Why I’m getting my MPH

In truth, I’m writing this post for selfish reasons. As I gear up for my move to Philadelphia, I’m getting asked at least once a day why I want to get my Masters of Public Health. Some are asking out of genuine curiosity, others with judgmental undertones behind their questioning. I’ve found that I often give a slightly different answer to almost everybody who asks — not because I’m unsure as to why I wanted to make this move but rather because the reasons behind doing it are so multi-faceted. Now I can just tell them to go to this post to get a real perspective behind the decision.

Let’s start with the basics (because a ton of people don’t even know what it means). Public health examines the health of people at population level through scientific analysis, regulation, and constant monitoring. There are a few key disciplines or scopes through which public health is practiced and studied, the main ones being epidemiology, public health policy, biostatistics, communicable disease, public health management/leadership, social/behavioral sciences, and occupational/environmental sciences.

This very well may change as I focus my interests within the curriculum, but I envision focusing the majority of my public health studies in epidemiology and public health policy, likely with a hint of biostatistics.

My initial general interests in public health developed in wake of my medical experience abroad during my undergrad years where I traveled to Honduras and Peru a couple of times for medical mission trips in order to provide relief in the forms of free medical & dental care to those in most desperate need of it. In addition to running the medical & dental clinics and the pharmacy, we spent time working on public health projects where we would help out with the construction of a school, bathrooms, staircases in order to assist in navigating the challenging terrain, and more.942097_10151933185414848_2089381592_n.jpg


One of the most astonishing and impactful takeaways I had after my travels to Peru in particular was the lack of access to clean drinking water that citizens had just a few miles on the outskirts of Lima, the capital city of Peru. Their stagnant water was stored in old barrels that were inconsistently filled by privately contracted companies facilitated by the local government. There was no set of quality standards or regulations for the water itself or the barrels.

The barrels were often formerly used for storage of harmful chemicals or oil/gas (and almost certainly were not sufficiently sanitized before being recycled to folks for use of water storage). Water provided was not regulated and contained all sorts of microbes and unhealthy levels of other trace ions & elements, not to mention that the stagnant water was an environment conducive to harboring mosquitoes and their eggs, which can carry malaria.


In the clinic and in the field, I kept asking a number of questions to myself. Why were these people sick with diseases that we have vaccines and simple treatment plans for back at home in the US? What are the root causes of these patients’ presentations with simple, easily treatable illnesses? Why isn’t the government regulating the quality of the water for its citizens? Study and applications of public health answers these sorts of questions.

I ended up working with an engineering group back at WVU to get their design for water purification systems into the hands of the group I traveled to Peru with, which is a story for another day. From these experiences in the clinic and in the field, my initial interest in public health was clear and began developing from here.

My interest in public health continued to be stimulated throughout the rest of my undergraduate coursework in classes both directly and indirectly related to public health from medical sociology to the basic communication of science to the public. In my first semester of medical school, I eagerly anticipated lectures for our public health course, while many other classmates saw it as being uninteresting and nothing more than a time sink away from focusing on our more intensive and “relevant” coursework — medical physiology, biochemistry, and physical diagnosis. I finished the course wanting to learn more, and I knew the only way to make it worthwhile would be to pursue it further as a masters degree where I could spend dedicated time focusing on the field.

The clinical research I’ve been engaged on thus far in medical school have honed my interests in epidemiology centered research (the study of patterns, causes, and effects of health/disease on populations), and training to earn an MPH will lay the framework for me to not only ask valid research questions but also devise a way to answer the questions, organize & analyze large volumes of data, and ultimately answer the questions.

I also have the opportunity to leave my home state of West Virginia where I’ve spent all my life and the institution I’ve spent the past 6.5 years at — West Virginia University for a short period of time to get the MPH, after which I will return to finish my last 2 years of medical school. I would be a liar if I said the opportunity to get out of West Virginia and temporarily relocate to a big city wasn’t a small part of the calculus. I would also be a liar if I tried to say the fact that I will be earning the degree from a prestigious and world renowned university (Penn) wasn’t also a small incentivizing factor (side note — I have no idea how/why I got accepted into their program).

An additional interest of mine in the field of public health aside from the epidemiology based research and fieldwork side of things is public health policy. In the past couple of years, the political and social climates have sparked a firestorm of personal interest in politics. I hope the public health policy education and experiences at Penn will permit me to be a more knowledgable advocate for patients and the public at large in the political arena.

Lastly, I have all the confidence in the world that the educational, fieldwork, and research experiences at Penn going to pay dividends for my professional career that I hope for in academic surgery as a clinician, researcher, leader, and advocate in my future.

In the spirit of full disclosure though, I’ve saved the most important reason for my move for last. In all honesty, the primary driving force behind going to Penn for the MPH is the prospect of running into former Vice President (and maybe future Presidential candidate…?) Joe Biden on campus. He is now leading the Penn Biden Center for Diplomacy and Global Engagement and so I plan to carry his book on me 24/7 until I run into him and get him to sign it. A selfie with Uncle Joe itself would be more than worth the tens of thousands of dollars it’s going to cost to pursue this worthwhile endeavor.

In all seriousness, I couldn’t be more excited about this move for all the aforementioned reasons both personally and professionally and look forward to reflecting on my experiences up there as I endure them on this page!

To conclude, I wanted to quickly thank all of my mentors at WVU, in case they happen to stumble upon this post, for their genuine advice and support of me in considering this endeavor. Thanks Dr. Mason, Dr. Ueno, Dr. Thomay, Dana, Brewster, Dr. Knight, and Dr. Grabo. From undergrad to medical school, I have the best mentors a student could hope for.

Cheers, y’all!10361597_10152885136954848_2039906251921942080_n.jpg

Paving the way towards health care for all

“Of all forms of inequality, injustice in health care is the most shocking and inhumane.” – MLK

I am very strongly of the opinion that equal access to quality health care should not be regarded as a privilege but rather ought to be viewed as one of the most basic right afforded to all. Much of the industrialized world agrees with this notion based on the infrastructure of health care in other countries. That’s not to say, however, that health care systems in other countries don’t come equipped with numerous flaws.

The implementation of the Affordable Care Act (ACA) was a monumental leap forward in terms of getting Americans access to quality health insurance but by no stretch of the imagination was anywhere near perfect. Thanks to the ACA, 91.2% of the US population was insured, but that’s not 100%. We could do better. We should, and hopefully we will.

Also under the ACA, governmental spending on healthcare hit an all time high — comprising a whopping 18.3% of our gross domestic product in 2013 (more than any other country by about 6%), not to mention that millions remained uninsured. That 18.3% is equivalent to the entire (yes, 100%) GDP of Germany.

So it would probably be reasonable to assume that if we spent this much money on health care that we would have to be at the top of the list as it relates to health outcomes, right? Wrong. Dead wrong. A couple of the most common measures to assess the health of countries are metrics like life expectancy and infant mortality rate. According to recent World Health Organization data (from 2015, published in 2016), the US ranked 31st in the world for life expectancy. Similarly, we ranked 26th in infant mortality rate, though this data is a little older published by the Centers for Disease Control.

Do you think this is acceptable? I would surely hope not. Shouldn’t the country spending more money than any country in the world also have the best health outcomes? Does 2+2 still equal 4?

We must do better. So, how do we do it? I would argue that it starts with recognizing health care as being a basic human right and not a privilege or a luxury.

A recent article in the New England Journal of Medicine highlighted the two current potential paths forward in order to take steps in recognizing health care a a basic human right and ensuring it for all Americans

I’m not advocating for either in this post at this point. Not enough is clear about either option to take a strong stance. One thing is becoming more clear though. Americans feel that the federal government is responsible to ensure health care for all Americans by a recently reported 60 to 39 margin.

At this juncture, are at a fork in the road as it relates to obtaining universal coverage for all Americans.

Road one — single payer
Road one is probably more familiar to you as it is undeniably more polarizing policy proposal and it was recently introduced in Congress — Senate bill S.1804 introduced in September by Senator Bernie Sanders. Under this piece of legislation, all health care would transition over a 4 year period to replace all current public and private health insurance programs (aside from veterans health care and Indian Health Service) with a government-run system for all. Under this system, private options for health care coverage would be nonexistent.

All Americans would be provided with coverage for “essential health benefits” as outlined by the current legislation, the ACA. Longer term health care would be provided through similar avenues as they are now via Medicaid, funded by contributions from both the federal and state governments. Some older folks would still have the option to buy into Medicare throughout the 4 year transition period in order to grandfather some folks into the new prospective health care system. It’s worth noting that perceptions of a single payer system are not favorable as a majority but that a third of Americans are in favor of the idea, which is a 12% spike in favorability compared to 2014 numbers.

A single payer system would require a difficult transition wherein over 300 million Americans would be required to give up their current insurance policy and be forced to rely on the government to ensure a smooth transition as well as their access to quality health care, which is a reasonable concern given the shortcomings of the initial ACA rollouts. Additionally, the article notes that funding for this sort of solution would require a tax increase unlike any other. This would require a reliance on employers to take the money not spent on providing health care for employees and use it to increase wages, an extremely shaky pole to lean on.

The key pro’s here are two-fold: 1. that this sort of centralized and unified solution (if done correctly) is a powerful message that Americans do value equal and affordable access to health care for all and 2. This type of health care reform would certainly decrease administrative costs associated with providing health care, which currently is a substantial burden on the cost of health care in the US.

Road two — incremental expansion
Road two is quite a different mean to a potentially similar end, that involves expanding and extending the type of coverage that 90% of insured Americans already have (Medicare, Medicaid, and employer-provided privatized insurance).

The idea here would be to expand Medicare to allow persons under 65 to enroll, which could provide the added benefit of lower premiums for younger workers by removing the older (and typically more costly) folks onto the Medicare plan. This would also result in cheaper premiums for the employer, which could make providing insurance for employees more financially feasible. Additionally, Medicaid would be expanded based on an increase in the income threshold that determines eligibility for enrolling in the program.

Pro’s here include not forcing people off of their current health insurance policy but rather truly expanding policy to make coverage feasible for all. Cons that fall under this sort of concept include the realization that merely expanding current networks will not be conducive to a decrease in health care spending. Additionally, it would require lots of coordination and reliance on states. For example, this plan would have to rely on each and every individual state to expand its Medicaid enrollment income eligibility threshold, which varies massively from state to state.

While the path forward is unclear, a few things are clear.
1. We must do better. The US provides the best health care in the world for those who have access to it. It’s time that we give access to all Americans, while making sure that the access citizens have remains the best in the world.
2. We must decrease our spending on health care. All too much money is being thrown into a raging fire that is the American health care system. The > $3 trillion we spend annually on health care for the current outcomes we have in this country is a massive problem that must not be overlooked, regardless of which of the two roads we choose towards universal health care.
3. We need to get everybody covered. We should not rest until not 97,98, or 99% of Americans are covered but rather until every single American is insured and has access to quality and affordable health care.

“The work of a physician as a healer cannot stop at the door of an office, the threshold of an operating room, or the front gate of a hospital … To try to avoid the political fray through silence is impossible … Either engage, or assist the harm.”

*For the purposes of full disclosure, this opinion piece I wrote was accepted for publication on Doximity’s Op-(m)ed blog. That said, I still retain the rights to the piece, which is why I’m still able to share it on my personal blog.*

The flu vaccine: Good enough isn’t, but it has to be for now

As December has rolled in, flu season is upon us and will soon be in full swing. If Australia provides any indication, which it often does, of what we might be in store for here in the US, then we are likely in for a rough season. In the time leading up to flu season, scientists in the US always pay close attention to influenza trends in the Southern Hemisphere in places like Australia to provide an idea of what we might expect in the States.

Data coming out of Australia is causing concern amongst scientists due to record high numbers of case incidence and outbreaks in the country in addition to increased numbers of hospitalizations and deaths per year due to influenza.

Flu season, the seasonal flu vaccine, and discussion of the prospect of a universal flu vaccine was discussed in a recent New England Journal of Medicine article authored by Paules et al.

Millions of people worldwide come down with the flu each year, and hundreds of thousands die as a result of the flu annually. People I talk to and information I see on social media sometimes ignorantly stakes the claim that this issue is not centric to the United States, which couldn’t be farther from the truth. As the article correctly states, the United States is burdened with anywhere from anywhere from 140,000 to upwards of 700,000 influenza-related hospitalizations and thousands die annually right here in our backyard at home.

Influenza is subject to a process known as antigenic drift, where the the virus’ proteins change over time. It is because of this process that new flu vaccines come out every year based on data from elsewhere in the world regarding what antigenic changes are occurring.

Sometimes the annual influenza vaccine is not as effective as intended due to changes in the antigens on the virus after it has already been decided what antigens the vaccine for that year will target. Alternatively, a strain of the virus with a different set of antigens could predominate over the predicted strain for that year. By no stretch of the imagination is it a guessing game, but rather the annual vaccine composition is a calculated prediction based on worldwide data.

Keeping this in mind, there are years where the vaccine is largely ineffective such as the vaccine in 2014-15 where the vast majority of the circulating strain in the United States differed from that year’s vaccine as mentioned in the NEJM article.

Despite the imperfections of the annual vaccine, it undeniably remains an essential public health tool and IT IS ALWAYS BETTER TO GET VACCINATED THAN NOT. Based on data put forth by the Centers for Disease Control (CDC) in the United States, it is likely that tens of thousands of cases of the flu in the United States alone every year. Get vaccinated. Flu season is already upon us, but if you still haven’t gotten vaccinated it isn’t too late. Every major pharmacy still has flu shots. I even just got my own relatively recently. An ironic aspect of medical school is that while it is a duty of ours to promote and encourage patients to make smart choices for the sake of their health, we sometimes don’t have the time to do the same for ourselves, but I still found time. It takes 15 minutes.

Given the imperfections of the flu vaccine, the NEJM paper makes the claim that we can do better. I agree. I think we can and we will. Ideally, with time, researchers will continue to work diligently towards a universal flu vaccine that is capable of providing adequate coverage for the virus despite its antigenic changes. The work for does not stop and will not stop, as it shouldn’t, until a universal vaccine is available for all. However, if this was an easy thing to accomplish, it be available already.

Going skin deep: Is a tattoo ethically binding?

There’s currently an image in heavy circulation making its way around the internet of a hospital patient’s chest tattooed with the words “Do **not** resuscitate”, accompanied by what is assumed to be the man’s signature. This 70 year old patient arrived at an emergency department unconscious with elevated blood alcohol levels. He did not have any form of identification on him, and his healthcare providers did not have an identifiable means by which they could contact the patient’s family.

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Photo credit to the New England Journal of Medicine and the

The healthcare team was unable to reverse the man’s unconscious state and were left wondering whether or not it was appropriate to continue care, or should they honor the patient’s tattoo. A DNR order is a medical order written and signed by a doctor and the patient that instructs care providers to not do cardiopulmonary resuscitation (CPR) if a patient’s heart stops or they stop breathing.

This patient’s case, including the picture of the tattoo, was recently published in the New England Journal of Medicine.

The doctors and nurses taking care of this patient initially continued treating the patient so as to “not choose an irreversible path when faced with uncertainty”, so they began resuscitating the patient. However, an official DNR order, which requires informed consent of the patient and acknowledging signatures by both the patient and their doctor, was eventually found. With this additional evidence, it was decided that the patient’s wishes ought to be honored. Care was withdrawn, and the patient passed away.

Reading this paper for the first time was perplexing in many ways from my perspective. Imagine inserting yourself into the shoes of that patient’s doctor and how you might react. Take away the official document, which supported the message of the tattoo and patient’s signature.

What if there was no DNR order officially signed by the physician and the patient? What if you were this unconscious patient’s physician and had no other data or information off of which you could make your decision? A critical question that comes to mind is whether or not that tattoo currently reflected the wishes of the patient. It’s tough.

Honestly, I don’t believe there is a truly right or a wrong answer, which is a scary reality because the ramifications here are life versus death. Since the time of this article’s publication on November 30 in the NEJM, many health professionals have taken to social media to voice their opinions on the matters surrounding how this case should have been approached (see this Tweet and its thread of responses). Seemingly everybody has taken a different stance on the matter. To me, this is not surprising because an issue like this requires much moral and ethical consideration.

In the ethics course at my medical school, the most interesting aspect of the course were our group discussions. The groups consisted of a small number of medical students, a physician, a hospital chaplain, a member of the hospital ethics team, and a lawyer. We would discuss different challenging cases, requiring us to defend how we would plan to manage the care of a patient and their specific ethical issue. Should you transfuse with blood products? Should you operate? Should you intubate? Should you withdraw care? When push came to shove in many instances, these overarching questions, with implications of live and death, were the questions we had to ultimately ask ourselves. The answers are often not clear cut. They are challenging. These sorts of questions inherently require us to draw upon our own experiences, moral compasses, and value systems in order to make an ultimate, often life-altering, decision on behalf of another human being.

Another key takeaway I had after finishing my medical ethics course was how important it is to keep a few ethical principles in mind when considering these sorts of dilemmas. Autonomy, beneficence, justice, and nonmaleficence.

Autonomy is a respect for the patient’s wishes, but it’s not quite that simple. While the patient ultimately makes decisions regarding their medical care, physicians must first create an environment wherein the patient can make an informed decision. The concept of beneficence centers around the idea of maintaining the welfare of the patient at the forefront of the physician’s intents and actions. The principle of justice is the obligation of the physician to do what is fair and just for the patient. Lastly, nonmaleficence centers around that common catch phrase amongst physicians for them to do no harm.

All this is to say that when it comes to making some of the toughest decisions related to medicine, the answer is almost never obvious. There is often no gold standard of practice or meta analyses of data on which we can base our decision. It just goes to show the humanity of healthcare providers, and we must have confidence not only in our medical training but also our moral compass in order to do what is right for the patient.

*For the purposes of full disclosure, this opinion piece I wrote was accepted for publication to be shared on kevinmd.com as well as Doximity’s Op-(m)ed and will be available there as well in the very near future. I’ll edit the blog to link the articles in when available. That said, I still retain the rights to the piece, which is why I’m still able to share it on my personal blog.*

This could be interesting… Or maybe it won’t be.

I’ve often thought about starting a blog/website for a few different reasons. I’ve always liked the idea of getting my thoughts down on paper (literally and/or figuratively) but never thought it through enough to develop a means by which I really felt compelled to do it and more importantly, do it consistently.

I also like to think that at least a few of my ideas, experiences, reflections, etc. are worth sharing with others whether it be for the purpose of education/learning, humor/entertainment at my expense, or just to let others know they aren’t alone when it comes to things that aren’t so fun to talk about.

I like to think of this as a jumpstart on my 2018 New Year’s resolution.

If there ever will be a time for me to get into the groove of this, it’s now as I take time away from medical school, which I’m sure I’ll be posting about on here at some point.

You can expect me to share content from all aspects of my life, ranging from medicine/science to running/training and finding awesome coffee & books plus mantras that inspire me and keep me going. There also might be the occasional political rant thrown in there too. ***YOU’VE BEEN WARNED!***

I hope that in time as I continue to populate the page with content, everybody who checks it out will find a shared interest or a common ground on some level.

Hopefully the elimination of net neutrality doesn’t end up hindering you guys’ ability to access this site… Oh no… I just thought about that. And I already got political in my first post. Shoot. ANYWAYS.

If nobody else, I’m sure my mother and grandmother will frequent the site to boost my page views and probably my sister/friends as well for the purpose of poking fun at me (Hi Mom & Nanny but not you, Karly).

Happy to have you along for the ride! This could be interesting… Or maybe it won’t be.

Cheers, y’all!