CTSI welcomes new KL2 scholars

KL2 Collage

(L. Auerbach, R. Chen)

The CTSI KL2 Career Development Program welcomed two new scholars on July 1st. The program provides two years of support for new investigators interested in a career in clinical or translational research

David Auerbach, PhD is a Senior Instructor in the Department of Medicine, Aab Cardiovascular Research Institute. He will be working on a project titled, “Electrical Disturbances in the Brain and Heart in Long QT Syndrome: A Dangerous Synergy.” He takes a multidisciplinary, translational approach to investigating genetic ion channel diseases of the brain and heart. His mentor is Arthur Moss, MD.

Wei Chen, MD is a Assistant Professor in the Department of Medicine, Nephrology. She will be working on a project titled, “Does Metabolic Acidosis Protect Against Arterial Calcification in Patients with CKD?” Her research focuses on identifying and correcting the risk factors that contribute to the high cardiovascular mortality in patients with chronic kidney disease. Her mentor is David Bushinsky, MD.

Click here for more information on current and past KL2 scholars.

Silence in the exam room: a CTSI scholar reflects on his year out

Josef Bartels spent a year at the CTSI as a medical year-out student, where he studied the role of silence in doctor-patient interactions and completed his MPH. He recently spoke with CTSI Stories about his year.

JosefBartels

Thanks for taking the time to chat, Josef. How did you come to apply for the Year-Out program?

It was early third year of medical school and I had an elective rotation in palliative care with Dr. Ronald Epstein. I really enjoyed what I did there because it struck a chord with my humanities background. In palliative care, you’re often at the point where there’s not much more you can do to cure. Instead, you’re dealing in issues that people have written about and physicians have been witness to for centuries – like the meaning of life, the meaning of suffering, and how to die with dignity. The lack of solid answers and the human messiness of it all really resonated within me.

I also realized there was something going on in those conversations that I wasn’t hearing as often in other medical settings. I have a musical background, and realized that there was a lot going on with tone and silence. It all reminded me of a Radiolab podcast I heard called The Musical Language, where they were talking about how mothers all over the world talk to their babies in the same notes – that if you take out the words and play it on a piano, it sounds similar even when from widely different linguistic lineages.

I wondered if there was also some musicality within medical conversations. Are there common patterns? Is silence meaningful? I told Dr. Epstein I wanted to study this, and he said he didn’t think I could pull off what I was considering in my spare time. So that’s when I applied for the Year Out.  Dr. Epstein agreed to be my mentor and helped me put together a research team with fellow year out scholar Rachel Rodenbach and Eastman School of Music professor of Voice Katherine Ciesinski.

Tell me more about these conversational moments that you mentioned.

I didn’t set out to study specific moments. I wanted to focus on the rhythm of medical conversations, and specifically the silence in these conversations. There has been a lot written about silence in psychology, linguistics, and neuroscience — so it was a wonderful exploration of a number of different fields in order to focus in on this one phenomenon that happens to be present in medical communication. When I started hearing different types of silences, there was one specific type that was fascinating, and that seemed to occur during these particular moments where there is shared meaning without words. These moments exist in medicine everywhere, but I think they’re more common in situations with mortal consequences and an opportunity for shared decision making, which includes almost every specialty.

So how did you design your study on these silences?

There was another type of silence that popped up a lot, and it was always associated with exam-room computer usage. There has been a lot written on computers and electronic health records, including some work that demonstrates a lot more silence now that there are computers in the exam room. That extra silence, the particular flavor associated with computing, is controversial. Does it give the patient the chance to ask questions? Does it indicate imperfect multitasking?

I set out to measure how long these silences were and how many there are, and I correlated those with counts of specific physician communication tasks. The results are intriguing and suggestive, though the confidence intervals are wide. If I had designed it from the beginning, I would’ve tried hard to find an outcome variable with a normal distribution. Either way it was valuable experience to learn statistics and practice quantitative analyses and manage a large data set, and the results were recently accepted for oral presentation at the International Conference on Communication in Healthcare.

I see. And the other part?

We’re calling these seemingly meaningful pauses in conversation “connectional silences,” because they seem to represent some kind of connection between the physician and the patient – or sometimes between a caregiver and the physician.

How did you define a “connectional silence” for the study? How did you know what to include?

This analysis relied heavily on grounded qualitative methods, which allowed us to develop a rigorous way of identifying a previously unstudied phenomenon. We developed inclusion and exclusion criteria, and then measured interrater reliability between three people identifying these silences to validate these criteria. For example, one of the inclusion criterion is there’s some emotion expressed by the patient which the physician recognized and then acknowledged. Then we ran it by a panel of physicians for additional validation that we weren’t just making these differences up.

For the analysis, I worked with Katherine Ciesinski to define these silences using musical notation, because it is designed to capture the data we were interested in; volume, pitch, rhythm, and tone. When you listen to these moments, they just sound special – they were qualitatively different, and we wanted to know why. We had to define what, exactly, was it that we were hearing in these silences? What is the sonic environment within which these pauses exist? We looked at pitch, volume, intensity, and then we looked at rhythm.

Rhythm was where patterns leapt out and connections became clear. Once we visualized the audio environment of the conversation, we could see that as the “connectional” moments approached, the length of time that each person spoke for began to merge. One person would talk for 5 seconds, then the other would talk for 5 seconds, then 2 and 2, then just a word each. The doctor and patient would match the length of their sentences. Other literature which focused on successful business deals and even successful courting showed similar rhythm in successful conversation patterns – they called it mirroring. Contrast that with a moment where the physician is providing a lot of info, giving a monologue for a minute or two, and then the patient just replies “OK, got it” – and not to put a higher value on one or the other, but they are qualitatively different, and we’ve been able to show that through a new window called dialog rhythm.

We think these patterns might be linked to mirror neurons, which are a hot topic these days. These neurons might light up when you really listen to someone, so a part of your motor cortex actually models what you are listening to, as if you’re moving your mouth and your own tongue. When you begin to respond, you match pitch, volume, and rhythm, because your motor neurons have just practiced it. It that sense, we might be getting close to another channel that can measure engagement, in addition to body position and eye contact.

Where do you go from here? Can you make a career studying silence in medicine?

The short answer is yes. Patient centered communication and a therapeutic relationship are gaining empiric support daily. From issues of medication adherence to physician burnout, we are recognizing that communication and the connection between people is the foundation of medicine, and leads to measurable and meaningful gains in health outcomes. Federal funding through NIH, PCORI, AHRQ and others are interested in exploring how the human experience affects and interacts with more “objective” data like BMI and blood pressure. It’s a relief to me that after a century of trying to control for the placebo effect, the mechanisms and pathways of this and other psychosocial effects of giving care and attention to a fellow human being are getting some attention. Medicine is going to be relationship-centered, because quality communication and caring relationships promote health and wellbeing, and have the potential to act before, during, and after a patient develops disease. Our research took us one step closer to measuring the quality of engagement between patient and doctor, a connection that can then be linked to any number of health outcomes.

In terms of next steps, I’d really like to see if a computer can pick out the silences that are associated with computer use, in order to give a non-invasive and simple measure of computer-centered vs patient-centered care. Then we could measure patient outcomes that might lead to computer redesign or the realization that it might be more effective to pay the physician (or a data expert) to manage the patient’s data separately from interacting with the patient. Electronic medical records have gone far beyond the charting of diagnostic rationale and are really entering the realm of big data. The task of forming a trusting relationship to facilitate preventive, diagnostic, and curative procedures is complex, and managing big data simultaneously may be dangerous in as many ways as it’s helpful. We’re really struggling to measure things like this that affect nearly every medical interaction every day. This is what motivates me to continue research in medical communication.

CTSI Welcomes New Year Out Trainees

New ART

(L. Erika Snow, R. Leigh Sundem)

The CTSI Year Out Program for Medical Students welcomed two new trainees on July 1st. The CTSI supports medical students interested in a year-out experience of mentored research in clinical or translational research; most students enter through the Academic Research Track (ART) program.

Erika Snow will be working with Dr. Scott McIntosh on a project titled “The Role of E-cigarettes as a Barrier to Smoking Cessation.” Dr. McIntosh’s research focuses on stop-smoking interventions with various populations and the training of physicians and other medical professionals in guideline-based nicotine dependence interventions. Erika will also pursue a Masters in Public Health during her year out.

Leigh Sundem will be working with Dr. John Elfar on a project titled “Erythropoietin for Compression Neuropathy: Preclinical Efficacy and Cellular Site of Action.” Dr. Elfar specializes in the treatment of sports and hand, wrist, elbow, and shoulder problems. His clinical interests include all aspects of upper extremity trauma and reconstruction as well as injuries in the competitive and recreational athlete.

Click here to view all previous CTSI trainees.

For more information on CTSI education programs like the Year Out program , contact Katie Libby, CTSI Education Program Manager, at katherine_libby@urmc.rochester.edu.

 

Need Study Coordinator Support for a Clinical Trial? We Can Help!

UR Connected is an application that supports connections between research coordinators and plug-ininvestigators or administrators. Coordinators can: post information about qualifications; advertise availability for new or additional projects; browse for job titles and HRMS IDs for posted jobs; Browse for opportunities to contribute in their spare time. Investigators and Administrators can: search for coordinators with qualifications and availability that match current needs; post HRMS jobs to make it easier for coordinators to find positions that involve research coordination; and advertise opportunities that are more limited than a posted position in HRMS. For more information contact researchhelp@urmc.rochester.edu.

Trying to find a collaborator at the URMC? We Can Help!!

The URMC Research Network website is a tool supported by the URMC that contains information from research clusterfaculty profiles and publications. You can search the database using key words to identify faculty with particular research interests. The faculty information displayed on the website comes from several sources including eCV, the SMD Dean’s Office, and PubMed. All people with a faculty appointment in the URMC School of Medicine and Dentistry are included in the URMC Research Network website except for those with only a “Primary Administrative” appointment.

URMC Supporting Global Health with Technology, Big Data

Researchers at URMC have commenced two projects to improve maternal and mental health in low- and middle-income countries by harnessing information technology and social media.

Eric Caine, M.D.

Eric Caine, M.D.

The first, led by Eric Caine, M.D., chair of the Department of Psychiatry, will train researchers from Vietnam, Cambodia, Laos, Myanmar, the Philippines, and Mongolia to use mobile technology and social media to discern when populations are under mental stress.

The second, led by Timothy Dye, Ph.D., professor of Obstetrics and Gynecology and director of biomedical informatics at the university’s Clinical and Translational Science Institute, and Deborah Ossip, Ph.D., professor of Public Health Sciences and Oncology, will train teams from Costa Rica, the Dominican Republic, Bolivia, and Honduras to use information and communication technologies to address in-country maternal health problems.

Tim Dye, Ph.D.

Tim Dye, Ph.D.

The projects are each supported by three-year $300,000 grants from the Global Health Research and Research Training eCapacity Initiative from the National Institutes of Health’s Fogarty International Center. The grants were limited to physicians and scientists who had previously received grants from the Fogarty International Center, and URMC is one of only two institutions in the country to receive multiple grants.

“As we move in to the era of big data, we are very well positioned to be a leader in biomedical informatics and data science,” said Stephen Dewhurst, Ph.D., vice dean for research at URMC. “These two projects really build on the research strengths we already have in place.”

Deb Ossip, Ph.D.

Deb Ossip, Ph.D.

Caine’s group, which includes Vincent Silenzio, M.D., co-director of the Laboratory of Informatics and Network Computational Studies, will train four researchers annually at the University of Rochester Medical Center.

The training program will focus on the use of mobile technology and big data to improve mental health; one potential application would be a program that scours Twitter for certain keywords that signal a population is under more mental stress than usual. The first four trainees arrived in late June.

Vincent Silenzio, M.D.

Vincent Silenzio, M.D.

“Next year, they’ll come back with four more trainees, and we’ll pair them up,” said Caine. “This way, we can mentor the mentors in addition to training the new people.”

Dye and Ossip’s project, which is called MundoComm, will attempt to improve maternal health, which has stagnated in some Latin American countries in recent years. Their program will provide online and in-country training on the use of information communication technology to help improve the health of women in pregnancy. Community-based field teams will use this training to develop and field test maternal health projects, while receiving mentorship from the MundoComm team.

“If there’s a problem with breastfeeding in a particular community, then a team of people — a clinician, a data technician, and an outreach worker, for example — would come in and learn how to use information technology to tackle it,” said Dye.

Both projects leverage the partnerships and connections that the researchers had previously made in Asia and Latin America. Caine’s project builds on the Asia-Pacific International Research and Education Network, while MundoComm closely involves several of Dye and Ossip’s former trainees from Costa Rica and the Dominican Republic who once studied in Rochester and are now in faculty positions themselves.

Novel Methods and Technologies for 21st-Century Clinical Trials

“New technologies are rapidly reshaping health care. However, their effect on drug development to date 1459F243510565C0D9F22F2E131324C7generally has been limited.” A recent article in the Journal of the American Medical Association (JAMA) Neurology highlights a literature review completed by a  team of URMC researchers led by Dr. Ray Dorsey, including CTSI Co-Director Karl Kieburtz. Dr. Dorsey is an Associate Director of the CTSI, and was formerly a CTSI Career Development Scholar.

The objective of the review was “…to evaluate disease modeling and simulation, alternative study design, novel objective measures, virtual research visits, and enhanced participant engagement and to examine their potential effects as methods and tools on clinical trials.” The article entitled “Novel Methods and Technologies for 21st-Century Clinical Trials: A Review” appears in the May 2015 edition of JAMA Neurology. The team conducted a systematic search of relevant terms on PubMed, references of previous publications, and private files. The search encompassed articles published from January 1, 2000, through November 30, 2014, and produced 7976 articles, of which 22 were determined to be relevant and were included in this review.

The review uncovered that “Few of these new methods and technologies have been applied to neurology clinical trials. Clinical outcomes, including cognitive and stroke outcomes, increasingly are captured remotely. Other therapeutic areas have successfully implemented many of these tools and technologies, including web-enabled clinical trials.” The team concluded that “Increased use of new tools and approaches in future clinical trials can enhance the design, improve the assessment, and engage participants in the evaluation of novel therapies for neurologic disorders.” Click here to read the full article.