In this issue:

YPS MEMBER HIGHLIGHT: Ryung Suh, MD, MPP, MBA, MPH

FOOD FOR THOUGHT: Chicken: Now Available with Less Poison

PRACTICUM ROTATION FOCUS: ACPM

YPS MEMBER HIGHLIGHT
Ryung Suh, MD, MPP, MBA, MPH
Chief Executive Officer, Atlas Research

1) How did you get interested in Preventive/Occupational/Environmental Medicine?

As with most substantive shifts in our professional lives, I had role models and mentors that opened up new opportunities for me. John Eisenberg was a mentor when I was a medical student at Georgetown University, and he nurtured in me both an interest in health policy and health services research. He was keynote speaker at a Prevention conference back when I was working for him, and he invited me to attend with him. The people I met and the ideas I was introduced to opened my eyes and generated great personal interest. Perhaps the next great influence was Jeffrey Gunzenhauser. He was a residency director for a preventive medicine residency, and I did a medical school rotation with him. Exceptional human being, great knowledge and experience, and sincerely interested in the welfare of his charges – by then, I was hooked – so I guess the important point is that all of us have the potential to influence young professionals and to shape their careers by simply being willing to share time, knowledge, and experiences with those around us.

2) Where did you do your training? Can you share some of your thoughts about that program?

I did my internship at Madigan Army Medical Center. I took a few years to gain experience out in the Army as a general medical officer and flight surgeon, and completed my Occupational and Environmental Medicine residency at the Uniformed Services University. I found both programs to be valuable. The curricular and didactic content prepared me well for my professional responsibilities and board certification, and the clinical or practical rotations were meaningful and effective in teaching me the required competencies. More importantly, they gave me an opportunity to develop deep friendships with those around me. Overall, if I were giving advice to young professionals looking to choose a training program, I’d say go meet the trainees themselves and assess the quality and diversity of the people that the programs are attracting. At the end of the day, we learn what we choose to commit our time and attention to, but the richness of our experiences comes from the people around us.

3) What do you do now? How did you end up with that job you have now?

I am the Chief Executive Officer of a health care consulting firm called Atlas Research (www.atlasresearch.us), and we advise health systems leaders with strategic advisory services, help develop and field innovative new health care programs and technologies, and improve care for populations of interest. When I left military service and clinical practice, I wanted to find a vocation that allowed me to be challenged every day, solving new problems and helping change organizations and health systems for the better. Health care consulting and the entrepreneurial challenge of building a new business has afforded me that opportunity, and I am really enjoying it. I also spend a considerable part of my time teaching and conducting sponsored research at Georgetown University, where I serve as an Associate Professor of Health Systems Administration. I’ve always had an earnest interest in health policy – it is, I believe, how substantive improvements in our health system are made – so, teaching and engaging in academic life keeps me better informed about the policy issues I’ve always been interested in.

4) Can you describe thoughts and what made you decide to get your MBA?

I’ve always felt that health care systems are driven by concurrent, but often conflicting, influences. Clinical expertise and the health care needs of a given population are often well represented by health professionals and consumer groups. The policy framework and the structural features of health system organization, delivery, and financing fall within the realm of policymakers and the health services researchers and analysts that inform the policy process. The resource constraints of a given system and the incentives that move payers, providers, and patients fall to administrators and business leaders. All of their voices are important, but we don’t always speak the same language or share the same values across these professional groups, and it leads to conflict and misunderstanding within our health system. I went to business school to better understand the world through the perspective of a business leader. I’d spent my professional life in the military, as a clinician (at both the patient and population levels) with an enduring interest in health policy issues, but I wanted to see the world in a new light. I do not see any intrinsic value in an MBA versus other graduate programs, but I do see value in immersing yourself in unfamiliar territory.

5) Do you have any advice for medical students considering PM or OEM?

I guess I don’t see myself as being old enough to be giving out too much advice, at least with respect to PM or OEM programs. I’m just five years out of residency, so I do not have the depth of experiences that others within our College have (and are happy to share). I suppose I can share advice that I used to give as a medical student to my fellow medical students. I used to be a National Coordinator for Legislative Action for the American Medical Student Association (AMSA), and I wrote a monograph that summarized every major health policy issue from that year. In my introduction to the monograph, I encouraged my fellow medical students to stop studying so much, to stop focusing on the minute details of their clinical rotations, to stop obsessing over their grades or how many smart comments they could offer on rounds, and to stop thinking about how self-important they were. There is a much broader world out there, filled with mysteries and challenges and concerns, and their ability to see themselves within the broader context of all of that is what allows them to be better clinicians, more self-aware human beings, and more effective leaders within our health care system. Our specialty, I believe, grants us more freedom to think in that way, but I would encourage them to do that regardless of the specialty that they eventually choose.

6) Do you have any advice for current PM residents? (this can be about finding the right job, deciding on a focus within PM, about life in general, etc)

Same advice, I guess. Don’t waste precious time worrying about the trivialities of daily life. There are times when that compulsive attention to detail will be very helpful, to you and to your patients, but most of the time it doesn’t help. Look outside the traditional pathways before you, and be unafraid to take the plunge or to make a residency director unhappy with your choices. Make the right choices and do it for the right reasons, but realize that you have great power and wisdom within yourself. Don’t be led around by the herd, and don’t become mediocre in the things you do. I can’t think of more trite phrases to throw at you, but I’ll tell you a brief story (my friends have heard this already). When I was a young boy, my father came to watch me during a soccer game. In my attempts to impress him, I put extra effort into all my runs and charges. After the game, my father looked at me and said, "son, you run really fast….but, at all the wrong times.” Very instructive on how to be professionally. Don’t waste time, attention, effort, or resources focusing on the wrong things – by which I mean the trivial things – but know when those fast sprints are needed to accomplish bigger things in life.

7) Where do you see yourself in 5 years? 10 years

Who knows? I enjoy where I am now, and that’s enough for me.

FOOD FOR THOUGHT
Chicken: Now Available with Less Poison
By Michael Crupain, MD, MPH

Many people would probably be surprised to find out that arsenic, the metalloid element sometimes referred to as "the king of poisons”, has been a common additive to chicken feed for over 60 years. Organic arsenic is the active component in Roxarsone, a drug that is fed to birds in order to speed growth, kill parasites, and improve the cosmetic appearance of their meat. It is estimated that about 2 million pounds of Roxarsone are fed to conventionally raised chickens each year and according to one industry representative 88% of all chickens receive the drug.

As of July 8, 2011, however, Pfizer the maker of Roxarsone, has voluntarily suspended sales of the drug. This moves comes on the heels of an FDA study in which increased levels of inorganic arsenic were detected in the livers of chickens fed Roxarsone.

While chickens are fed Roxarsone, an organic form of arsenic, recent studies have suggested that the arsenic can be converted to the toxic inorganic form, by bacteria present inside a chicken’s gastrointestinal tract and in chicken manure.

Inorganic arsenic is classified as carcinogenic to humans,and chronic, low level exposuresare associated with medical complications including damage to cells and chromosomes, which can lead to skin, bladder, liver, and lung cancers as well as conditions such as heart disease, stroke, peripheral vascular disease, anemia,diabetes mellitus, and peripheral neuropathy. New data also suggests that arsenic may be an endocrine disruptor.

The United States Food and Drug Administration originally approved Roxarsone for use in animals in 1944. The FDA risk assessments on the safety of arsenic containing drugs was done over half-a-century ago with data supplied by the industry about residue levels in meat and the estimated average per-capita chicken consumption at that time. Since then, however, the amount of chicken consumed in the United States has increased dramatically. While in 1960’s the average American ate approximately 28lbs of chicken per year, by the year 2010 the average annual per capita consumption had tripled to almost 90lbs.

This means that consumers are likely being exposed to significantly higher levels of arsenic than would have been considered during the original studies assessment conducted by FDA. Industry trade groups have repeatedly asserted that studies that have examined arsenic residues in chicken have found the levels to be less than the permissible tolerances set by the FDA. Despite this, these tolerances were set in the 1950s, without the benefit of the public health research community’s current understanding of arsenic’s carcinogenic effects and potential to induce other adverse health outcomes.In addition, chicken waste containing arsenic can contaminate the water that people drink as well as the meat of other food animals and potting soil mixtures.

Surprisingly, arsenic-containing feeds have been shown not to be cost effective to industry. In a recent study published in the Journal of Applied Poultry Research, investigators found that chickens fed a diet without arsenic or other growth promoting antimicrobialswere statistically indistinguishable from chickens that were fed arsenic and other antimicrobials (the researchers actually saw a trend for increased production indices in the chickens not fed the drugs). Under pressure from public health advocates, both Foster Farms and Perdue, two of the countries biggest chicken producers, have both claimed to stop using arsenic containing drugs in their chicken feeds and these drugs have never been approved for use in the EU and should not be used in organically grown chickens.

It is noteworthy that while sales of Roxarsone have been voluntarily suspended by its domestic manufacturer, the FDA has not withdrawn its approval of the drug. According to the New York Times, Pfizer plans to do full scientific assessment of the drug before it tries to return it to the market.

”While a voluntary cessation of sale of arsenical drugs may sound like a step in the right direction, FDA should do its job and withdraw the approval for Roxarsone,” says Dr. Keeve Nachman of the Johns Hopkins Center for a Livable Future. "Allowing Pfizer to self-police sets a bad precedent with regard to how FDA handles legitimate public health concerns associated with drugs used in food animal production.”

PRACTICUM ROTATION FOCUS: ACPM
By Ashley Maltz, MD, MPH

What do ACPM President Miriam Alexander, the medical director of Xerox, Inc., and Texas Congressman Dr. Ron Paul have in common? Well, for one, they are all physicians who play integral roles in shaping the future of public health and preventive medicine; and two, I had the good fortune to meet all of them during my two month-long Pfizer Health Policy resident rotation at ACPM, as networking was a huge component of my time. The time spent talking with each of these three physician leaders during my rotation proved to be invaluable as it tremendously increased my health policy know-how.

As part of my responsibilities at the College, I worked alongside the Director of Health Policy, Paul Bonta, to organize meetings for ACPM Board members with their respective congressional staff members. Working one-on-one with Mr. Bonta to ensure increased funding for preventive medicine residencies furthered the development of those skills. For those unfamiliar with Paul, he is an excellent resource for all things health policy and preventive medicine. I often stared in awe while he fluidly presented facts and figures associated with the Preventive Medicine specialty to congressional staff members. Thanks to his efforts over the years, significant increases in funds for the preventive medicine and public health workforce have become a reality. Unfortunately, these funds are now being threatened and we must work to find alternate sources of funding for training. Working with Paul and the rest of the ACPM staff was a highlight of my rotation!

Additionally, I was able to attend numerous health care policy summits, most focusing on the changes occurring under the Affordable Care Act. One summit that served as a highlight featured preventive medicine advocate Senator Tom Harkin (D, Iowa). This was especially exciting for me as Senator Harkin has been an advocate for many of the social and health care issues that I support (including legislation for the founding of the National Center for Complementary and Alternative Medicine (NCCAM) and the Americans with Disabilities Act (ADA)). I was even able to have my picture taken with the well-known senator!

Another exciting summit featured the former Surgeon General, Dr. David Satcher, speaking about solutions to the obesity epidemic, while other experiences allowed me to interact directly with staff members from the AAMC, CDC, HRSA and HHS. I was also able to publish an article in the magazine of the National Association of Community Health Centers entitled, "Preventive Medicine Physicians: Unique Skill Sets that Can Enhance the Health Center Mission”.

By spending time with ACPM, exploring the inner workings of our federal governmental processes and the direct influence that I, as a Preventive Medicine resident had on legislation, I was encouraged to continue my role as an advocate for preventive medicine and public health. I hope to incorporate the skills I learned during my two month rotation into my future practice as an Integrative and Preventive Medicine physician. I highly recommend that every preventive medicine residency take advantage of this enlightening health policy experience. To add to the excitement, Washington, D.C. is an incredible city to explore!

For more information on the rotation or to apply, please see http://www.acpm.org/?Rotations_Pfizer or contact Paul directly at pbonta@acpm.org

Stay tuned for the next newsletter which will highlight a conversation with a Fogarty Scholar (and MSS member)!

If you had an interesting experience related to Preventive Medicine or would like to submit an article for the RPS-YPS-MSS Newsletter, please send an email to acpmrps@gmail.com.