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Academic vs Clinical Medicine

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Andrey Pavlov

on 24 March 2014

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Transcript of Academic vs Clinical Medicine

What is research?
Research is many things, depending on the field you are in and what you are interested in. There are different kinds of research from "bench" research to clinical trials to quality improvement to meta analysis to translational, just to name a few
How is research actually done?
There are limitless ways to do research and it really depends on the kind of question you are trying to ask. It can involve going out into the field and collecting data, or it can be using really cool laboratory equipment to look at molecular interactions, or using computers to aggregate patient data and find out what is going on.
Why go into academic medicine?
There are any number of reasons. You may discover that you actually don't like working closely with people on an every day basis. You may really, really love science. You may feel a "calling" to make a difference to the whole of medicine rather than just the patients you see.
What is community/clinical medicine?
Community medicine is all about treating patients on a daily basis. The "pure" clinician does not do research. He or she uses the knowledge gained from research to directly and actively help people every day
Why go into community medicine?
Just like academic medicine, there are many reasons. Most people go into medicine because they want to help people directly, because they like interacting with people from all walks of life, or sometimes because they just really don't like research!
Academic vs Clinical Medicine
What is "bench" research
This is what most people generally think of when they hear the word "research." It involves being in a lab and doing experiments on small parts of big systems or using model systems
What is meta-analysis?
The more complex something is, the more times we need to repeat an experiment in order to understand what is really going on. Many times that makes the cost and logistics of doing the research really, really high. So we developed tools to get the data from a lot of smaller trials and integrate them into one "big trial" so we can try and see what is really going on.
What is academic medicine?
In the purest form, it is the scientific basic of medicine. You go through medical school and residency but then don't actually see patients in you career (outside of clinical trials)
Does that mean I am less of a doctor or less important to people?
No! In fact, some would argue you are more important to people. But just like everything worth doing, we need all kinds of people to make it happen!
What do you mean by "small part of a big system?"
Well, biological organisms, like people, are really big and complex. So complex we can't really understand all of it at once. So we will do experiments to look at just one small part of it. Like what happens to just a few cells in a petri dish if we add a certain compound to it
What is a "model system?"
Well, most of the time early research is too dangerous to try directly on humans but it seems to have promise when we do petri dish type work. So we use special animals as "model systems" to see if the effect is still there on a whole system instead of just the small part. This works because every living thing on the planet is related to each other because we all, including humans, evolved from the same ancestors. There are differences though, so we can't directly translate this research to humans. We can improve our odds though by making very special animals called "transgenics" which we have altered the DNA to make them more like humans or more like the disease we are trying to study. For example, we have mice which have an immune system that is identical to humans and completely different from normal mice.
What are clinical trials?
Clinical trials are studies that involve actual human beings. They have special rules and codes of ethics that must be followed and you must be specially certified to do human subjects research. There are special groups called IRB's which must approve all clinical trials. There are still different kinds ranging from prospective randomized controlled trials to retrospective chart reviews and everything in between. It allows us to see what actually happens in real people when we practice medicine.
What is translational research?
Much like it sounds, this is "translating" other kinds of research into something useful for people. So that bench research that then went on to be tested on a model animal is now going to be tested and used on humans. It is very difficult since the vast majority of bench and animal research turns out not to work quite as well in humans, but it is the best method we have (so far!)
What is quality improvement research?
It is research that involves taking what we know and using it better. For example we know that washing hands saves lives in the hospital. But how can we make sure more people actually do that? We do research to find out why people aren't doing what we know works and test ways to make it easy for them to do the right thing.
With all these options, how do I choose?
You don't necessarily have to! There are plenty of examples of academic physicians going back to clinical practice and vice versa. You could also do what I am doing which is combine the two. Have a clinical practice and see patients regularly, but do research as well. You can integrate it however you feel works best for you. Some people like to spend 80% of their time seeing patients, some only 20%. You can do research on your own patients by developing a protocol and enrolling them in it as you see them and treat them. You can do quality improvement research on your own practice to see where you could do better and publish it so others can learn from you and try it themselves. You can even spend part of your time doing bench research. Some people integrate it all into their daily routine, some people only see patients for part of the year and only do research for the rest of the year. The sky is the limit, as long as you have good ideas and work hard!
So how do you even become a physician anyways?
First you need to get your college degree
Going to a good college helps, but it is really about your academic success, scores, extra curricular activities, and being willing to go away from home if necessary. You need a 4-year college degree in any subject, with some minimum requirements for courses like organic chemistry, physics, and others. You have to take a test called the MCAT and score well during college in order to be eligible to apply. Starting to learn how to do research and actually doing research in college is always very helpful. Becoming a physician takes a lot of work, dedication, and sacrifice and you need to show the admissions committees that you are able AND willing to do it!
What next?
You apply through a service, go on interviews, and hopefully get in somewhere! The competition is extremely fierce and even really well qualified people get rejected for any number of reasons. Getting rejected from med school doesn't necessarily mean you won't be a good doctor. There are also options outside the US which can be easier to get into or have their own benefits as well. I myself got rejected twice before finally getting in to the UQ-Ochsner program. The key is being tenacious!
What is medical school like?
To put it plainly, it is really hard.There is a LOT to learn and it always feels like you can never possibly learn enough. But, with the right background (having a college degree in science, particularly biological sciences) and if you really like medicine, it feels easy. For me it was never too hard because I just loved learning how to be a doctor! You spend your first 2 years just doing classroom and lab work and then your second 2 years rotating through various fields of medicine and actually seeing patients and DOING medicine! If you work really hard and show you learned well, you can do really amazing things. I even got to do brain surgery! You also have to take lots of tests, including some really hard ones called the USMLE. At the end of those 4 years you are a doctor, but you still need to do more training and learning before you can go out and practice medicine. We call that residency.
What is residency?
Residency is what every doctor does after medical school. It is where he or she learns the specifics of the field of medicine they are interested in, as well as how to actually DO the medicine involved. There are many different fields of medicine and there are dozens of different residencies to go into. The shortest residency is 3 years and the longest is 7 years.You can then be "done" and go practice as an attending, or go on to fellowship.
Wait, fellowship? What's that?
After residency, if you want to become more specialized you can then do a fellowship in a sub-field of your residency training. These can range anywhere from 1 year to 3 years long. A very few of them are even longer.
What kind of fields of medicine are there?
One of the greatest things about medicine, besides being able to help people and really make a difference in someone's life, is how much flexibility you get to pursue what really interests you. Between residencies and fellowships there are literally hundreds of fields you can go in to. And from there you can further sub-sub-specialize your practice by focusing on a specific type of medicine. And of course, each field has a community and an academic side! I, for example, will be doing an internal medicine residency that is 3 years long. From there, I could go into things like cardiology or gastroenterology, but what I want to do is called pulmonary critical care. It is another 3 years of fellowship to learn more specifically about lungs and how to care for really, really sick people. Then, I am thinking about doing ANOTHER fellowship called "interventional bronchology" which involves putting cameras, needles, and scalpels into people's lungs. I want to do this because I like to do procedures, but didn't like it enough to go into surgery.
Wow! That seems like a lot of time to be in school!
Yes, it certainly is. By the time I am done I will have spent 17 years learning and training after finishing high school. But, as you progress you start getting more and more responsibility, get to do more and more cool things, you start getting paid as a resident and fellow, and the whole time you get to learn more than almost anybody else on the planet about your particular field. And if you decide you really don't like it there are many options for physicians - hospital administration, politics, law, industry consultants. No matter what you do in life, if it is worthwhile it will take time and be hard. But the rewards along the way more than make up for it.
How can I learn more?
For right now the best thing you can do is keep learning and keep your minds open. The more knowledge you have the more opportunities will be available to you. If you work hard, are caring, and even just a little bit knowledgeable people will want you to come work with them. That might mean medical school or it could mean something else. Knowledge is power and lets you have the opportunity to do really awesome things in the world. Later on, if you are still interested in medicine you can do things like Ochsner's STAR program, or shadow a local physician, or volunteer at a hospital, senior center, palliative care center, etc. In college you could work as a scribe, become an EMT (which is what I did), do research in biological or medical sciences, or work as a tech in a hospital (which is also what I did). If after all of that you feel like medicine is still what you want to do, then dive in! If it really is the field for you, the rewards are amazing and there is nothing like it in the whole world. And, as I just explained, you can tailor it all to be the best fit for you as you gain more knowledge and seniority.
So what do I do?
I just graduated from medical school in November and will start my residency in July. Since my interest is in critical care, specifically a disease called sepsis, I spent a lot of my time working and learning in the ICU and have been doing research in sepsis. When I start residency I will continue my research while learning more about how to be an internal medicine physician and prepare for my fellowship.
What is sepsis?
It is a condition when an infection gets into your blood and makes you extremely sick. There are over 850,000 cases of sepsis a year in the US alone and typically 30% of people who get sepsis die from it. That means 255,000 people a year die from it.
How do you do research in sepsis?
Sepsis is a molecular disease. What that means is that what is going wrong is happening on a tiny, tiny scale - smaller than the cells in your body. It involves a bunch of molecules in your body called "cytokines" which initiate signalling cascades that make your cells act haywire. Bench research involves looking at small parts of models and animal models to see exactly how these complex molecular systems go out of whack and to test and see what we can actually do to help stop it from killing people.
But I don't do bench research. I do clinical trial and quality improvement research. So what that means is we took people admitted to Ochsner over a 4 year period with sepsis and enrolled them in our study where we did certain things we have good reason to believe will help them. Then, I took all that data and made a big Excel spreadsheet with it (I put in over 30,000 entries by hand!) and then look at the data and run statistical analyses to see if we were having an effect. In our data, we showed that we decreased death by 10% - all just by improving the quality of the care we delivered! No "new" science, just better ways of applying what we know. This means that if we could do the same thing across the entire country we could save 85,000 lives a year! I also focused on where we could do even better, showing where most of the deaths occurred and trying to figure out how we can improve that. Last year I won an award for my research and got to go to Philadelphia to present my findings at an international conference.
by Dr. Andrey Pavlov
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