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SF2UF Ms. Leanne Dumeny, Changing the Practice of Medicine: Why do an MD/PhD?

SF2UF Ms. Leanne Dumeny, Changing the Practice of Medicine: Why do an MD/PhD?

– Thank you so much for the invitation, I really appreciate it
and am humbled by it. So today I’m going to talk
to you, like she mentioned, a little bit about the MD/PhD program and so the title of my talk is Changing the Practice of Medicine and why might you wanna
consider doing an MD/PhD? So as an overview, today
I’m going to talk about before I became a Gator, my time while I was undergrad at UF, the MD/PhD program overall, why I did it, and why you might wanna consider it and then potential role models that also went through MD/PhD programs. So before UF I grew up
in Sanford, Florida. So it’s about two hours south of here, an hour north of Orlando. It was a pretty nice place to grow up, kind of middle of suburbia and there I went to Seminole High School and while growing up there I became interested in
science, as many people. I was interested in science
kind of middle school and through high school
and when you think science you can become a scientist; however, I didn’t actually know what that meant. I had a premature idea of what it meant to become a scientist. Really there’s not that
much exposure to scientists in high school or even in the media. Really the only idea of scientist I had was Dexter’s Laboratory
or The Big Bang Theory and even at the time they
weren’t quite cool yet so I didn’t have I guess a good idea of what it meant to be
a scientist at the time. So I pursued something else, so the idea of becoming a physician. Fortunately, my family member, my family has a lot of
members who are in medicine. So I have nurses, occupational therapists, a lot of missionaries in my family and so the idea of serving
people really attracted me and I felt like it was in my blood as well and so it seemed like a great fit to be able to pursue the
path to become a physician. So I applied to UF. I fortunately was able to get in and I would say I was a
typical premed student. You know they tell you to do volunteering, they tell you to do some leadership, do some shadowing as
well, and I did all that and they also tell you it’s a good idea to do some research to
get into medical school. It seems like a good fit for me since I was interested in science and so I pursued trying
to do some research again to just get exposure and
to also help my application. I was interested at the
time in becoming a surgeon not just because of Gray’s Anatomy but because I was also interested
in working with my hands. I was active in a lot
of sports and so to me it kind of fit that I would
be able to help people through working with my hands. So with those two ideas I pursued
a research lab in surgery. So I worked under Dr. Scott Berceli and he’s a vascular surgeon also an MD/PhD and his research is in vascular biology and he works with the idea
of vein bypass graft failure. So his overall research mission is to improve the understanding
of intimal hyperplasia and then hopefully
through this understanding he can find applications to
improve long-term outcomes and durability of these vein grafts. And so that idea really attracted me and I was able to learn a
little bit more about surgery and as well get my feet wet in the lab and learn more about research as well. So my undergraduate project, I apologize if it’s a little hard to see. But I primarily did immunohistochemistry. So my primary stain
was a stain called BrdU and this is a stain which pretty much you can find cells
which are proliferating. So we’re interested in
cellular proliferation because Dr. Berceli is interested
in neointimal hyperplasia. So the idea that cells
are growing in the intima. And so I performed so many
stains, so many stains and unfortunately I did
become a little discouraged because it required so
much troubleshooting, just hours and hours
of trying to figure out what conditions were right, how long to leave
something in the bath for, and so I was a little bit discouraged about research at the time because it didn’t seem
like I was going anywhere. I was just pretty much just doing stains during my free time and it wasn’t until I presented
my research at a symposium that I realized kind
of what research meant and it kind of enlightened me to what the potential
of research could do. So I always encourage any undergrad to present their research
for a couple of reasons. One, you get practice in communicating, so that’s a skill that you
need pretty much in any career as well as communicating in
science is quite difficult at least for me, and so
getting the practice to do that I really appreciated the chance
to do that as an undergrad. And the second thing I think
with presenting your research you get exposure to actually
other medical research. So I was kind of in my silo doing stains, just in vascular biology and I
got to see some other posters and realize kind of the
breadth of medical research, that there was health outcomes research, that there was other
stains that could be done and so I really appreciated
that opportunity to be able to just kind
of get the full scope of what medical research could entail. And then I also learned
through the presentation that you can actually participate in changing the paradigm of medicine. So even though I was just
doing stains continuously, if I thought a little bit
further about its applications and its being able to help patients and reduce vein graft bypass failure then it excited me a
little bit in the sense that I was actually participating in how medical practice could be changed. So I certainly encourage
you to present your research if not getting these realizations,
it’s just a good thing to be able to practice
communicating science overall. So having kind of the bug in wanting to change
the practice of medicine I pursued that further; although, I took what some
might consider a detour. So this is Hough Hall. So this is pretty much where the graduate business
students go to class and whatnot and it might be considered
a detour but I felt like it was actually a great
experience to do this. So I did a program called
the Masters in Management. I always thought that the business, since I was always in science
I thought that business was just this mysterious thing that I never really had exposure to. In fact I overheard a
conversation from another student talking about economics
and it sounded fascinating and so trying to kind of think through, oh what does the economics
of healthcare look like and once I started looking
into this further I realized well there’s actually quite
a lot of inefficiencies in healthcare and so being able to get sort of a foundation in
business might help me to be able to kind of
understand these things and become a better physician. And so I decided to pursue the program and so I did a masters in management and I definitely don’t regret it. It’s helped shape how I
think of problems today and I definitely don’t consider
it a detour as some might. So through doing that program and kind of trying to prep my application and thinking through things I kind of thought through
what my priorities are. It’s kind of easy to
get lost in everything with medical applications. They ask for so much often it feels like and there’s so many things
you could possibly do like while you’re an undergrad. And so I really had to sit
down and focus and think okay what are my priorities and it’s okay to change priorities but I wanted to focus
on these and use these as how I make my decisions. So the first thing for me
faith is very important. So for me my personal belief is that God put us on
this planet for a reason, each of us has a purpose, and so for me trying to
understand what my purpose was and trying to use that to
guide what decisions I made for my career. Second is family. So family is very important to me as well and so using them kind
of as a guiding point and making sure that I was
able to prioritize them regardless of what I do, so if
something comes up with them I would be able to put that thing down and go take care of family at the time. And so that’s something
that has also driven some of my decisions. The third thing, and that’s the thing I realized through the management
program and doing more reading and more self learning is that I was interested
in fixing medical practice. So originally I wanted
to become a physician to treat patients and be
able to take care of patients but I realized I was a
little more interested in being able to fix how
medicine was practiced and so using that again as
a point for my decisions. And then lastly surprisingly
food actually dictates how I make my decisions. So sometimes depending on
how, what workshops I go to or what seminars I go to, this
hasn’t steered me wrong yet. So I really appreciate food and it continues to stay
a part of my priorities. (background noise covers dialogue) (chuckles) So thinking of all of that, and again I told you I did some reading and trying to understand what I was interested in
trying to fix with healthcare. So over time I was
exposed to certain issues with how medicine is practiced. So I’ll talk about these reasons. So the first thing, a limited
understanding of disease. So in high school and
sometimes even undergrad, things are put very clearcut. So it makes it sound like we
have science all figured out, everything is ABC and
we know what’s going on. And so trying to understand
a little bit more about the nuances of what’s going on. For example, we know that
smoking can cause lung cancer but what’s not known is
are there certain genes that can protect you or help you reduce the
susceptibility to cancer or are there certain
environmental conditions or exposures that might make one protected for getting lung cancer. And so there’s just these certain nuances and things that we still don’t understand about things that we
think we’ve known forever. And so that was something
that I was attracted to with the idea of fixing
medical practice and research. The second thing is that there
were significant disparities in disease prevalence. So I took a class and
it kind of exposed me to some of the disparities
in access to healthcare and it just astounded me how different we can have
prevalences among different groups such as Hispanics and African
Americans and Caucasians and so that really intrigued me that we can have so many
differences between groups. The third thing and this is the thing that
bothered me the most actually was the slow translation of research. So there’s all these great research ideas being done at the bench and
great clinical trials being done but I read something that said on average it takes about 17 years from
when that research was done to actually being implemented
in clinical practice. 17 years, like that number
bothered me quite a bit. There’s all these great things being done and yet patients of this generation maybe won’t be able to
experience that benefit. And so I wanted to, I am still interested
in trying to figure out how to speed up this process
and this introduced me to the field called
implementation science. So the idea of efficiently being able to bring these new evidence into clinical practice a bit more quicker. So that’s something that
still drives me to this day. And then lastly I was also exposed to the
amount of waste in healthcare. So actually recently an
article came out in JAMA that showed that 25%
of healthcare spending is considered waste and
that’s billions of dollars. It’s billions of dollars that we could use for other services and
helping other people. And so that’s also something
that kind of bothers me that I think can be fixed
with medical practice. Figuring out how to make it more efficient so that we can reduce the
waste and improve outcomes in patients overall. So with that I was set
on trying to figure out how I can change the
paradigm of medical practice and I figured out that
doing an MD/PhD program would teach me how to do medical research so that I can better understand
how to discover problems, learn about problems, and
actually solve the problems through training and research. So a little bit more about
what field I decided to go in. I think that I could
make the biggest impact through the four things I mentioned through cardiovascular disease. So you can see here this
is a table that was shown or reported by the World
Health Organization. You see the top 10 global causes
of death in the year 2000. The top cause is ischemic heart disease and over time ya know we do
have medical improvements and so taken with the year 2016 you can see that the chart
has changed quite a bit but still at the top of the
chart is ischemic heart disease. And so heart disease
continues to play a role and is a problem globally
and not just globally it’s also in the United
States, it’s a major problem. So the top issue, or
the top cause of death is usually kind of wrestling between heart disease and
cancer but I still am interested in trying to pursue, trying to improve cardiovascular diseases. Also with cardiovascular diseases, that’s where we see some of
the greatest disparities, again something I’m interested in. So you can see here the
CDC has an infographic that says African Americans
are more likely to die at earlier ages from all causes and some of the things
that attribute to this is the differences in prevalence
of cardiovascular disease. So you can see here high blood pressure, diabetes, and stroke and for essentially
most of these categories African Americans have
the highest prevalence of these diseases. And so I felt like this is something that if I look through
cardiovascular disease I could also make an impact
with health disparities. So the other thing that I learned that could help me
address those four things that I’m interested in pursuing is the idea of precision medicine. So a while back during
the Obama administration he essentially gave a speech
that was addressing something called the Precision Medicine Initiative and so I’ll just read a quote. So, “Doctors have always recognized “that every patient is unique “and doctors have always tried
to tailor their treatments “as best they can to individuals. “You can match a blood
transfusion to a blood type, “that was an important discovery. “What if matching a cancer
cure to our genetic code “was just as easy, just as standard? “What if figuring out the
right dose of medicine “was as simple as taking our temperature?” So reading that and listening to him give the
State of the Union Address about this initiative,
it really inspired me and realized if I pursue this
field I could actually address some of the things I was
talking about as well. So for example figuring out
the right dose of medicine. So if we’re able to give the
right dose at the right time then we would be able to reduce
adverse events, for example. And so we would be able to reduce some of the issues with spending, we’d be able to improve care overall. So I thought that precision medicine would be a great field to pursue. Something a little but further, so you can see why I’m
in the genetics program. So this is the idea that
currently we treat patients usually as an average. So based on evidence-based medicine, we consider patients on
as a whole and on average but we can use certain
pieces of information. So in this graphic they
highlight omics data. So genomics, so the idea
of variation in one’s DNA; transcriptomics, so the idea of variation in gene expression. So using these omics we can
better categorize patients and we can either use
it using one of these or a multitude of these and we can figure out
through those markers what patients would
benefit from which drug. So you can see here for
example this patient, or these set of patients would do better, on this therapy based on this
certain omics information. And so I was interested in
pursuing genetics and genomics so that I can better understand
kind of how this works and try to apply this to clinical care. So fortunately I was able
to find a group at UF that did this and so for my MD/PhD I’m currently working with this group, the Center for Pharmacogenomics
and Precision Medicine. So this is my mentor on your left and her name is Dr. Larisa
Cavallari and she is a pioneer in the field of pharmacogenomics
and precision medicine and what led me to her
is her initial research when she came to UF
looking at pharmacogenomics applied to cardiac stents. So the idea that we can
improve outcomes in patients by understanding which
drugs work better for them after they’ve received a cardiac stent and so that idea just blew me away and so I had to join this
lab as best as possible and fortunately they accepted me. So I’ve been doing research
with them for my graduate work. So for my graduate work I’m working on two things primarily. The first thing, so I’m trying
to apply precision medicine to heart failure. I’m working on a particular heart failure that’s called heart failure
with preserved ejection fraction because this particular
type of heart failure doesn’t have as many
therapies available to them. And so I’m trying to apply the
idea of precision medicine. So these are different things you can add but I’m particularly looking at omics and health systems data to be able to find a particular
phenotype of patients that benefit from a drug
called spironolactone. And so ideally I can find a
particular phenotype of patients that will benefit from this drug, improving outcomes in these patients, and not exposing other patients to the risk of spironolactone. For example this drug
can cause hyperkalemia and we wouldn’t want to
expose patients to this risk if they weren’t going
to benefit from the drug in the first place. So that’s one thing that I’m
working on during grad school and hopefully in the future from this work we would be able to incorporate this into electronic health systems. So the idea that if a physician
wants to prescribe this drug to patients in the
electronic health record some notification will pop up saying maybe this drug
isn’t great for the patient or maybe you should prescribe
this drug to the patient, maybe we should change the dosage. So hopefully from my research we can start to generate
outcomes like that in the electronic health record. So the second thing I’m
working on is the idea. So genotype-by-discrimination interactions associated with blood pressure
in the Jackson Heart Study. So genotype-by-discrimination
interactions. So I spoke earlier about
how genetics can play a role into precision medicine but there are actually other components that can play a role in someone’s health. So in this infographic you can see here that genetics can help determine risk. Lifestyle is associated
with one’s behavior and environment and exposure,
they all play a role in how someone essentially
how their health is. And so these things can also
interact with each other although this isn’t as well understood but it is a growing field
trying to understand for example genetics by
environmental interactions. So I’m particularly interested in genetic-by-discrimination interactions because I’m looking in a population, the Jackson Heart Study is a
population of African Americans and so African Americans tend to report more
levels of discrimination. And so the idea that discrimination could potentially affect one’s risk and can influence one’s
own genetic susceptibility, that’s something I’m
interested in learning in blood pressure. I mentioned also earlier that
hypertension is prevalent in African Americans and so by better
understanding the mechanisms behind blood pressure
we can hopefully improve this disparity that we
see with hypertension in these patients. So with that being said,
so why do an MD/PhD? So Dr. Brass, he’s an MSDP
or an MD/PhD Program Director at University of Pennsylvania and he spends a lot of time
trying to convince people why is an MD/PhD program so great and why you might wanna consider it. So what he says in a journal
article, and I quoted it here, “MD/PhD trainees are
being prepared for careers “in which they will spend most
of their time doing research “or translating that research “into new therapeutic and
diagnostic approaches.” So you can see in this quote a bit of what I was interested in. So I’m interesting in
translating that research, making sure I can apply it to patients. So MD/PhDs can essentially
do basic research or they can work on translating
this research into patients. And this brings up the idea
of translational research. So just to give a background,
there is a spectrum of translational research
that can be done. We typically start at T0. T0 is the form of basic science. So what you might be most familiar with, animal studies, in vitro studies. So this is considered the foundation and the basic science that occurs. And so this research then
has to be translated. So we have essentially
four types of translation that can occur and the first
one, translation to human, this is often first in human trials. So once we have something in T0 we then have to see if it works in humans, if it’s safe in humans. So that’s T1. For T2 that’s the translation to patients. So once we see if let’s say
a drug is safe in humans then we translate it to patients who actually have the disease
to see if it’s efficacious. So that’s typically a phase two or a phase three clinical trial. So a physician scientist can
contribute in that sense. There’s T3, so this is
translation to practice. This is a bit what I mentioned earlier with the idea of implementation science. So the idea that we can learn how to
implement these findings into medical practice. Some people assume that
once the research is done then automatically it’s
accepted into medical practice when unfortunately or
fortunately that’s not true. There has to be a certain
amount of physicians that uptake a practice and then we have evidence-based guidelines and so there’s the idea
that we have to learn how to apply this to medical practice. And then lastly we have T4, so the translation into populations. So this is more like epidemiology and more population health type research. So this is the idea that once we have all
of these things settled and we realized that
it’s good for patients and it can be implemented
in a clinical practice then we wanna see if we can translate it to multiple groups to
the wide scale population and ideally we can improve public health and improve as many patients, improve outcomes in as
many patients as possible. So that’s kind of the spectrum
of translational research and you have people, scientists as well as physician scientists working on all parts of the spectrum, also kind of cross talking between these parts of the spectrum. And so this is just something that I was interested in learning about because again I wanted to make sure that I could apply my
research and making sure that it was translated into patients and applied into patients. So, just a brief overview of
what an MD/PhD program is. So this is the MD/PhD
program at Wisconsin. Thank you Wisconsin. They had a great figure. So first you would do your preclinical med school coursework. So that’s typically where you
learn pathology, histology, pretty much all the basic coursework that a traditional medical
student would go through and after that, depending on the school, you would go through clinical rotations. So at Wisconsin apparently they do 12
months of clinical rotations right after that. At UF we actually defer
this 12-month rotation to after graduate school is done. So it varies depending on the school. So this PhD research and coursework, this could be anything
depending on the school. You can have it in ya know the traditional biomedical sciences, so physiology, genetics. You can also do it in
sociology, anthropology, public health, epidemiology. And so depending on what school you go to, whatever program is available, you can essentially pursue your PhD in whatever your passion is and however you wanna make
the impact on medicine. And so again I mentioned most schools have their clinical
rotations after the PhD but there is some variation. So once you finish that
you defend your thesis and then you go to what’s called the fourth
year of medical school where you do internships and electives so where you try to figure out what kind of clinician you wanna be. And so most schools let
you kind of experiment with whether you’re interested
in pathology, radiology, cardiology, and so you get exposure to, enough exposure to find
out what is your passion for clinical medicine. So that’s the overall view of what an MD/PhD program entails. There is, like I said, some variation. What they try to do also during this PhD so that you don’t forget
your clinical skills is they’ll have some sort
of clinical component. So oftentimes it’s
shadowing, volunteering. So here we do volunteering
at the equal access clinics. So that’s a free health clinic that’s given to the public in Gainesville. So that’s an option and
so there’s multiple ways that you can kind of keep
your clinical skills intact during that PhD training. So I’ve also provided
examples of MD/PhD careers. Often people ask me okay
well you’re doing an MD/PhD, what can you do in the future? And so I’ve decided to show a few people who I’ve considered as role models as I learned over time
kind of what they do. So there’s different forms
of careers that you can have. This isn’t an exclusive list
and it’s also not to say that you have to do an
MD/PhD program to do these but these are MD/PhD people. So I don’t wanna say that
you have to do an MD/PhD to be able to contribute to medicine but it is one way to contribute. So first the most traditional
route is academics. So you would treat patients in the clinic or in the operating room, you can do research as a
principal investigator, and then you would also
teach medical students and graduate students in your lab. And so these three things are considered kind of the tenants of academics
and there is some variation depending on what that person’s passion is but that is traditionally what
we see MD/PhD and academics would do these three things. And so these people are at a heavily research
funded medical school. So University of Florida,
University of Miami, Emory, Harvard so those
kind of medical schools that are heavily research funded. So one person that’s actually here at
the University of Florida is Dr. Duane Mitchell. So he’s an MD, PhD and he
works on immunotherapy. So this is the idea that you
can use your own immune system to fight cancer. It’s an amazing concept
and so he’s the Director of the UF Brain Tumor
Immunotherapy Program. And so he’s trying to do research to be able to use immunotherapy to essentially cure brain cancer. So that’s, this is someone who’s currently at the
University of Florida and he’s just a great person
and a great inspiration for a lot of the MD/PhD students at UF. So this is someone else
I’ve also looked into, Dr. Kirsten Bibbins-Domingo. So she’s at University of
California in San Francisco and she’s a pioneer for health equity and she’s a cardiovascular epidemiologist. And what she does is a lot of work with
cardiovascular disease and helping to improve health equity within cardiovascular diseases and she has also served as the Chair for the United States
Preventative Task Force and what that is, is
essentially a task force that helps clinicians
figure out how to determine what are preventative services. So for example understanding
how to do mammograms or how to screen for colorectal cancer. This task force is, they are the people who develop these guidelines
that the clinicians follow and so she’s a pioneer
in that regard as well. So academics, after
academics there is industry. So some people go straight into industry, some transition from
academia into industry and so you can work either in R and D, so research and
development, or some people who’ve transferred in from
academia work in administration. So for example they
work as the chief health or chief medical officer. And so there’s opportunities working with pharmaceutical
companies, working with biotech. So for example Google
has a health division that some physicians are working in now and you can work in startups. So a lot of, a handful
of physician scientists do start their own businesses and they start their own startups and pursue research on their own terms outside of an academic institution. So that’s an option for some as well. So someone currently doing
this is Dr. Levi Garraway. So he is also a pioneer in
the field of cancer genomics and the idea that we can
target certain cancers and use precision medicine
to better improve outcomes for cancer patients. So he actually within the last few weeks accepted a position at Roche and he’s working as the
Chief Medical Officer there and working on product
development as well. And so this is an example
of a role in industry that an MD/PhD can pursue. Lastly that I’m gonna
talk about is government. So there are MD/PhDs that
work in public service to improve public health and they also can work on
developing health policies. So there’s a variety of places
one can work in government but these are just a few examples. So the CDC for example, the
NIH, or essentially any division that’s under the Department
of Health and Human Services. So these are just
opportunity in government again to do public service and to help develop health
policies to improve, again improve outcomes. So an example of this
is Dr. David Satcher. You might know him. He, under the Clinton administration, was the Surgeon General as well as the Assistant
Secretary for Health and before that he was
actually the head of the CDC. So he’s had quite a number
of roles in public service and he’s done a tremendous amount of work for mental health as
well as health equity, improving health equity. And so just again another example of how you can serve in
public service as an MD/PhD and improve health outcomes. So hopefully that was
a bit of an eye opener for trying to see what an MD/PhD can do and they’re certainly inspirations to me. I do have just a bit of advice that I like to give undergrads whenever I talk to them
one on one or in a group. So the first thing I advise
is to seek mentorship. This can be through graduate students, a postdoc, or a faculty member. I think that I was able
to kind of understand what I was interested in in talking to multiple faculty members and definitely don’t be afraid
to seek out that mentorship. If one of them says no that
doesn’t mean they’ll all say no. So I would definitely encourage
you to pursue mentorship and it doesn’t have to be local as well. A lot of people in my experience have been open to email mentorship as well at other institutions. So I definitely encourage
you to seek that out. The second thing is to
find what your passion or your purpose is and I would
urge you to try new things and try to figure out what your fit is. If you see something not working for you don’t be afraid to shift. I know a lot of people
are afraid to do that but if I didn’t try like
going into the business school I wouldn’t have found kind
of how I was interested in the inefficiencies of healthcare. So I definitely encourage
you to try new things and try to figure out what your passion is and use this to help drive you as you continue throughout your career. The third thing is don’t
count yourself out too early. So I didn’t think I was gonna get accepted into the management program. Again, I’m just the premed student, what would they wanna do with me? But I really wanted to pursue it and so I sent the application in and fortunately they accepted me. And so I’ve just had the mindset to even if I’m discouraged
or something like that I still want to apply
for as high as I can go. Even if I don’t think
I’ll get it I still apply because who knows? They might actually like your application and they see something in you that you don’t see in yourself. So I definitely encourage
you to cast your net out wide and as far as possible. And then the last thing is to persevere. So if you definitely are
interested in an MD/PhD program like that’s the one thing that
they always tell everyone, you have to be able to persevere. It can range from anywhere from
a seven to nine-year program and so being able to
persevere through that is what’s needed to come
out on the other side. And then even after that
for trying to do residency and then just continue with your career you need a lot of perseverance. So whether you pursue MD/PhD or whether you do another career I still think perseverance is needed to be able to be successful. And also ask for help. So I mentioned finding mentors
but also asking for help if you’re having troubles in a class. I know that it’s difficult with a lot of mental health issues and being able to find the
encouragement to continue. And so definitely ask for
help either from your family, either from a professional. I just highly encourage everyone
to do that if it’s needed. So that’s all that I have for today and I’d like to take any
questions if there are. (applause)

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