone else’s. This issue of Georgetown Medicine humbly reminds us that physicians are just human. Although we are subject to the same traumas in life as the patients we treat, we are still expected to perform. Adverse events, whether personal or professional, give us an opportunity to gain better insight into the lives of those we take care of. If we pay close attention, we will be humbled by what they endure. I used to get annoyed when a patient fell in the post-op recovery period. Like many surgeons, I was convinced they were sabotaging my work. In the first three weeks after my accident, I fell three times and was not trying to sabotage anyone. Falls are painful, embarrassing, and intimidating. Each one sets you back. It takes grit to get back up and try again. I now have much more patience as a physician. I better understand that recovery is an ebb and flow, an ongoing dance between success and failure. “The obstacle that is in the way must become the way.” Nearly 2000 years ago, Roman leader Marcus Aurelius outlined his Stoic formula to grow from adversity. My personal obstacle has given me perspective and taught me resiliency. Experience allows us to become powerful teachers, healers, and better advocates for our patients. n Michael M. Karch is an Associate Professor of Orthopaedic Surgery.
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G L O BA L V I E W
How culture shapes mental health By Lauren Wolkoff (G’13)
hen catastrophe struck Japan in 2011 in the form of a massive, magnitude 9 earthquake and a subsequent series of tsunamis, international media marveled at the steely resolve of many of those who suffered great loss of family or property. What in other places might have triggered a more visible outpouring of grief and despair, in Japan seemed to render a kind of national stoicism, media outlets reported. For Western press in particular, this was newsworthy. But in Japan, the response to this tragedy reflected the Buddhist concept of gaman, a nationally held value similar to endurance or perseverance, as well as a priority placed on social harmony and calm in the face of extraordinary circumstances. In this example and others, researchers increasingly appreciate how culture, values, and mental health are enmeshed and remarkably complex. Even what constitutes a disorder may vary across cultures. While mental illnesses comprise a wide range of emotional, cognitive, and behavioral changes, there are accepted clinical guidelines for categorization, diagnosis, and treatment set by organizations such as the American Psychiatric Association and the World Health Organization. Yet behavior that is defined as a disorder by American or European biomedical standards may be seen as benign among other populations. “Having depression or anxiety, or how we respond to trauma, is quite different than having a heart condition,” says anthropologist Emily Mendenhall, PhD, MPH, Provost’s Distinguished Associate Professor in Georgetown’s Walsh School of Foreign Service. “The way we think and move and interact with the world is all filtered through culture. How you grow up and how you think about the way the world works is a powerful conduit for how you perceive and embody both positive and negative experiences in your life.”
Biases and blind spots Understanding the impact of culture on mental health requires
that researchers and clinicians challenge their assumptions and acknowledge their biases and blind spots. This is particularly important in the context of the Western biomedical model of mental wellness, which tends to dominate research, clinical training, and the development of treatments. Many research study groups are relatively homogenous and do not reflect the world’s cultural diversity. Thus treatment protocols and evidence-based practices that stem from that research reflect the same homogeneity. “I always ask the question: ‘evidence-based for whom?’” says Tawara Goode, MA, assistant professor of pediatrics and director of the National Center for Cultural Competence at Georgetown University Medical Center. Evidence derived from studies based solely on American populations produce findings that do not apply to all, Goode notes. “If you are taking a practice to another country, how effective could it possibly be without cultural adaptation?” Yulia Chentsova-Dutton, PhD, associate professor of psychology at Georgetown University, specializes in cultural psychology, a subspecialty concerned with how cultural factors—including values, beliefs, and behavioral norms—can affect one’s psychological functioning. She cites the example of emotional suppression, when people keep their feelings inside instead of expressing them outwardly. “In American and European populations, emotional suppression is associated with all sorts of negative consequences, both in the moment and in the long-term,” she says. “But we don’t have any evidence that there are similar negative consequences in Asian populations. We assume that expressing emotions is beneficial, but in Asia the basic psychological data underlying these assumptions are just not there.” Challenging assumptions can be an uphill battle based on how definitions of disease and suffering are constructed. Psychiatric diagnoses, treatment, and research in the United States are largely defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). First published in 1952,
Illustrations by Anna Godeassi
M ENTAL HEALTH
exporting assumptions The real-life implications for patients, families, and entire communities loom large. Clinicians who have not been trained to apply a cultural lens and who fail to delve into a patient’s cultural context may end up misdiagnosing symptoms—or missing symptoms altogether. This can lead to patients being prescribed drugs they don’t need, not receiving treatments they do need, or disappearing from the system entirely because of cultural or language barriers. These issues tend to surface when Western clinicians and researchers make assumptions about what types of behaviors, attitudes, and norms are optimal— contributing to what some mental health experts see as form of medical colonialism. For instance, assumptions about how depression manifests can differ widely across cultures and communities. By exporting these assumptions, we may fail to see how cultures have ways of dealing with depression or distress that may be more effective in their context, according to ChentsovaDutton. “Cultures have developed a long history of adaptive strategies based on their own ways of understanding and responding
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to distress, and we effectively erase those understandings when we bring in our own,” she says. She cites the example of how American clinicians look at the connection between self-esteem and depression. “One of our assumptions basic to our Western understanding of depression is that people who are not depressed should have a positive view of themselves. So now we are training Chinese physicians to pay attention to whether patients are expressing feelings of worthlessness,” when in fact that population’s response to distress may manifest very differently, Chentsova-Dutton says.
Becoming viral The dominance of Western medicine can have the effect of introducing mental health concepts or conditions, diagnoses and even disorders, into a culture where they don’t exist—or replacing something that is locally understood with something foreign. For example, eating disorders that tend to be prevalent in the United States, such as bulimia and anorexia, have been exported to other cultures where they did not traditionally exist. Chentsova-Dutton notes that this is not just because of the influence of Western television and other media on notions of ideal body type, as might be assumed, but also because of a proliferation of information about these disorders. She recalls how in Hong Kong, following a public outcry after a young woman died of anorexia, the media began reporting on the disorder to make sense of the tragedy. Yet the victim had a different presentation of anorexia that is unique to China, and not the Western form of the disorder. Still, the sudden prevalence of information about Western anorexia began to take over, triggering a surge in its reported incidence. “When we export ideas about the body—both in terms of the ideal body type as well our ideas about what the disorders are—it can be disastrous in that we suddenly see them in all these places we haven’t before. They can become viral in certain contexts.”
power of community Western notions about mental illness also can have great bearing on understanding serious psychotic disorders. Researchers have shown that people who suffer from
the American Psychiatric Association’s treatment guide is now in its fifth edition, published in 2013. Internationally, the World Health Organization’s International Classification of Diseases and Related Health Problems (ICD) is the standard. “Biomedicine itself—the clinical practice of medicine in the United States—is a culture,” Mendenhall says. “The DSM-5 is a collection of symptoms for and definitions of mental illness. That in itself indicates that when you’re looking at depression or anxiety or PTSD, these are not static disorders. They are something that has been constructed.” A constructed disorder suggests that cultures have their own ways of viewing mental health that may not be captured by—or may directly contradict—a biomedical model. Simply put, Western definitions of mental illness may be too static to capture the range of human experience, especially when cultural difference is considered. “In every culture, people express, measure, understand, and interpret psychological suffering in different ways,” Mendenhall adds.
schizophrenia and who hear auditory hallucinations, such as voices, may hear them differently depending on their social and cultural context, notes Mendenhall. For example, recent research out of Stanford found that patients who suffer from schizophrenia in the United States tend to hear voices that are more harsh or violent than those heard by people in India and African countries, where voices are heard as more benign, playful, or even God-like. Some cultural psychologists and anthropologists believe this is because Europeans and Americans have a more individualistic sense of self—grounded in Descartes’ principle of “I think, therefore I am”—while people in other parts of the world are more community- and relationship-oriented, so voices are heard as less intrusive. “There is no question that how you see your community and the world plays a powerful role in how you see the self,” Mendenhall says. Throughout history, in some societies, spiritual leaders— including shamans, prophets, and mystics—have displayed certain characteristics that bear similarity to schizophrenia. In other words, someone diagnosed with schizophrenia in the United States might be considered highly creative, holy, or even magical in non-Western countries—and therefore could develop a radically different framework for processing and expressing the same tendencies.
Language as a window, and a barrier Along with different ways of understanding and experiencing suffering, every culture has a different language to express it. Some anthropologists believe these semantic nuances, sometimes referred to as “idioms of distress,” can hold an important key to understanding cultural differences. Mendenhall cited how Mexican immigrants in the U.S., for example, have been shown to use specific Spanish terms, such as susto (roughly translated as fright) or nervios (roughly translated as nerves) to describe complex syndromes associated with depression, anxiety, and trauma. “These emotions are perceived within the community to cause other types of sickness, and therefore the terms hold great power,” Mendenhall says. Yet just as language can offer a window into cultural differences, it can also serve as a sizable barrier, according to Nima Sheth, MD, MPH, associate professor of psychiatry at Georgetown University Medical Center who works primarily with victims of trauma or torture, asylum seekers, and refugees. When working with immigrant populations in the U.S who do not have facility with English, for example, clinicians who are not proficient in the patient’s language or culture must consider their words carefully to avoid confusion, or ensure a qualified interpreter is in the room and fully briefed beforehand.
Federally funded institutions are legally required to provide interpretation and translation services in these instances.
Stigma of mental health Beyond language, people’s comfort level with discussing mental health can be a formidable nonverbal variable. “In many cultures, doctors are so well respected that it is considered disrespectful to ask any questions,” Sheth says. “So the patient agrees with everything the doctor says but then goes home and doesn’t take the medication because they were too scared to ask about it.” Patients whose culture does not necessarily embrace the American norms of mental health on the whole may have a harder time talking about their symptoms with a physician who does not share their background, she says. Some may prefer to handle their mental health symptoms such as depression or anxiety through their religious leader. Others may be leery of taking medications prescribed by doctors they view as disconnected from their experiences. Sheth says she tries to offer them a space to speak without judgment or pressure, and invites them to include their spiritual leader in the conversation if they prefer. “As time goes on, if they start to open up about their struggles, I discuss how it might be helpful— but reiterate to them that it’s not necessary— for them to take medications in order to heal. I continue to discuss the full range of treatment options, which helps them to remain in treatment, as staying in treatment is the most important thing,” Sheth says. “I also let them know they can run the decision by their priest or spiritual leader and that I’m happy to include them in the treatment. I think that remaining open to whoever that patient wants to be involved can really break down the stigma and help open the conversation.” Stigma and unconscious bias work both ways, Goode points out. Studies have shown that certain racial or ethnic groups are overdiagnosed for some mental health conditions compared to other groups. For instance, Goode says young African American boys in the United States tend to be diagnosed with behavioral issues and aggressive tendencies at a higher rate than white boys. “The literature shows that it is sometimes the implicit biases
A growing demand As the population in the United States grows increasingly diverse, and the global population becomes increasingly mobile, the need for mental health professionals to be trained in how to provide care in culturally appropriate ways is more pressing than ever. Clinical psychologists and psychiatrists need to broaden their repertoire of skills to meet this growing demand, ChentsovaDutton says. But perhaps even more fundamental is the need to increase the diversity of future clinicians to better match that of the patient population. “Immigrants and minority patients do not generally do well in clinical assessment and therapy,” she says. “The most common scenario is they don’t come in at all. The next is that they come once, take a glance around at who is there to work with them, and never come again.” And while psychiatry as a field has made a concerted effort to increase its diversity, clinical psychology lags in this effort, in that the training programs tend to be highly selective in ways that systematically disadvantage minority students, she notes. Goode agrees. By failing to fully acknowledge and reckon with diversity in mental health, Goode says, “we run the risk of missing out on effective ways to provide services to individuals, families, or entire communities.” Mendenhall notes that when it comes to optimizing mental health care, the United States can take lessons from other countries that leverage alternative models of care delivery. Examples include integrating mental health into primary care, and task-sharing among a range of health-care workers—such as midwives, nurses, or community health workers—so that patients are less limited by where they can receive care. “People working in low- and middle-income countries do task-sharing a lot better than we do in the U.S. We have all the resources, but what we don’t have is the flexibility within our system to consider the fact that we don’t necessarily need psychiatrists or drugs to take care of everyone who is suffering from anxiety or depression,” Mendenhall says. For example, some people may not need to see a psychiatrist, but could benefit from seeing a social worker or psychologist or joining a support group to address the root of their stress, which could be financial or social rather than medical. For Mendenhall, this gets to the anthropological concept of
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syndemic care, rooted in the idea of caring for the convergence of health problems against the backdrop of social and economic inequalities. “Mind and body are so intimately interconnected in people’s everyday lives. Other countries seem to do better at recognizing that the way we perceive our suffering has a powerful role in how we respond to it.”
A matter of social justice For clinicians and researchers who care about these issues, grappling with the cultural aspects of mental health—and what some see as the related colonialism in the practice of psychiatry and clinical psychology—strikes at the very core of health equity and social justice. “The magnitude of symptoms of common mental disorders, or emotional idioms, within a community can be a really powerful representation of overall health and well-being. So looking at the prevalence of depression, anxiety, and other issues—in whatever ways you are measuring them—is a pretty good indicator of how people are dealing with adversity in the world,” Mendenhall says. Goode notes that achieving true health equity means addressing the cultural underpinnings of mental health. “Many cultural groups embrace belief systems that integrate physical, emotional, and spiritual aspects—all three are necessary for their overall health well-being,” she says. Such a holistic approach to mental health is well-suited to Georgetown, where platforms such as the university-wide Global Health Initiative (GHI) provide seed funding for multidisciplinary teams to study major global health issues. Sheth, who in 2017 received GHI funding to study refugee and asylee mental health in the greater Washington, D.C. region, says Georgetown has provided her a forum for collaboration with colleagues from across the university, the School of Foreign Service, the School of Nursing & Health Studies, and departments of international migration and anthropology, among others. She and Mendenhall are currently exploring a new collaborative research project, along with other colleagues from the university and MedStar Georgetown University Hospital, looking at trauma and recovery of refugees and asylum-seekers in the region. “Georgetown is uniquely positioned when you think about it,” says Sheth. “The focus on interdisciplinary work, the Jesuit mission of social justice, and the support and interest in global health makes us a leading place to bring about change in the global mental health arena.” n Anna Godeassi
of those who are doing the testing,” Goode says. She added that provider bias underscores the complexity of the factors that tie into mental health. “Particularly in the United States, race, ethnicity, socioeconomic status, and the language that one speaks have significant impact on who receives mental health services, the effectiveness of the mental health services system, and the quality of those services,” she says.
FACULTY POINT OF VIEW
Gun Violence and Physicians Our lane, whether we like it or not
hysicians know all too well that gun violence is a public health problem of epidemic proportions. The medical community’s outrage and activism in response to the NRA’s assertion that doctors should “stay in our lane” when it comes to gun violence signals shifting momentum in the effort to address the epidemic of firearm morbidity and mortality in the United States.
A public health issue The media and the public tend to focus attention on gun violence in the wake of the increasingly frequent mass shootings. As heartbreaking as mass shootings are, they represent only the tip of the iceberg in this gun violence epidemic. After being told to “butt out” of the gun violence debate, physicians have been increasingly vocal about the carnage of gun violence they confront on a daily basis. Emergency room doctors, surgeons, trauma specialists, and others have posted horrifying images and personal stories related to the toll of gun violence. Psychiatrists have shared their experiences of the patients who died by firearm suicide and the families left grieving. Just like any other public health problem, gun violence is our lane, whether we like it or not. Each year, over 36,000 Americans are killed—nearly 100 every day—and more than 100,000 are injured by firearms. Of total deaths, about one third are homicides, including a significant number of deaths related to domestic violence. Access to a gun doubles the risk of death by homicide. Black Americans represent the majority of individuals who die by gun homicide.
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Black children and teens are 14 times more likely than white children and teens of the same age to die by gun homicide.
The epidemic of gun-related suicide deaths Suicide deaths, the 10th leading cause of death in the United States, are increasing, accounting for about 65 percent of all gun deaths yearly—far and away the largest single category of firearm deaths. About half of the approximately 44,000 annual suicide deaths involve firearms; of those, nearly three-quarters of the deaths are of white men. Meanwhile, suicide is the second leading cause of death among teens and young adults, with about 40 percent of those deaths due to firearms. Access to firearms triples the risk of death by suicide; gun suicides are concentrated in states with high rates of gun ownership.
Advocacy in legislatures— and in our offices If gunshot deaths, wounds, injury, and suicide—in the tens of thousands each year—are not our lane, what is? One method of serving public health needs is advocating legislative changes in firearm regulation. Most Americans support interventions such as expanding background checks, closing gun show loopholes, banning assault rifles and high-capacity magazines, raising the minimum age to purchase firearms to 21, and implementing “red flag” legislation, allowing law enforcement to separate people in crisis from their firearms. As private citizens, physicians may choose to advocate for these changes. However, a change in medical practice
can also serve public health, and would not require legislative or political change. More than a third of households in the United States have firearms, and most of those households have more than one. Access to a firearm increases the risk of suicide, homicide, and accidental firearm death for everyone in the home—spouses and children—not just the owner. Physicians providing primary medical and mental health care should routinely ask: Does the patient have access to a firearm? Do other members of the household have access to a firearm? Is the firearm safely stored? Is the patient or anyone else in the home in crisis? If so, have plans been made to separate the high risk individual from access to the firearm, at least until the crisis is resolved, if not longer? If you are practicing in a state that has passed red-flag laws, does your patient know how to use these laws to activate law enforcement to separate a loved one in crisis situation?
patient care, not politics The “advice” to “stay in our lane” was only the most recent iteration of opposition to physician involvement in addressing the problems of gun violence. A few years ago, those who oppose change attempted to pass “gag law” legislation, ultimately overturned in the courts, to prevent physicians from talking to their patients about risks associated with access to firearms in the home. But this concerted opposition to physician involvement in the debates over firearm legislation reform raises the question: Why do those who oppose change fear physicians’ voices?
By Liza H. Gold, MD
IS SUES IN BIO ETHI CS
The reason is obvious: they think it’s about politics. But the truth is that when physicians speak about issues affecting their patients and the public health, they are concerned about human lives, not political positions. This belief is the basis for the respect and authority that society bestows on us. Thus, when physicians unite to address public health issues, we often succeed in promoting social change, which is exactly what “pro-gun” political forces fear. A public health epidemic is not a political issue. Preventing needless death and injury are not
constitutional issues—they are human issues. Just as other public health risks have been successfully integrated into routine medical care, such as regular questioning regarding tobacco and seatbelt use, physicians can and should integrate a routine assessment of risk related to firearm death or injury—as well as firearm safety counseling—in patients’ regular medical and preventive care. Physicians are in a unique position to help our patients prevent firearm
injury and death. Will every patient be forthcoming about firearm access or adopt the counseling we provide? Of course not. Despite the well-documented risks of developing lung cancer, people still smoke; despite the increased risk of death and injury, people still drive without wearing seatbelts. Like these other public health issues, gun violence is our lane. n Liza H. Gold is a clinical professor of psychiatry and author/editor of Gun Violence and Mental Illness (2015).
ON C AM P US
Progress in Neonatal Seizure Pharmacology
energized training environment drives ambitious translational research By Elyssa LaFlamme (G’22)
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seizure, versus the combination,” he points out. Using cutting-edge technologies, his lab also examines how stimulating or silencing the activity of specific neuron populations along the seizure pathway can disrupt or prevent its propagation. This line of research could result in the development of alternative treatments to the current first-line medications. “If we can identify critical nodes in the circuit that work across lots of different seizure types, these could be potential targets for deep brain stimulation in people,” he says. Forcelli first joined the department as a graduate student through the Interdisciplinary Program in Neuroscience in 2006. While he has published extensively on seizure circuitry and neonatal pharmacology, he credits his pre- and postdoctoral trainees for the breadth of his research, which ranges from cellular function to circuitry to cognition. “I have a lot of fun sitting down and talking with my trainees to design experiments together, helping them troubleshoot, trying to interpret the results together, writing together— although I don’t think that they always like that part!” he laughs. His devotion to their success rivals his scientific ambitions, and his mentorship style, which MD/PhD candidate Safwan Hyder characterizes as “repeated instances of selflessness,” inspires loyalty and a strong work ethic. “Dr. Forcelli is so excited about science that it overflows into you, and
then you become more invested and more excited,” says Evan Wicker, a doctoral candidate in the lab. Forcelli’s enthusiasm isn’t reserved for big breakthroughs but extends even to the smallest pieces of data. “There are some weeks when experiments just don’t work,” Sean Quinlan, a postdoctoral fellow, confides. “I can do an experiment ten different times and it’ll fail, but he still gets excited that it’s been done and that now we know ten ways it doesn’t work.”
“I love when the results come in,” Forcelli confirms. “The answer is there, waiting to be uncovered from mounds of data, and it’s so exciting because that answer leads to the next experiment.” n Elyssa LaFlamme, the magazine’s Spring 2019 Science Writing Fellow, is a once and future goatherd from Portland, Oregon, and a doctoral candidate in the Georgetown University department of pharmacology and physiology.
verlooking the magnolia trees lining the north end of campus sits an illustrious hub of neuropharmacological research: the department of pharmacology and physiology. There, Assistant Professor Patrick Forcelli (G’11) leads a lab studying neonatal seizure pharmacology. Mounting evidence from patients and from research in animal models suggests that exposure to common epilepsy drugs, phenobarbital in particular, causes lasting damage to cognitive and motor functions in the developing brain. The research aims to minimize these adverse side effects and maximize therapeutic potential. Epilepsy is a deceptively complex condition. Seizures hijack brain circuits that serve normal processes including movement, learning and memory, and social behavior, so epilepsy—and its medications—have pervasive consequences. Because clinical trials involving infants are risky and rare, neonatal seizures are treated with drugs developed for adult patients. It is dangerous for pregnant patients with epilepsy to suspend seizure control, so infants may also be exposed to these drugs in utero. “An early injury to the brain can impact the whole trajectory of life,” Forcelli explains. “Our goal is to improve therapies for neonatal seizures, and in doing so improve outcomes for the rest of their lives.” Forcelli uses research models to identify and compare specific drug effects on cellular processes and neural pathways. “Only in an animal model can we separately assess the impact of the medication, versus the impact of the
Match Day 2019 by the Numbers most popular specialties among School of medicine students who matched:
Internal medicine Anesthesiology Orthopaedic surgery Emergency medicine Pediatrics General surgery Neurology Family medicine
35 15 15 15 14 12 9 8
A L UM N I CON N E C T I O N S
What’s in my white coat? Interview by Chelsea Burwell (G’16) Tara Kelly (M’08, R’12) is an obstetrician and gynecologist at MedStar Georgetown University Hospital and assistant professor at the School of Medicine.
2. I typically pack light, but I definitely have my phone with me. I have plenty of pictures of my daughter on there that I look at during the day for inspiration. I use apps like a digital pregnancy wheel to track and update patients’ due dates, and a pap smear screening guideline. 3. Being in circulated air spaces, I keep lip balm on me at all times. Low-glam, but necessary.
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4. Probably the most medical thing I have is my doppler, which I use to listen to babies’ heartbeats during the routine obstetric care. It’s one of the more favorite moments of prenatal appointments for expecting moms. 5. I have measuring tape with me to measure the fundus of the patient’s uterus. This helps us keep track of the baby’s growth rates throughout the pregnancy. 6. My days are pretty varied—which I like—and I’m often on call for surgery or labor and delivery, if I’m not in clinics seeing patients. I keep a hair tie close by for when I have to scrub in and get to the operating room.
1. Naturally, I keep a pen on me, especially when I’m seeing patients in the clinic to update their charts and jot down any notes during the exam. On an average, I see about 25-30 patients a day. Getting to know and talk with my patients is something I really love; my field is lucky because we can focus on problems and how to fix them, but also sustain meaningful, long-term relationships with those in our care.
Friendship, learning, and lunch with The ROMEOs
Top photo Phil Humnicky/Bottom photo Lisa Helfert
t’s a sight to behold: before noon on a rainy Friday in November, the quiet neighborhood DeCarlo’s Restaurant comes alive as dapper men and women trickle in. Despite the weather, the back room fills with around 50 participants. They are the Georgetown ROMEOs: Retired/Retirement-approaching Old Medics Eating Out. The self-proclaimed informal group of physicians—all trained by or connected with the School of Medicine and MedStar Georgetown University Hospital—fills an important social void for the D.C.-area retirees. “Medicine is a very collegial profession,” says ROMEOs president Michael Ball Jr. (M’59, W’65). “Physicians constantly interact with patients, patients’ families, colleagues, and consultants. But when a physician retires, this interaction suddenly stops.” Beyond sustaining friendships, the group also provides a monthly opportunity to explore and engage with today’s pressing medical issues. ROMEOs had a humble beginning. In late 2000, when the newly retired Oscar Mann (M’62, R’65, W’66) was
recovering from a stroke, his friend Ian Spence (now retired from the clinical urology faculty) began taking him out for lunch every few weeks. One day they were joined by Mann’s former colleague and new retiree Frank G. MacMurray (who taught internal medicine and died in 2010). The group continued to grow, and within a few years had become a standing monthly lunch and lecture gathering. In 2014, OB/GYN Nancy Ripp Clark (C’77, M’81) joined as the first of now many female ROMEOs. Each month the ROMEOs gather to break bread and engage with Georgetown faculty on topics such as simulation learning, cancer immunology treatment, current antibiotic needs, new library learning tools, bias in medical care, and new understandings of the human brain linked to ethics. No formal dues, no attendance requirements, and no obligations bind the ROMEOs together. Instead, they come together voluntarily out of appreciation for each other and a shared passion for lifelong learning.
“The bottom line is, we enjoy each other!” says Ball. “I feel certain that Georgetown ROMEOs around the country would have as much collegial enjoyment as we do.” n Jupiter El-Asmar (F’17)
To reach out and connect with other alumni in your area, contact firstname.lastname@example.org.
Alumni Supporting Scholarship During Medical Reunion in October, members of the Medical Student Alumni Ambassadors share a laugh with Janice Massey (M’78) at the Commitment to Excellence reception in Riggs Library. The annual event is held to honor members of the Warwick Evans Society, named for the first medical graduate of Georgetown University and founded in 1991 to support scholarship at the School of Medicine. To join the society or for more information, contact email@example.com.
Reflections on medicine with
Bill Licamele (C’68, M’72, R’74, W’76)
I grew up in Connecticut. My dad wanted to go to med school but didn’t have the money. As the town pharmacist, people went to him for advice. He was my role model. I went to a Jesuit high school, Fairfield Prep, and our star basketball player was recruited to Georgetown. Almost ten percent of our class came here. Best teacher in med school was Charles Rath, who taught laboratory diagnosis. He gave open book tests because he said much will not be true in 30 years, and he was right. You can always look stuff up. Things change. The key
is to be open to learning. Proctor Harvey, the preeminent cardiologist, was the gentlest, wisest man in the world. He said listen to the patient because often they’ll tell you what’s wrong. He spent time with patients—hard to do nowadays. I went into psychiatry for the long-term relationships with families. I started teaching at Georgetown but it didn’t pay much, so I had a private practice too. I saw a girl when she was 6 or 7, and then a couple of years before I retired, she brought her own child in to see me. Child and adolescent psychiatry is fun. You can do play therapy like games, basketball, or art. Kids communicate beyond words. They have development on their side. Most parents are looking for practical advice, how to set limits and deal with problems. It’s rewarding to see kids get better over time. Back when I was in training in the 70’s, there was little use of medicine except for stimulants for ADD. They said kids don’t get depressed but that wasn’t true. I wrote papers on children’s reaction to hospitalization, and on children of divorce—pediatricians became more aware of how to help them. Today adult psychiatrists have been pushed to become diagnosticians and medication managers, while in child psychiatry, there is more variety in treatments—working with families, behavioral treatments, talking, play therapy.
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For a while people were handing out medications for depression without doing a good diagnostic evaluation. For kids with a strong family history, medication was helpful but needed a complete approach with therapy, talking to parents, talking with the school. A drug would get approved without studying it on kids, and people were forced to use it because there were no options.
Now there’s more brain research on treatment with medications. ADD and ADHD were under- and over-diagnosed. Sometimes pediatricians put kids on medication without looking for underlying issues like learning disabilities or anxiety. Some parents were resistant to medication. Others want to immediately put kids on medication without figuring out what’s going on. In 1976 I had a 12-year-old patient who was depressed and anxious and had to be hospitalized. My former supervisor called me and said he had Tourette’s Syndrome— with multiple motor and vocal tics lasting over a year. I had never heard of it. Eventually it became my area of expertise. Georgetown’s Tourette’s clinic was opened in 1982 for about 15 years—a one-stop shop for teaching and evaluation. There’s a fine line between tics, compulsions, obsessions, and tic-like thoughts. A 7-year-old having a tic is not unusual— you don’t treat it. At that age most are transient tics related to a natural rise in dopamine.
My Georgetown class of 1968 is very close. Those were turbulent times. We watched the city burn from the roof of Darnall. But we had our 25th reunion at the White House. I met my wife when I was a psych fellow and she was the in-house school teacher at the hospital. Annamarie knew a lot about raising kids! She is the rock of our family. We have seven grandchildren and one on the way. I’m a crazy Georgetown basketball fan. Had tickets since 1964. I used to have patients say, “Gee you were pretty loud at the game Saturday.” n
The child and adolescent psychiatrist retired in 2014 after nearly 40 years at Georgetown. He is father to three Georgetown alumni. His dedication to the university runs deep—including courtside at Hoya basketball games.
“Now the space will match the level of care we give.” — Kerri Layman (F’00, M’06, R’09) I grew up in a small town and was first in my family to go to college. Georgetown made my world a whole lot bigger. I went into emergency medicine because it’s a little of everything, and the doctors are approachable. We have to establish rapport quickly, and we depend on each other. Our current space was built when emergency departments were emergency rooms. The new pavilion will nearly double our ED capacity, from 17 to 32 beds and rooms for consultations. We’re upgrading equipment, lighting, technology, plus the space will be quieter, more private, and more efficient. Better for us, better for teaching, and better for the patients.
Partner with us to transform health care at Georgetown. Invest in the future of medical excellence at Georgetown by supporting the new medical/surgical pavilion. Email GUMCgiving@georgetown.edu or call 202-687-2222.
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FROM THE ARCHIVES: Georgetownâ€™s Family Therapy Pioneer The prolific, renowned psychiatrist Murray Bowen (1913-1990) was part of the Georgetown School of Medicine faculty from 1959 until his death. An innovator in the field of family therapy, he developed a systems approach to understanding the function of interdependent human relationships that foster emotional connection and support. The U.S. National Library of Medicine in Bethesda, Maryland, houses a colorful collection of archival material from his family and from the Bowen Center (formerly the Georgetown University Family Center), including writings, videos, and oral historiesâ€”some of which can be found online at murraybowenarchives.org. Bowen is pictured below at age 25 outside his first medical office in Crossville, Tennessee. At left, he describes his family systems diagram.
Photos courtesy of the Bowen Center for the Study of the Family
Mental Health: How we foster wellness within