Throughout medical school, I broke up the monotony of studying for hours on end by training for endurance sporting events. It was easier to get through all-nighters and tests when I knew I had a half-marathon to run at the end of the week. But eventually, up to 20 hours of training per week started to seem excessive on top of my studies. If I wanted to continue training, it would have to be for a more meaningful purpose than simply relieving medical school stress, I decided.

After researching several options, I found Ride for World Health and knew instantly that it was what I’d been looking for. Ride for World Health is a nonprofit that promotes education, advocacy and fundraising to combat global health disparities. Its cycling team completes a 3,700-mile cross-country journey each year from San Diego to Washington, D.C. The 16 team members, who are mainly medical students, raise money to support world health and teach Americans about international health initiatives via a coast-to-coast lecture series, which they present in most of their destination cities as they pedal across the nation.

Ride for World Health was a way for me to combine my two greatest passions, world health and cycling. As I write, our team is in Louisville, Ky., and well over 2,500 miles into our ride.

I first became interested in world health during my first summer of medical school, when I volunteered in the mountains of central-western Mexico. The Tarahumara, an indigenous tribe, lives and works in these mountains. The tribe is isolated from most of the developed world. As I traveled through the mountains making house calls, working in small clinics, and helping out in a missionary hospital, I saw many medical problems that I couldn’t imagine seeing in the U.S. These problems came from the area’s tuberculosis epidemic, extreme poverty, malnutrition and lack of clean drinking water. After I witnessed the great health disparity between the U.S. and one of its neighboring countries, I became more interested in learning about other global health problems and what people are doing to correct them.

Spreading the word

As a lecturer on the Ride for World Health team, I have not only educated others on world health issues, but also learned a great deal about them. In our lectures, we often discuss the eight United Nations Millennium Development Goals, created by the UN in 1990 to be completed by 2015. The goals include primary education for all, gender equality, drastic reductions in child mortality and infectious diseases, and an improvement in maternal health. A few of the goals have already been met, and global health leaders are working hard on the others.

During this trip, I’ve been lecturing on noncommunicable diseases (NCDs) and what steps can be taken worldwide to prevent and reduce the occurrence of these illnesses. NCDs are often overlooked as the UN prioritizes the aforementioned development goals. However, NCDs contribute to 36 million worldwide deaths annually and, according to the World Economic Forum, drive 75% of global health care costs. Most people consider these chronic diseases, such as diabetes, cancer, and heart disease, to be problems of developed countries, but 80% of the 36 million deaths occur in low- and middle-income countries, according to the World Health Organization.

So far on this trip, I’ve given talks to elementary classrooms, community and church groups, and medical students and professionals. I’m hopeful that the knowledge and awareness we are spreading across the country will inspire others to create new opportunities for improvement of world health.

Life-changing experience

As I mentioned, we are more than 2,500 miles into our trip and will be nearing the end in two short weeks. On this refreshing break before my residency starts in July, I’ve had a chance to focus and reflect on why I am entering the medical field. Participating in Ride for World Health has further solidified my desire to help others and better their lives. I’ve also built relationships with other medical students from all over the country going into nearly every medical specialty. I am the only osteopathic medical student on the team, and I won over my teammates by providing post-ride manipulation sessions.

Aside from the reflecting, teaching and fund-raising, our team has enjoyed an abundance of unforgettable moments and laughter. The riders come with a wide variety of biking experience. One rider had only ever been on an indoor trainer, but after a few weeks and a couple of “learning falls” she was biking like a seasoned rider. We’ve ridden 10-plus days so far, which is enough for anyone to feel comfortable on the bike. At night, we stay in churches, community centers and school gyms. The sleeping arrangements lend the trip a summer-camp vibe and allow more of the money we raise to go directly to our beneficiaries.

We’ve enjoyed gorgeous views from the tops of mountains to the middle of deserts and everywhere in between. Sampling the food from across the country is a definite perk as well. Some of my favorites include date milkshakes in Dateland, Ariz., a town flush with date trees; green chili hamburgers from Blake’s Lotaburger near Albuquerque, N.M.; and barbecued brisket and chicken from Interstate Barbecue in Memphis, Tenn.

But the most enjoyable part of the ride by far is talking with people we meet along the way, whether they stop us as we ride, attend one of our lectures or meet with us in their community. People start out curious about why we are riding and then become inspired and eager to take part in improving world health. For instance, one couple who pulled over on the roadside to ask us about our trip donated $200 on the spot after learning about our mission.

I would recommend Ride for World Health to any medical student who is interested in cycling and world health. The organization’s website has more information about our trip and participating in future rides. All medical students can partake regardless of their biking experience or knowledge of international health issues. Personally, I’ve found teaching and learning about global health to be endlessly rewarding. Ride for World Health has been a life-changing experience for me. With all I’ve seen and learned so far, I’m even more psyched to incorporate world health into my future career as a DO.

Blake Middleton, OMS IV, will graduate this month from the Oklahoma State University Center for Health Sciences College of Osteopathic Medicine in Tulsa.

But on softball night, the clouds of dust kicked up by runners sprinting toward first base takes on an almost ethereal glow.

Yes, it could be just the field lights reflecting off the Coccidioides immitis-laden particles. But I like to think of the dust as a little accoutrement to an always mystical night when 10 to 12 medical students take an hour-long study break to play softball.

According to our academic calendars, we second-year medical students shouldn’t have time for school yard games.

Monday through Friday, for three to seven hours per day, we sit in the same auditorium with about 250 of our future colleagues and absorb the lecture material. When not in class, we are expected to digest the day’s new knowledge, while recalling information studied as early as yesterday or details learned two years ago.

On top of all of this, we should be conditioning ourselves to pass the eight-hour long board exams that we’ll take at the end of the school year. If we survive the second-year licensing-exam gauntlet, we may advance one year closer to becoming real-life physicians.

Between studying for school and prepping for board exams, a medical student may have difficulty finding the time for anything other than being a medical student.

Somehow—whether it is for our sanity, for our friendships, for our procrastinating tendencies—my intramural softball teammates and I make the time.

“You have to keep your life balanced,” says Richard J. Van Tienderen, OMS II, an intramural softball player at the Midwestern University/Arizona College of Osteopathic Medicine in Glendale. “If I studied all of the time, I’d go crazy.”

First-year fouls

When I emerged from the first-year exam season known as “Black January,” I recognized my incessant studying and school-centric lifestyle were taking a toll.

My life lacked balance: I slept when I could, ate what I could, and moved as necessary. If you didn’t go to class or study on the library’s third floor, I probably didn’t know you.

But one winter day, as I made my daily trek to the library in the desert heat, a classmate asked if I wanted to join his softball team.

“It’s just intramurals,” he said as I tried to remember the last time I actually picked up a softball. “It’s lower division.”

I’ve never been one for team sports and athletics. I cling to my schoolwork like a safety blanket and take pride in my English degree from the all-female Wellesley College. I’ve done yoga and jogged about the neighborhood, but ask me about sports and how to play them … people still remind me that I cannot run through second base.

The chance to hang out with my classmates in a setting other than a dimly lit lecture hall or a fluorescent-lit library, however, was too good to pass up.

And besides, strengthening my friendships and my body while giving my mind a little respite could only improve me for the better: That’s Osteopathic Medicine 101.

I never bothered to ask him, “Why me?” because I suspected it had to do with the game’s rules that called for two female players on the field. I just asked him, “When and where?” so I could show up and play ball.

Timeout

Generally, medical students are perseverant, lifelong students. We sit quietly, reading books, taking notes and prioritizing schoolwork over weekend parties. There are those of us who may almost brag about our lack of sleep or how many board-exam prep questions we have yet to answer as if to prove our commitment.

We tend not to discuss what we do when we’re not studying.

But one of the goals of an osteopathic physician is to find and promote health: the dynamic balance of mind, body, and spirit.

And no matter how much we may want to deny this, we can’t always be concentrating.

Elizabeth Lehto, OMS II, and Shireen Rabiei, OMS II, play pingpong like the amateurs that they are, but the Californians laugh as they whack the plastic ball into the ceiling lights. They are all giggles when they smash the ball across the community game room, narrowly missing their spectators.

Mark McPherson, OMS II, even finds his study timeouts to be essential learning tools.

“Breaks are absolutely necessary,” says McPherson, who likes to work up a sweat at the gym when not studying. “My studies tend to be more effective if I have a time frame to work with.”

The Big Blue Veins

Back at the softball sandlot with those glowing dust clouds, I step into the batter’s box.

With my hair in a high ponytail, my white visor and my personalized royal-blue team shirt stamped with the number 24, I stare down the pitcher. No longer the first-year female softball rookie, I’m now a second-year veteran player for the Big Blue Veins.

Not much has changed since last year. I’m still clueless about sports. I’m only beginning to understand how rightfield and catcher positions can be game changers. My hand-eye coordination has not improved.

But I’m a happier person than I was last year.

Intramural softball gave me the opportunity to slow down, spend time with classmates and make friends for at least an hour each week throughout the spring.

In the Big Blue Veins’ dugout, I would often find guys from the Sigma Sigma Phi osteopathic honor fraternity talking sports. I would also find some of my teammates’ significant others and their growing families, who provided me with a lifeline to the world outside of medical school.

“[Softball] is a good mental break for the students,” said Shabneez Khan, a sales strategist from San Francisco who is married to the team’s pitcher, Shamroze Khan, OMS II. “It helps students be part of something active outside of class.”

Sadly, those charmed nights on the baseball diamond when I’d join my teammates in putting down the books and picking up bats are over.
Next year, Big Blue Veins players will be scattered throughout the country, working hard and learning lots about medicine and themselves during third-year clinical rotations.

“I know I want to be some form of doctor,” says Daniel Orosco, OMS II, of Camarillo, Calif., who will return with his wife to their home state.

Like Orosco, many on the team have yet to commit to a particular medical career path.

But as medicine forever pushes us to do more than we have time for, I hope that we don’t lose sight of the important things and people in our lives.

Healthy medical students should beget healthy physicians; healthy physicians should beget healthy patients.

And for the past two years, making time for my softball study breaks has proved nothing but therapeutic.

Leslie Tamura, OMS II, attends the Midwestern University/Arizona College of Osteopathic Medicine in Glendale.

When she had free time, Dr. Copley tried to relax by taking walks, hiking and cross-stitching. Then something changed. She gradually noticed that her favorite hobbies no longer brought her pleasure.

“I felt like I just didn’t care anymore about the things that I used to as far as interests or being around people or being around my family,” says Dr. Copley, who is now finishing her final year of an internal medicine residency in Norton, Va.

Dr. Copley realized she needed help, but had reservations about speaking with her family physician, who also happened to be her attending.

“I didn’t want him to think differently of me or think I was overreacting,” Dr. Copley says.

Eventually, Dr. Copley decided the pros of seeking help outweighed the cons. She discovered that her worries were unfounded. Her attending was very receptive to her concerns, she says, and he treated her for depression. She says medication, along with the easing of her hours, helped.

“I started noticing a difference in my mood in a couple of months,” she says. “And when my intern year stopped, that helped a whole lot too. I was working fewer hours, and I wasn’t on call as much.”

As a physician who has struggled with a mental illness, Dr. Copley isn’t alone. And like her, many physicians are reluctant to seek help. But a lot of them never overcome the personal and professional barriers to treatment that they face.

Fears of stigma, confidentiality breaches and professional repercussions are common reasons physicians don’t obtain treatment for depression and mental illness, according to a recent General Hospital Psychiatry study.

Physicians commit suicide at a higher rate than the general public, and medical students are more likely to struggle with depression than their peers, studies suggest. The misgivings physicians and medical students often have about getting help stem from their role as healers.

“As physicians, we’re trained to block out our own personal emotional issues and focus on our patients, our patients’ families and others,” says psychiatrist Daniel E. Wolf, DO, who practices in Seattle. “And a lot of doctors are not going to talk about things that they think others may view as weak or vulnerable because they think, ‘We’re the doctors and we’re supposed to fix people, not need help ourselves.’ ”

Nearly half of respondents to a 2005 survey of British physicians said they had an episode of depression at some point, according to the International Journal of Social Psychiatry. In addition, 7% of respondents said they self-prescribed antidepressants, citing confidentiality worries and a desire to handle the illness themselves.

Psychiatrist Blake Casher, DO, says confidentiality is a common fear.

“A lot of physicians may not seek help because they are afraid that it’s going to go on their record somehow and it will come back and hurt them, whether it’s with their license or with their hospital or another affiliation they have,” says Dr. Casher, an associate clinical professor of psychiatry at the Michigan State University College of Osteopathic Medicine in East Lansing.

Dr. Casher has let his physician patients enter through his office’s back door so patients and acquaintances wouldn’t see them in the waiting room. He notes that mental illness still carries a stigma that physical illness doesn’t.

“People may feel that somebody who’s had a history of depression is unstable,” he says. “It’s not that different, medically, from somebody who has a heart condition. But people don’t look askance at someone with a heart condition.”

Beyond general concerns about reputation, many physicians also harbor fears that seeking help could have far-reaching professional consequences.

Checking the ‘Yes’ box

State medical boards have a history of asking license applicants whether they have had a mental health problem. Physicians worried that seeking help could result in license problems, says Warren Pendergast, MD, the president of the Federation of Physician Health Programs, a nonprofit that provides resources to the state programs that help and advocate on behalf of physicians with psychiatric and substance-abuse problems. However, a physician who reveals his or her history of treatment for mental illness will not necessarily encounter license problems, Dr. Pendergast says.

Moreoever, state medical boards are evolving how they fulfill their obligation to protect the public from unfit physicians while respecting physicians’ wishes for confidential mental health treatment. Some states have even removed questions about physicians’ mental conditions.

“It’s better than it used to be,” Dr. Pendergast says. “More states are encouraging physicians to get help and not asking them this question. The states are encouraging physicians to get help through their own doctors or through physician health programs.”

Seattle’s Dr. Wolf notes that the Washington State Medical Board once asked physicians applying for an initial medical license if they ever had a drug, alcohol or mental health problem. But the medical director of the state physician health program lobbied to have the language changed. By the mid-1990s, the two organizations agreed on new language, and applicants were instead asked if they have ever had a drug, alcohol or mental health problem that is not already known to the physicians health program. The reworded question allowed physicians to seek help anonymously.

“[The medical director] got that changed specifically so that people in his program—at any time we had 100, 200 physicians in there, and now there’s more—would not be penalized for being in recovery,” he says.

Today, the language is even less specific. Applicants for allopathic and osteopathic physician licenses in Washington are simply asked to disclose if they have any medical conditions that limit their ability to practice medicine.

The extent of mental health questioning on physician license applications in other states varies widely. A 2009 study found that more than two-thirds of allopathic state physician license applications had questions pertaining to mental health or substance use that were possibly or most likely impermissible under the Americans with Disabilities Act.

Compounding physicians’ sense of vulnerability, license applications are public record in some states.

But states need to know their licensed physicians are fit for their duties, Humayun Chaudhry, DO, the president and CEO of the Federation of State Medical Boards of the United States, wrote in an email.

“Medical boards have the pre-eminent duty to protect the public, which includes licensing only individuals who are fully qualified to practice medicine,” Dr. Chaudhry wrote. “Boards must have sufficient information with which to make a good decision about granting a doctor a license to practice medicine. The answers to these questions are necessary for boards to make a thorough evaluation of a candidate.”

Among states with the most practicing DOs, Michigan, New York and Pennsylvania have license applications that do not include questions about physical or mental health beyond those about substance abuse, while California, Florida, Ohio and Texas have applications that do.

One of those states, Ohio, is currently considering modifying its questions on mental health, says Sallie Debolt, the state medical board’s general counsel. The questions protect the public, carrying out the board’s mission, she says.

“The Ohio Revised Code gives the board the authority to take action if a physician has a mental or physical illness that makes him or her unable to practice according to acceptable standards of care,” Debolt says. She notes that cases in which the state board does take action based on a physician’s mental illness are rare, and that physicians shouldn’t assume that answering yes will result in license problems.

Physician suicide

Licensing fears aside, the driven, independent nature of many physicians, which sustained them through training and into their everyday practice, can also work against them when they’re depressed.

“A lot of us are type A personalities. We’re the type of personality that thinks, ‘I can handle this, I can get through this myself,’ ” says the AOA’s 2001-02 president, James E. Zini, DO, a family physician in Mountain View, Ark. “But if you truly are depressed and suicidal, you do need help.”

Sometimes, a tragic consequence of not seeking help is suicide. Up to 400 U.S. physicians end their own lives every year, according to Medscape. The American Foundation for Suicide Prevention (AFSP) launched a suicide prevention program specifically for physicians in 2008, the organization’s only occupation-based program.

Current and reliable data on physician suicide are not readily available. A 2004 aggregate study from The American Journal of Psychiatry found that the suicide completion rate of male physicians is 1.4 times higher than the general population’s while female physicians commit suicide at 2.3 times the rate of the general public.

A recent study published in General Hospital Psychiatry found that a job problem was substantially more likely to contribute to physician suicides than nonphysician suicides. Because physicians’ identities often center around their careers, professional setbacks may be more devastating to them than they are to people whose identities are less tied to their jobs, the study’s authors suggest.

Some physicians speculate that the changing nature of medicine may have something to do with physician depression and suicide. Today’s medical environment is more stressful than the one physicians practiced in 35 years ago, Dr. Casher notes.

“Doctors are finishing medical school with huge debts,” he says. “And you’re not your own boss. Most physicians are working for hospitals or for HMOs. It’s very hard to maintain a practice anymore and have that independence. Physicians tend to prefer autonomy. They really don’t like taking orders from somebody telling them how to practice.”

External factors are slowly eroding the control many physicians have over their work, Dr. Zini notes.

“So many pressures outside of the doctor-patient relationship affect my ability to practice the art of osteopathic medicine,” he says. “Government interference. Poverty. Patients’ ability to help themselves. Doctors are becoming more and more responsible for outcomes in all these new models of treatment. These are all pressures that play a role in the health of the physician.”

Have physician depression and suicide rates changed much in the past several decades? It’s hard to say. Reliable statistics showing physician depression and suicide rates over time are not available, says Paula Clayton, MD, the AFSP’s medical director.

Depression and medical school

Different pressures test the mental health of medical students: living up to expectations, jam-packed schedules, tests, homework. Brian Denny, OMS II, whose name has been changed for privacy, has experienced depression and suicidal thoughts since he was a teenager. In high school, he learned ways of coping with his occasional depression that worked most of the time. But the stress of medical school brought his symptoms back full force.

“There would be stretches of time when I was withdrawn from people and I wasn’t really able to concentrate on my studies,” Denny says. “And the week before exams I was just really withdrawn. It got to the point where it was affecting my grades, so I had to talk to my adviser and my friends.”

Eventually, Denny worked with his school’s education specialist, who helped him change his study habits, which led to reduced stress. He says the school’s faculty has been extremely supportive.

“When my grades did slip, there was always my faculty adviser or another faculty member keeping track of students’ progress, and someone would talk to me about what’s going on to make sure I was OK,” he says. “That helped me a lot, just having someone come check on me every once in a while.”

Medical students’ concerns about mental illness are similar to those of physicians: They worry that asking for help may impact their reputation or standing. But Denny says he doesn’t feel like there’s a stigma to seeking help where he attends school. In fact, he has a few friends there who also struggle with mental illness.

“Everyone here is going through the same process, and they know the stress is there,” he says. “So nobody is going to make fun of you for getting the help you need.”

The depression rate in medical students is more than double that of the general population, Inside Higher Ed reported in 2009. And mental health worsens as students progress through medical school, according to survey results published in JAMA in 2009. The survey found that third- and fourth-year respondents were significantly more likely to report suicidal ideation than their first- and second-year counterparts.

Recognizing the importance of medical students’ mental health, the AOA House of Delegates passed a resolution in 2011 recommending increased awareness of depression among medical students and that those affected be provided with treatment options.

In the past few years, Bridget E. McIlwee, OMS IV, says she believes the issue has gained prominence at medical schools.

“There have been more studies and articles coming out, even in the mainstream media, pertaining to medical student depression,” says McIlwee, who graduates this month from the Midwestern University/Chicago College of Osteopathic Medicine in Downers Grove, Ill. “I think awareness of the subject is increasing, though a little bit more slowly than most people would probably prefer.”

The same year that the AOA House passed the resolution, the AOA’s Commission on Osteopathic College Accreditation independently revised its accreditation standards for medical student health care, stipulating that students of osteopathic medical colleges must be provided with confidential physical health services and 24/7 access to confidential behavioral health care services.

With these resources available to students, will they use them? McIlwee says she knows students use MWU/CCOM’s counseling center, but that others may still be reluctant.

“Even if they’ve learned about the chemical imbalances that are responsible for depression and anxiety, due to medical students’ general tendency to be perfectionists, these illnesses are still seen as weaknesses,” she says. “And this may play a big role in why students don’t seek out counseling at their schools.”

What needs to change?

Physicians say the medical profession as a whole—including regulators, educators, students and physicians themselves—needs to be more accepting of mental illness.

“The physician needs to feel like he or she can get some help and not worry about repercussions,” Dr. Casher says. “I’ve seen some physicians who will pay out of pocket so there’s no record of it, but most physicians are not likely to do that. If they could somehow be made to believe that getting help is not going to hurt them professionally, that would make a big difference.”

Dr. Pendergast agrees, noting that physicians will also self-treat rather than get help, which he says is never a good idea.

“There needs to be a change in the medical culture to make it more acceptable and appropriate to get help, rather than denying the problem,” he says. Although some have stopped, state medical boards and other credentialing bodies should not ask questions about mental health on their applications, he adds.

Physicians can help each other by reaching out to colleagues who seem depressed or aren’t acting like themselves, says Dr. Zini.

“If we see depression in our colleagues—those we have a close personal relationship with and therefore a trust relationship with—we should speak out,” he says.

For physicians who recognize depression in themselves, Dr. Zini advises them to get help as soon as possible—and to recognize that they’re not alone.

“Depression is more prevalent than most people understand,” he says. “I have treated fellow physicians. And anybody who tells you that he or she hasn’t had some depression is not being realistic. We all will have some. I have not ever felt that I was suicidal, but I’ve had colleagues who did, and they received help and are functioning well now.”

The same goes for medical students, says McIlwee, who cites the higher rate of depression among medical students when compared to their age-matched counterparts.

“There are a large number of medical students who have the same issues and the same feelings, and there are plenty of resources out there to help them,” she says.

To physicians who harbor worries about licensure, Dr. Pendergast says not getting help can cause more damage. Untreated depression is a greater risk to a physician’s license than disclosing mental illness to a state medical board, he says, because it will negatively affect the physician’s personal life and, very often, work life as well.

Most physicians, says psychiatrist David A. Baron, DO, would not hesitate to treat or refer a patient who is feeling depressed and that life isn’t worth living—and they should remember this when they think of themselves.

“Physicians need to say that we’re not supermen or superwomen,” says Dr. Baron, who is the vice chair of psychiatry at Keck Hospital of USC in Los Angeles. “And if we’re feeling the same symptoms, we owe it to ourselves and to our patients to go and get professional consultation.”

“Manufacturers still had to make products that tasted good. So when they took the fat out, they added more sugar, creating products even higher in calories,” she remembers.

A gluten-free diet benefits patients who have celiac disease, but it has not been shown to promote weight loss or alleviate the symptoms of autism or attention-deficit/hyperactivity disorder, two conditions for which the diet is hyped to treat. Such a diet, in fact, can produce harmful side effects, including weight gain and vitamin B deficiencies, says Dr. Cheney, a family physician in Lone Tree, Colo.

“As I tell patients who ask me about this diet, a lot of the products marketed as gluten-free will have more sugar, saturated fat or different types of additives to make them more palatable,” she says.

Many osteopathic primary care physicians such as Dr. Cheney, who try to persuade patients to eat healthfully and exercise, must also dispel misconceptions about diets and particular foods, ingredients and processes.

Battling ‘quick fixes’

Celiac disease affects 1 in every 133 individuals in the U.S., but that didn’t stop actress Miley Cyrus from tweeting that all of her fans should embrace a gluten-free diet for better skin.

“As a society, we want a quick fix for our problems, so we tend to believe what we see on the Internet,” Dr. Cheney says. With so many people carrying smartphones and tablets everywhere they go, erroneous information can be transmitted like never before.

“People have the University of Google at their disposal and come in with some dangerous notions about diets that I try to counter,” says Stanley E. Grogg, DO, a professor of pediatrics at the Oklahoma State University College of Osteopathic Medicine in Tulsa. One of his biggest concerns is the increasingly popular vegan diet, which eliminates all animal products.

“A vegetarian diet isn’t all bad if kids are eating eggs and cheese. But a true vegan diet without any animal protein can harm children,” Dr. Grogg says. “It can cause decreased bone density, so kids get more fractures, and can adversely affect their growth.”

Noting that “it isn’t easy to sort through all of the information available about nutrition and food choices,” the Centers for Disease Control and Prevention devotes several pages of its website to evidence-based healthful eating. While he likes this and similar government-sponsored websites, Dr. Grogg tends not to suggest them to parents.

“Many people distrust the government and would not consider these sites good, neutral sources of nutrition information,” he says.

Instead, Dr. Grogg urges parents to look at the latest “Best Diet” rankings of U.S. News & World Report. “These diets are backed by scientific evidence, and the website explains them in an easy-to-follow manner,” Dr. Grogg says.

All of the diets at the top of the list stress eating fruits and vegetables, lean protein, whole grains and low-fat dairy products while reducing salt and sugar. Dr. Grogg advises parents that such common-sense balanced diets benefit the whole family.

Adarsh K. Gupta, DO, in comparison, promotes the National Library of Medicine’s MedlinePlus to his patients and even passes out information cards touting the site’s URL. The Stratford, N.J., family physician also asks his patients to use Google Scholar rather than the basic Google search engine when looking for studies on particular medical topics.

For his part, Steve Feder, DO, a pediatrician in Boothbay, Maine, steers parents to HealthyChildren.org and the website of the American College of Osteopathic Pediatricians for nutritional and other information.

To address particular health issues, such as obesity or diabetes mellitus, DOs may suggest specific diets and food.

When patients need to lose weight, for example, Patricia J. Ausman, DO, recommends the Weight Watchers program, which is ranked as the top weight-loss diet and one of the best overall diets by U.S. News.

“Weight Watchers teaches you portion control and how to prepare your own meals,” she says. “In contrast, on a fast weight-loss diet like the Jenny Craig program, people can lose weight while they’re on it by sticking to the prepackaged meals. But once they go off of it, they gain the weight back because they’re not really taught how to eat.”

On the table

In some parts of the country, more and more patients are telling their DOs that they buy only organic produce, grown without synthetic pesticides, and organic meat and dairy products, produced from pasture-raised livestock not given antibiotics or growth hormone.

People who feel passionately about organic food often do eat more healthfully than the general population, Dr. Cheney says. “But the studies on organic versus nonorganic are up in the air,” she argues. “It’s hard to say for sure that antibiotic-free milk, for example, is much better for you because it takes years for health problems to show up that we can link to such issues.”

Because organic foods tend to be more expensive, not everyone can afford them, Dr. Cheney notes. This keeps her from recommending them to most of her patients. For patients who have the means, however, she does suggest buying the organic versions of produce eaten with the skin on.

For the most part, though, she simply asks her patients to choose fresh food over processed food whenever possible. While the jury is still out on many of the additives in processed food, these products are known to contain excessive salt and sugar, Dr. Cheney says.

Dr. Grogg urges parents from all socioeconomic backgrounds to plant vegetable gardens with their children, noting that food stamps can be used to purchase vegetable seeds. Those who live in apartments can sometimes start community gardens, as well as grow fresh herbs on their windowsills.

For patients who don’t want to garden, Dr. Cheney will suggest visiting farmers’ markets, where produce prices are typically lower than those of supermarket chains. Some patients resist her advice, however.

“Unfortunately, processed foods are cheaper and more convenient. They’re in a package and there to grab,” Dr. Cheney says. “And our American palates have become accustomed to processed food. It tastes good.”

When patients continue to buy processed food for convenience, affordability or taste, Dr. Cheney advises them to read labels. “I may tell a patient, ‘If deciding between two cans of green beans, choose the one lower in sodium, with the fewest listed ingredients.’ ”

But Dr. Ausman stresses to patients that processed food really is not more convenient.

“Patients complain that preparing food at home takes so much time, but I tell them it really doesn’t,” says Dr. Ausman, who practices family medicine in Philadelphia. “I tell my patients, ‘Don’t buy frozen microwavable food. You can make your own.’ ”

Dr. Ausman urges her patients to cook in bulk on the weekends and freeze the leftovers. “I’ll tell them that these homemade frozen meals are a lot more healthful for them and don’t have all the chemicals,” she says.

She frequently shares recipes and cooking advice with her patients.

“I was trying to get one of my diabetic patients to lay off heavy sauces,” Dr. Ausman remembers. “I told her how to cook carrots with just a smidgen of butter and tarragon. The next time I saw her, she said, ‘I never knew carrots were sweet.’ She had never truly tasted a carrot before. She had only tasted the sauces that were on it.”

So that children grow up enjoying lower-sodium food, Dr. Grogg encourages parents not to keep a salt shaker on the dining table, though he tells them that cooking with some salt is acceptable. He also advises families to use salad plates rather than dinner plates for major meals so less food will be consumed.

More or less

Primary care physicians may concur on the superiority of fresh versus processed foods, but there is less agreement on the benefits of taking supplements.

“After age 2, multivitamins are a waste of money,” Dr. Grogg says. “They go in the front end and out the bottom.”

Dr. Ausman, in contrast, recommends multivitamins and Vitamin D-3 supplements to patients.

“I think everyone should be on a D-3 supplement because we’re a nation that is D-3-depleted,” she contends. “Most of us have office jobs, and we’re not getting out in the sunshine. When we do get out, it’s usually for limited amounts of time, such as getting in and out of a car while running errands.”

The president of the Maine chapter of the American Academy of Pediatrics, Dr. Feder points out that roughly 80% of the parents he sees are already using some aspect of complementary and alternative medicine to treat their children. Rather than tell them not to use supplements or herbal remedies or other alternative modalities, he steers them toward those that have been supported by some scientific studies and away from those that have clearly been refuted.

Using The Holistic Pediatrician as a guide, he has recommended, for instance, that children with ADHD take Omega-3 fatty acid supplements, which, he says, can reduce the amount of stimulant medication needed.

Dr. Feder says he tactfully tries to disabuse parents of such fallacies as sugar or food coloring causing hyperactivity.

“I will ask, ‘What kinds of things have your heard? And what have you tried?’ ” he says. “I will then discourage them from what we know doesn’t work, suggesting options that are more promising. Knowing that your physician has an open mind about alternative medicine goes a long way toward fostering trust.”

More than any other substance, food has been credited both with causing disease and promoting health. Helping patients cut through the clutter is essential, many DOs say.

While factors other than diet affect health, there is no doubt that food has a big impact, Dr. Cheney says. “But the day we can convince all of our patients to make better choices,” she says, “will be the day we can quit practice and retire.”

Homer B. Angstadt, DO, 88 (PCOM 1959), of Largo, Fla., died April 17. Visit Dr. Angstadt’s online guest book.

Delos H. Fry, DO, 81 (COPS 1961), of Longwood, Fla., died Jan. 1.

A. Alvin Greber, DO, 80 (PCOM 1958), of Aventura, Fla., died April 6. Visit Dr. Greber’s online guest book.

Brian Liska, DO, 58 (MSUCOM 1980), of Rochester, Mich., died Oct. 9, 2012.

Deloris J. Riddlesprigger, DO, RN, 71 (MSUCOM 1980), of Southfield, Mich., died March 31. Visit Dr. Riddlesprigger’s online guest book.

Sheldon L. Sirota, DO, 78 (ATSU-KCOM 1962), of Valley Stream, N.Y., died April 21. Visit Dr. Sirota’s online guest book.

Carla D. Waller, DO, 40 (KCUMB-COM 1998), of Bartlesville, Okla., died April 4. Visit Dr. Waller’s online guest book.

“Pathologists must be definitive and honest,” says Dr. Moskowitz, who practices in northern Ohio. “When I see cancer, I call it, but I have to be absolutely sure.” Pathologists sometimes press other physicians for more complete patient histories, which aren’t always available, and they may stress the need for a differential diagnosis when uncertain about results.

Because pathologists don’t share their findings directly with patients, they can leverage objectivity, Dr. Moskowitz says.

Although many would describe themselves as introverts, pathologists need to be good communicators.

“Pathology has moved away from the stereotype of loners practicing in a vacuuum,” says David Allison, DO, in his fourth year of an anatomic and clinical pathology residency at the University of Illinois at Chicago (UIC) College of Medicine. “It is definitely a team-based field.”

Pathologists serve on hospital committees on patient safety, quality assurance and laboratory utilization, Dr. Allison says. And they collaborate with oncologists, surgeons and other medical specialists in multidisciplinary cancer-case conferences (known as tumor boards).

On the front lines of diagnosing disease, pathologists need to interact effectively with other physicians and hospital administrators—in person, on the phone and through written reports.

“We seek residents who can look you in the eye and speak well, though they don’t have to be exceptionally outgoing,” says Mark T. Friedman, DO, the program director of the anatomic and clinical pathology residency at St. Luke’s-Roosevelt Hospital Center in New York City.

Those who subspecialize in forensic pathology need especially strong communication skills because they interact with police officers and firefighters at crime scenes and testify in court, says Gregory McDonald, DO, who oversees the forensic medicine program at the Philadelphia College of Osteopathic Medicine.

Similarly, pathologists who teach need a fair amount of charisma to share their passion for the field with medical students, residents and fellows.

Though their personalities vary, pathologists tend to have one trait in common, says Candice C. Black, DO, the pathology residency program director at Dartmouth-Hitchcock Medical Center in Lebanon, N.H. They enjoy working behind the scenes and do not crave external validation.

“If you are the type of person who needs external praise to be gratified in your work, then pathology may not be for you,” Dr. Black says.

Most pathologists have minimal contact with patients, notable exceptions being those in the subspecialties of blood banking-transfusion medicine and cytology. So individuals who relish getting to know patients and receiving thank-you’s for compassionate care should probably select another specialty.

“We do care deeply about patients, however, which is why we want to get it right,” Dr. Moskowitz says. “My osteopathic training helps me empathize with patients and holistically connect the dots to arrive at an accurate diagnosis.”

Those who become pathologists typically did not enter medical school with the notion that they would train in this specialty, unless they were specifically interested in forensic pathology, popular TV shows having glamorized the work of medical examiners.

Dr. Allison became aware of pathology as a field in his first year of medical school. “In my rotations in my third and fourth year, I realized that for me the real art of medicine is in making the diagnosis,” he says. “Pathology is one of the few fields where that is your primary job.”

One residency route—ACGME

There are no AOA-approved residencies in pathology, so individuals pursuing this specialty are limited to programs accredited by the Accreditation Council for Graduate Medical Education (ACGME), of which there are more than 140.

The vast majority of pathology residents today are in four-year combined residencies in anatomic and clinical pathology, but some programs allow trainees to complete three-year residencies in either anatomic or clinical pathology if they plan to pursue a subspecialty in one or the other of these main pathology divisions.

In a nutshell, anatomic pathology involves diagnosing disease through the gross and microscopic examination of tissues and cells, as well as performing autopsies when indicated on entire bodies, while clinical pathology involves laboratory analysis of bodily fluids and tissues. General pathologists may do both anatomic and clinical pathology.

Medical students who want to become pathologists in the U.S. must take part in the National Resident Matching Program (NRMP). Students match from their fourth year of medical school—a transitional year is not required.

In the 2013 NRMP match, 583 pathology positions were available. With more than 100 applicants vying for each position, pathology appears to be highly competitive. But the prospects for snagging a residency spot aren’t as dire as they first seem because many of the applicants are international medical graduates, Dr. Black says.

“Most U.S. grads who want path will get it,” she says.

ACGME-accredited pathology residencies may favor graduates of U.S. medical schools for a variety of reasons, including number of years since graduation, the quality of medical education, perceived dedication to pathology, visa issues, and the less-than-fluent English language skills of some foreign applicants, according to Dr. Black.

IMGs sometimes gravitate to pathology, even if they specialized in something else in their home country, because they seek a specialty in which they don’t have to converse with patients, English not being their first language in many cases.

Nevertheless, some IMGs are desirable candidates because they have many years of prior experience in pathology, Dr. Black says. And some ACGME pathology programs will take an IMG over a DO, she cautions. Because she has heard the occasional MD program director make disparaging remarks about osteopathic medical education during pathology conferences, she believes that a smattering of ACGME pathology programs discriminate against DOs.

Dr. Black and Dr. Friedman are the only osteopathic physicians serving as pathology residency directors.

“I cannot show favoritism to a DO candidate, but I do think I am more open to reading the applications of osteopathic medical students because I am a DO,” Dr. Black says.

Through talking with residency program directors and residents and looking at resident rosters on program websites, osteopathic medical students can glean which pathology residencies welcome osteopathic physicians.

UIC’s pathology residency program, for example, is especially DO-friendly. Seven out of the program’s 20 residents are osteopathic physicians, including all three chief residents, Dr. Allison points out.

Best impressions

St. Luke’s-Roosevelt, which has 20 pathology residents, receives 500 or so applications each year for four to six openings. To come up with a short list of candidates, Dr. Friedman says he first looks at the credentials of the applicants who are U.S. citizens.

“We’ll look at the medical schools they went to and their transcripts, and we’ll look at their board scores,” Dr. Friedman says. He prefers candidates who score at least in the 80th percentile on the Comprehensive Osteopathic Medical Licensing Examination of the United States (COMLEX-USA) or the United States Medical Licensing Examination (USMLE).

“If an applicant failed one step of the exam once but did well on the repeat, we’ll consider him or her,” Dr. Friedman says. “But if someone has more than one failure, we’ll move on to the next applicant.”

Dartmouth-Hitchcock’s pathology residency doesn’t require a minimum percentile but expects applicants to have passed all components of the USMLE or COMLEX-USA. “I will consider someone who has had maybe one failure if he or she is a really exceptional candidate in other ways,” Dr. Black says. “But if someone takes an exam again and fails it again, that’s really a red flag.”

Dr. Friedman has noticed that three-quarters of the roughly 20 DOs who apply to his program each year have taken at least Step 1 of the USMLE. In most cases, he doesn’t recommend this.

Osteopathic medical students who have strong COMLEX scores have no reason to take the USMLE because they risk getting lower scores, which will count against them, Dr. Friedman says. Pathology program directors who look favorably on DOs are familiar with COMLEX and don’t require the USMLE.

“If you do well on COMLEX, the USMLE will only hurt you,” Dr. Friedman says. “If you didn’t do well on the COMLEX, you can take USMLE Steps 1 and 2 to show that you are capable of doing well, but you had better do well. You’re not going to get in with a bad score.”

Both Dr. Friedman and Dr. Black try to filter out individuals who are simply applying to pathology as a backup if they don’t match into their first-choice specialty.

“We look for people who are committed to pathology and love the field,” Dr. Friedman says. Enthusiasm and dedication can sometimes be gauged by candidates’ personal statements and letters of recommendation.

“We want to have a sense that the candidate has a reason for choosing pathology other than ‘Nothing else seems like a good fit,’ ” Dr. Black adds.

Residency directors also weed out applicants who pursue pathology because they think they will have regular work hours and more free time than physicians in other specialties do. “If an applicant comes to us and talks about lifestyle, we’ll say, ‘So you don’t want to work hard?’ ” Dr. Friedman says.

Osteopathic medical students who are interested in pathology need to serve elective rotations in the specialty and make a great impression, residency directors say. But it isn’t necessary to do a formal rotation at every place one is applying for residency.

“If you are interested in pathology, do a few rotations and try to excel,” Dr. Allison advises. “Work hard. Be at the training site all day. Do what you’re told. And keep up with the reading. Outdo yourself and get good letters of recommendation from the supervising faculty.”

Medical students who want an overview of the specialty can read Robbins and Cotran Review of Pathology, which is the field’s bible, according to Dr. Allison.

To help decide whether they want to become pathologists, students can do an observership in a medical center’s pathology department. Essentially an intense shadowing experience, observerships don’t offer academic credit. But they provide an opportunity for students to not just find out about the field but also make a positive impression that could lead to an elective rotation and ultimately a residency later on.

Dr. Moskowitz recommends that individuals interested in pathology apply to many different programs. Being flexible about location helps ensure that one will land a position, he says.

But pathology candidates should carefully assess each program they are applying to, Dr. Friedman advises. The St. Luke’s-Roosevelt pathology residency, for example, is a medium-sized program for training “meat-and-potato generalists,” he says.

Individuals who know before residency what subspecialty they want to pursue should consider programs at institutions with the desired fellowship. Those planning on careers in academia should look at large programs affiliated with universities that focus more on research.

“You really have to do your homework,” Dr. Friedman says. “Talk to as many people as you can at different programs.”

Beyond residency

More than 90% of pathology residents go on to complete one of more than 20 types of subspecialty fellowships, and some do more than one, according to Dr. Black.

“Nowadays you have to do subspecialty training because no employer will take you out of a four-year program,” Dr. Friedman says. “Most of our residents are doing not just one but two fellowships.”

Anatomic pathology subspecialties include cytopathology, forensic pathology, gynecologic pathology, dermatopathology, breast pathology, and bone and soft tissue pathology, as well as pathologies of each organ system, from cardiovascular to gastrointestinal and hepatic.

The subspecialites of clinical pathology include hematopathology, cytogenetics, blood banking-transfusion medicine, molecular pathology, medical microbiology and clinical chemistry.

Almost all pathologists, DOs as well as MDs, become board-certified by the American Board of Pathology (ABP), a member of the American Board of Medical Specialties (ABMS). But DOs also have the option of being certified by the American Osteopathic Board of Pathology (AOBPa).

“A lot of DO pathologists don’t know about us,” says Dr. McDonald, DO, the AOBPa’s immediate past chairman.

Dr. Moskowitz is AOA-boarded, which allows him the same hospital privileges and ability to participate in insurance plans that being ABMS-boarded would.

Being AOA board certified, moreover, would be an advantage for pathologists who seek administrative positions at osteopathic medical schools or who want to develop and direct AOA-approved pathology residencies and fellowships in the future.

Dr. Black, however, doesn’t see the point of taking board certification examinations that are not linked to one’s pathology training. To take both the ABP and AOBPa boards would be prohibitively expensive, unnecessary and cumbersome, she says. Dually boarded osteopathic physicians must satisfy both ABMS maintenance of certification and AOA osteopathic continuous certification requirements.

Once in practice, pathologists usually are employed by hospitals or by practice groups that contract their services to hospitals, while some work for private laboratories or pharmaceutical companies. The pay for pathologists is in the mid-range for medical specialties—$221,000 a year on average, according to a 2012 Mescape survey.

Although residency directors don’t want candidates to bring up the topic of work-life balance during their interviews, pathologists do have more manageable hours than most physicians, Dr. Moskowitz says.

In addition, pathologists can have exceptionally long careers. Because pathology is not as physically demanding as most other medical specialties, pathologists can practice well into their 70s and even into their 80s.

“The career prospects for pathologists are excellent,” Dr. Black says. “We’re about to have a big shortage of practicing pathologists in the U.S. because a lot of very old pathologists are about to retire.”

The great thing about the osteopathic medical profession is that we have the ability to make miracles happen. We do it through research, built through collaboration on a foundation of science. The AOA is advancing research through several bold new initiatives, but the fact remains: We can, and should, do much more.

Advancing osteopathic research

Over the course of my AOA career, I have personally observed “miracles” evolve from research conducted by DOs. The Multicenter Osteopathic Pneumonia Study in the Elderly evaluated the efficacy of osteopathic manipulative treatment in treating elderly patients with lower respiratory infections. Terrie E. Taylor, DO, distinguished professor of internal medicine at the Michigan State University College of Osteopathic Medicine in East Lansing, continues her efforts to eliminate malaria in the African nation of Malawi. Diabetes care is being transformed in Appalachia thanks to research led by Jay H. Shubrook Jr., DO, at the Ohio University Heritage College of Osteopathic Medicine in Athens, while the research of Leonard H. Calabrese, DO, in Cleveland breaks new ground on the benefits of empathetic care provided by DOs.

But these rigorous efforts will be threatened unless the AOA and rest of the profession support them. The AOA Council on Research is taking the lead on a strategic direction for osteopathic research. The council drafted a 10-year strategic plan for the profession’s research through multi-stakeholder discussion and teamwork, which was approved by the AOA Board of Trustees in March.

The council’s plan makes recommendations, suggests strategies, identifies responsible parties, and defines a timeline for advancing osteopathic medical research over the next 10 years. Everything depends on funding, however. Should it receive funding, the plan envisions several outcomes, including cultivation of active research cultures on our medical school campuses, publication of hundreds of peer-reviewed original manuscripts, and establishment of our profession as a leader in investigating manual medicine and in coordinating and disseminating such research.

Teamwork with AOA official family

Clearly, the AOA by itself cannot accomplish the goals of the council’s strategic plan. Thankfully, we have many supporters, including the Osteopathic Heritage Foundation in Columbus, Ohio, which for years has provided generous funding for AOA grants, enabling several published research projects. We hope to work further with the foundation in the coming years. The American Academy of Osteopathy (which has developed its own strategic plan for research) and the AOA have formed a small task force to discuss how we might collaborate.

Such collaboration is critical, as we know the impact osteopathic medical research can make when funded and well-done. An example is a trial led by John C. Licciardone, DO, that was published in the March/April issue of Annals of Family Medicine. Conducted at the Osteopathic Research Center in Texas and funded by the National Institutes of Health—National Center for Complementary and Alternative Medicine and the Osteopathic Heritage Foundation, the trial examined OMT and ultrasound therapy in the treatment of 455 adults with chronic low back pain. Patients who received ultrasound therapy did not see any improvement, but patients who received OMT saw significant improvement in pain, used less prescription medication and were more satisfied with their care. Dr. Licciardone’s team published three substudies of their trial in The Journal of the American Osteopathic Association. These substudies will be recognized with the AOA’s George W. Northup, DO, Medical Writing Award during AOA’s annual business meeting in July.

Federal initiatives and challenges

We are also heavily involved with the national Patient-Centered Outcomes Research Institute (PCORI), an agency created by the Affordable Care Act. AOA President Ray E. Stowers, DO, encouraged DOs to apply for PCORI research funding. We have also been invited to provide feedback on PCORI priorities. A DO was selected for first PCORI workshop in October 2012. The AOA National Osteopathic Advocacy Center in Washington, D.C., has hosted meetings of the PCORI/Partnership to Fight Chronic Disease. And this is just one of many federal entities we support and work with to expand research.

Yet as I’ve said, we as a profession must do much more. The profession’s lack of research spills over into payment issues. Carriers often do not properly reimburse OMT because they are not familiar with our modalities and the great benefits they provide to patients. Without an evidence base, OMT may not be included in essential benefits packages under the Affordable Care Act.

The AOA is not blameless. We allocate only 3% of our budget to research funded by the Osteopathic Research and Development Fund—nowhere near enough to support the amount of research we need. This is a problem. We must increase the fund’s corpus to support new osteopathic research projects as we did in the 1990s, when the AOA instituted a $50 assessment on all members on top of their dues. Another goal of the Council on Research’s strategic plan is to have $3 million to $9 million available annually within 10 years to support research within the osteopathic medical profession. My calculations (I’m a lawyer, not a statistician) show we could raise the first $3 million in three years with a $25 assessment. Is it time to do this again?

Making miracles happen

While OMT and the benefits it provides to patients might not seem like a miracle at first glance, anything that can help save a life, relieve chronic pain, or prevent a life-altering condition might be viewed by that patient as miraculous. And what better way to “Provide compassionate, quality care to my patients,” as the Osteopathic Pledge of Commitment calls us to do, than through research and advancement.

In 1915, Dr. Still urged the osteopathic medical profession to “stand behind all legitimate research institutes and give them your support.” We must come together as a profession to expand our research base, to prove the efficacy of what we do, and to ensure that the osteopathic medical profession can survive in the future health care world of comparative effectiveness, essential benefits and quality measurement. I call upon the AOA to put our money where our mouth is and institute a research assessment by 2015. We can DO it!

Some physicians send out press releases and update their websites and social media pages after every new job appointment or award. The opposite is true of Alan N. Langnas, DO. Though a leader in the field of transplant surgery, with hundreds of published articles to his name, Dr. Langnas doesn’t seek publicity and is less well-known than he could be in the osteopathic medical profession.

“I’m very fortunate because I’ve had a wonderful career,” says Dr. Langnas, a U.S. News Top Doctor. “I’m a man of a certain age, but I still enjoy going to work and doing what I do.”

As the director of his hospital’s Center of Transplantation, Dr. Langnas oversees all liver, kidney, intestinal and pancreas transplants at the University of Nebraska Medical Center (UNMC) in Omaha. In a more hands-on role, he directs the center’s liver and intestinal transplantation programs, spending much of his time in the operating room. He also supervises several treatment programs for people with liver, pancreatic or intestinal diseases who don’t need transplants.

During his nearly 25 years with UNMC, Dr. Langnas has assumed progressively greater administrative responsibilities. And since 1997, he has been the program director of the transplantation surgery fellowship that he himself completed a decade prior.

“Alan Langnas has an incredible amount of enthusiasm for and involvement in the field of transplant surgery, but he is not someone who goes around boasting of his accomplishments,” says Glenn Fosdick, CEO of the Nebraska Medical Center, UNMC’s teaching hospital in Omaha. “I remember one scenario in which we were doing four pediatric liver transplants on the same day, using four teams. I suspected this was a first for any medical center in the U.S. and suggested to Alan that we get the word out to the press. He initially said, ‘Maybe next time.’ I had to push for him to speak to the media.”

UNMC does approximately 120 liver transplants a year, drawing patients from all over the country, and has developed an international reputation in both pediatric liver and small bowel transplantation. Dr. Langnas expanded UNMC’s liver transplantation program and pioneered its intestinal transplantation program, one of only a handful of such programs in the country.

“It was really by chance that I got into transplant surgery,” says Dr. Langnas, who trained in general surgery at Botsford Hospital in Farmington Hills, Mich. “I had already accepted a job as a general surgeon but learned of an unexpected opening in a transplant surgery fellowship at Henry Ford Hospital in Detroit and decided to go for it.” Afterwards, he completed a second fellowship, at UNMC, his passion for transplantation growing ever-stronger.

“For all of us in medicine, the most gratifying part is being able to help people. In transplantation, this feeling can be even more intense,” Dr. Langnas says. “Because we are taking care of people who are terribly sick and giving them a life-saving organ transplant, the results we see in patients and their families can be quite dramatic. From the practitioner’s point of view, this is very rewarding.”

Compassionate care

“Dr. Langnas is just outstanding—compassionate, diligent about details, a very good leader,” says Joann Schaefer-Haines, MD, one of his liver transplant patients. “He is also very humble.”

Afflicted with a hereditary liver disease, Dr. Schaefer-Haines first saw Dr. Langnas for a pre-transplant procedure to buy her more time before the actual transplant, which he performed in 2008. She had life-threatening complications after the transplant, which he successfully addressed.

“Dr. Langnas definitely takes care of the whole patient,” she says, noting that he showed interest in her quality of her life, not just the condition of her liver. “I am a runner and have other interests, and he cared about these things. He cared about my getting back to a normal life.”

Dr. Schaefer-Haines, who belongs to the same gym as Dr. Langnas, encounters him periodically as she goes about her daily routines. “When he sees me working out on the treadmill, he’ll get on the treadmill next to mine and start chatting,” she says. “He’ll ask me what I’ve been up to and how I’m feeling. I don’t see a lot of physicians who’ll do that.”

“I’m running marathons now. I feel like a million bucks—the healthiest I’ve ever felt in my entire life,” Dr. Schaefer-Haines adds. “I owe so much to Alan Langnas. He is a stellar physician.”

Transplant surgeons provide their patients with lifelong care. Even when patients come from other states or countries, Dr. Langnas monitors their laboratory results, adjusts their anti-rejection medication, consults with their internal medicine specialists and primary care physicians, and asks to see them at least once a year for a follow-up examination.

“One of the unique aspects of transplant surgery is that you get to know people over the years. Alan receives so many cards from patients, especially those who had pediatric transplantations and are growing up and want to thank him,” says Wendy J. Grant, MD, who trained under Dr. Langnas and has been part of his transplantation team for more than a decade. “We also have a transplant reunion every year. At least 300 patients come to this, and they are so excited to see him. Alan has been involved in all of their care.”

‘Straight shooter’

Despite his affable, down-to-earth demeanor, Dr. Langnas has extremely high standards, Dr. Grant notes. “He has high expectations of himself and everyone around him because there is so much at stake,” she says. “This makes us all better at what we do. And he is incredibly proud of all that we have accomplished. I know that none of us would be as successful as we are without his leadership, without him pushing us.”

When Dr. Langnas observes less-than-exemplary work at the Center of Transplantation, he doesn’t hesitate to point this out. “He is a straight shooter, and that’s one of his best qualities,” Dr. Grant says.

Innovations and obstacles

While the broader medical community is struggling to respond to the federal push for electronic health records and accountability for patient outcomes, the field of organ transplantation embraced EHRs, patient registries and outcomes monitoring years ago, Dr. Langnas says.

“All of our results are on public websites and have been for 10 years,” he says. “Everything we do is transparent to patients and the entire U.S. population. As a consequence, we are held accountable, which is as it should be.”

Dr. Langnas notes that one of the Center of Transplantation’s strengths is its robust quality-assurance and performance-improvement program. “We measure everything because if you can’t measure it, you can’t improve it,” he says.

The biggest and most heart-wrenching hurdle Dr. Langnas faces is the shortage of donated organs. “At least 10% of patients waiting for a liver, heart or lung transplant die before one becomes available,” he says.

According to the organization Donate Life America, 120,000 men, women and children in the U.S. are awaiting organ transplants.

The availability of organs has not kept pace with technological and procedural advances in transplantation. Dr. Langnas attributes this to Americans’ lack of comfort with the concept of organ donation and the government policies that reflect such uneasiness.

“In some other countries, there is presumed consent. Everyone is presumed to be an organ donor unless a family specifically opts out,” Dr. Langnas says. “In the United States, we have to opt in.”

Organ selling is illegal in the U.S., but Dr. Langnas believes that there may be a role for carefully “incentivizing people to donate organs.”

“But such a change must not lead to rich people approaching poor people for organs,” he says. “It would have to be a transparent, monitored, government-regulated process. The person donating the organ might get a payment, but that payment cannot come directly from the person in need of the organ.”

Don’t compromise

Considered an innovative administrator because of his commitment to team-based care, Dr. Langnas is also highly regarded as a mentor of younger faculty members and trainees.

“He sets a great example for his fellows, residents and students,” says Dr. Schaefer-Haines, who until recently served as Nebraska’s chief medical officer, a position she held for several years.

What advice does Dr. Langnas give his youngest trainees? “I tell students, ‘Follow your dreams. Follow your heart. Do what is right for you because becoming a practicing physician is a very long haul. You will have worked extremely hard to get there, so it’s important to pick what you love.’ ”

For students who shy away from surgery out of fear of long hours, he doesn’t mince words.

“ ‘In high school, did you work really hard to get good grades?’ I’ll ask. They’ll say yes. ‘In college, did you work really hard to get accepted into medical school?’ Again, they’ll say yes. ‘Now in medical school, are you working really hard?’ Of course. ‘So why, when you finally get to decide what you are going to do for the rest of your life, would you pick your second choice instead of your first choice?’

“You have to be true to yourself. Otherwise you’ll pick a field you don’t love. And you’ll be 40 years old and bored out of your mind and miserable. So stick with what you love. The quality-of-life stuff will sort itself out.”

Dr. Smith coordinated an evacuation of West Rest Haven, located a quarter-mile from the plant. Around 7:50 p.m., after he and the nursing home staff moved most of the patients, they felt the explosion, which caused the building to begin to collapse.

“All of a sudden in a blink of an eye, there was the most massive explosion you could imagine,” he says. “The building literally was on top of me. I don’t know how I got out of there alive.”

Dr. Smith’s role in the fertilizer plant explosion in West, Texas, last week was just starting. The explosion left 15 people dead and more than 200 injured. Dr. Smith sustained injuries himself, and his home and office were both severely damaged in the blast.

After the explosion, Dr. Smith went into disaster mode, he says. While the nursing home staff evacuated the seniors, Dr. Smith exited the fallen building and tried calling 911, but couldn’t get a signal on his cellphone. He tried the ambulance radio in his car instead, but he couldn’t get a signal on it, either.

Dr. Smith says he’s worked in many disaster relief efforts, such as the aftermath of Hurricane Katrina and Hurricane Ike, but this was the first time he felt absolutely overwhelmed.

“I didn’t know where my people were,” he says. “I had no way to get a hold of them.”

After trying his cellphone and radio, Dr. Smith raced to the medical air-evac helicopter base near the nursing home.

“Get on your radio, please,” he told a staff member. “Can you dispatch to McLennan County that we’ve had a massive casualty with hundreds of injured and probably many fatalities. Get everything we can down here: fire trucks, haz-mats, everything.”

Dr. Smith left the helicopter base and went to the EMS station to load up oxygen canisters to take them to the evacuated seniors, who were at the community center.

His cellphone still not working, Dr. Smith then walked to a triage station set up on the high school football field to ask the nurses there where the greatest demand was.

“Dr. Smith, you’re no longer Dr. Smith—you’re patient George Smith,” one of the nurses told him.

Covered in abrasions and lacerations on his face, back and legs, Dr. Smith hadn’t had time to think about his own wounds yet.

“I had too much to do,” he says. “I was in shock.”

Dr. Smith quickly left the triage station for the command center, where he was asked to stay and assist an area justice of the peace, who would pronounce the deaths. At that time, they were expecting 60 to 80 bodies.

Stationed at the command center, Dr. Smith took the opportunity to give a few interviews. He talked with the BBC and Piers Morgan on CNN, among others. In the interviews, he still had blood on his face from his wounds.

Dr. Smith speaks with Piers Morgan on CNN after the explosion.

By 4 a.m., on no sleep, Dr. Smith honored a promise he had made to a nurse that he would seek treatment. After getting his wounds sutured at the hospital, he headed to a friend’s house to get some rest. But by then it was 5:15 a.m., and he had agreed to speak to a morning television program, so he headed back out to do the interview.

The chaos of the explosion has passed, but life for Dr. Smith and the other residents of West is far from back to normal. All of the dead were friends of Dr. Smith’s, so he’s been attending funerals and wakes. Because of the damage, it will be some time before Dr. Smith can practice out of his own office. But a friend offered him space in her clinic to use, and he plans to start practicing there in a few weeks. The Texas Osteopathic Medical Association has set up a practice relief fund for Dr. Smith.

In the coming months, Dr. Smith hopes to play an active role in the rebuilding of West. “We’re a town of 2,800,” he says. “We all love each other.”

The citizens of West are lucky Dr. Smith was there to help after the explosion, says Jeffrey D. Rettig, DO, a colleague of Dr. Smith’s who lives in nearby Groesbeck, Texas.

“George is a great person,” says Dr. Rettig, who practices family medicine. “He’s a very good doctor. He’s very committed to his community and his patients, and I think that bore out in this tragedy as well.”

Dr. Smith says it’s a blessing that there weren’t more fatalities and injuries, and that everyone in his family was safe and not seriously injured. When asked for other silver linings from the explosion, he notes wryly that fewer people will mistakenly ask, “Where in West Texas?” when he tells them where he’s from.

“But now, I have a feeling people will know where West, Texas, is,” he says.

Dr. Smith advises other osteopathic physicians who serve in emergency medical services leadership positions to always remember that the unexpected could happen at any time. It’s also important to remind staff that they are serving others, he says.

“Just be prepared to handle whatever will happen,” he says. “Do the best you can to devise plans for disasters such as this. Make sure that your people know what to do if they can’t get a hold of staff and if they can’t get a hold of you.”

I had spent two years learning in school about Fryette mechanics; cranial motion; high-velocity, low-amplitude (HVLA) techniques; and myriad related topics. My professors shared astonishing anecdotal stories and studies supporting the efficacy of OMM. My classmates and I practiced what we learned in lecture in our clinical labs.

This was all fantastic, but I still wondered if OMM actually worked. I found certain concepts, such as cranial and counterstrain, particularly hard to believe. While muscle energy, HVLA and soft tissue all made sense to me, these other two really puzzled me. The bones of the head move? There is a rhythmic impulse that I can feel? I can move your arm in this certain position and hold it there for 90 seconds and your pain will be gone? Really?

Sometimes it’s a little difficult to comprehend things you haven’t yet experienced. I read about the effectiveness of some techniques but hadn’t yet performed them and seen the results firsthand. In our osteopathic manipulative treatment labs, we practiced on each other. For the most part we are relatively young, healthy medical students. We don’t have a ton of somatic dysfunction. Maybe a small kyphosis after sitting in the library for twelve hours a day, but nothing like the dysfunctions of the chronically ill or those with severe musculoskeletal issues.

I had doubts that what worked for my healthy classmates would work well for a patient with chronic arthritis or irritable bowel syndrome, and I wasn’t sure if my OMM rotation would change anything.

Real-world exposure

But when I walked into the third-floor office for my first clinical rotation, I tried to keep an open mind. The Orlando, Fla., clinic was large, with about 15 exam rooms, each with its own blue OMT table. OMM was this clinic’s main focus, and its attendings, neuromusculoskeletal medicine fellows, and family medicine residents were booked solid from 9 a.m. to 5 p.m. They were always busy because they got results, I learned, and their patients kept coming back.

So many of the cases I saw illustrated what I had only read about in textbooks, and seeing real improvement in patients is what convinced me that OMM really worked.

I remember one patient, a 55-year-old man, who came in with chronic back pain of 35 years that a chiropractor had relieved numerous times in the past. However, he had seen his chiropractor six times in the past two months with no relief, and the chiropractor told him there was nothing else he could do. The patient drove an hour to see us. His initial complaint was low back pain, and a sensation of veering to the side when he walked. He had been out of work for a month because of the pain and discomfort. We learned that he had been in a motorcycle accident at the age of 16 and had dislocated his left hip. A thorough structural exam revealed a three-quarter-inch leg-length inequality that was not amenable to a number of our techniques—it was “stuck.” He had been compensating for this inequality for the last 30-plus years.

We removed some other dysfunctions and prescribed a heel lift for the short leg. A month later, his back pain and his mood were much better, and he was back to work. We did not “cure” him, but we did greatly improve his quality of life.

Another patient could find no relief for her regular, disabling migraines. Whenever she had one she would visit the office, and the attending would perform cranial. Within a few minutes, her pain level would decrease, she said. Although she still needed prophylactic medication, I could see the benefit of these techniques.

There was also a patient who had a history of severe necrotizing fasciitis of his lower leg, which had disfigured it badly, causing contractures and pain. He said the only thing that helped was OMT, in particular soft-tissue and lymphatic techniques.

And one time, an attending diagnosed a woman’s mechanism of injury just by observing her posture while sitting on the examination table. With no prior history he was able to deduce that she had been stopped at a red light and was rear-ended while her foot was on the brake pedal (crazy, I know).

And this was just the outpatient clinic. The physicians and I also performed daily inpatient rounds. We treated patients from age 11 to 89—many even requested OMT. In one case, a patient was admitted for severe chest pain, and everything in his workup was negative. His physician consulted the OMM department. Our attending examined the man and found a severely dysfunctional right posterior rib. He asked me to grab a hard compression board to place under the patient. He then performed a double-arm supine technique, which put the rib back into its correct place. The look of relief over the man’s face was incredible.

These experiences have carried over into how I think about treating patients and even into my personal life. I’ve fixed my wife’s superior pelvic shear that she developed while training for a marathon. I’ve treated my sister when she came down with pneumonia. I’ve even treated a patient with a clear-cut history of a cervicogenic headache in the emergency room.

No opportunity wasted

Some medical students and physicians are leery of OMM because they’ve heard horror stories about trying to bill for it, but this wasn’t my experience in my rotation. I learned that if an exam shows evidence of somatic dysfunction, a physician can treat, code and bill for it in just a few minutes. To learn more about this, speak to your attending physician. [Editor's note: Members can also contact the AOA's Practice Management department for help with billing and coding.] Payment is based on locale, but at my clinic, treating one or two regions of the body netted the physician an extra $32. Nine to 10 regions would be an extra $75. Over time this will add up.

If you’re getting ready to embark on your third-year rotations, I suggest you try to leave any biases you have behind. Take advantage of your OMT rotation and absorb as much as you can. Be hands-on and practice. That’s what you’re there for. If there’s something you don’t remember, look it up. I use “5-minute” consult books, and you can also download smartphone applications. The app OMM Guide by James Lamberg (free!) has OMM techniques, guidelines on the osteopathic medical assessment and more. Developed by the American College of Osteopathic Family Physicians, DO OMT ($9.99) has 120-plus step-by-step videos illustrating various techniques.

If you have weaknesses, focus on them now because this is where you will refine your techniques. Once your rotation is done, apply what you’ve learned to other rotations. Use your visceral techniques in surgery or your lumbosacral techniques for obstetrics. Explain and demonstrate to your MD preceptors and counterparts what you’d like to do if they seem apprehensive. You can pull up some of the good studies and evidence-based guidelines that are out there. Get as much experience as possible and find your own anecdotal evidence, or work with your preceptor and get a study started.

Learning OMM has forever changed the way I think about and practice medicine, and I hope other skeptics read my story and decide to give OMM a chance. It is yet another layer of care you can provide to your patients, and they will love it.

Kevin D. Hageman, OMS III, attends the Georgia Campus-Philadelphia College of Osteopathic Medicine in Suwanee.