Cancer Causes Control (2014) 25:1131–1140 Serum levels of vitamin D, parathyroid hormone and calciumin relation to survival following breast cancer Linnea Huss • Salma Butt • Signe Borgquist •Martin Almquist • Johan Malm • Jonas Manjer Received: 3 January 2014 / Accepted: 5 June 2014 / Published online: 22 June 2014Ó The Author(s) 2014. This article is published with open access at Springerlink.com
Sooner or later, every man in Australia runs into problems with impotency buy viagra australia like other bodily functions, must be in order.
Dartmed.dartmouth.eduDavid Nierenberg, M.D.: Pharm stand
By Jennifer Durgin
There are two sure ways to get pharmacologist David Nierenberg, ing. By the time he was 15, he had taken all the science courses that
M.D., fired up: take notes with a drug-company pen or mention his high school in Chappaqua, N.Y., offered. So, in 1965, he enrolled DMEDS, the Dartmouth Medical Encounter Documentation in Phillips Academy, a boarding school in Andover, Mass. He then System. The former rouses his ire, the latter his enthusiasm.
carried his passion for science to Harvard, where he earned a degree On this particular day, he's teaching pharmacology to second-year in biochemistry in 1971. medical students. As the students suggest possible drug treatments for He planned to go on to medical school but wanted a break from two fictional patients, he pushes them to think through their answers academic rigor. So he headed to Oxford on a Harvard fellowship to step by step—from considering the symptoms and physiological mech- work in a research lab. "Research has a very different tempo and feel anisms of each condition to evaluating which drugs to prescribe. than taking four or five courses every term," says Nierenberg. The class "is supposed to be about pharm, but you can't really think In 1972, he returned to Harvard for medical school. After com- about drugs until you've thought pleting his M.D., he did an in- through the pathophysiology," ternal medicine residency at Nierenberg believes that using pens and other freebies to
explains Nierenberg, who is also Boston's Beth Israel Hospital and market pharmaceuticals prevents doctors from being "clear-
senior associate dean for medical a clinical pharmacology fellow- education. He is conversational headed about prescribing the drug that is most effective."
ship at the University of Califor- with the students, sometimes hu- nia at San Francisco (UCSF).
morous, but never condescending and always precise. It's clearly a When the head of clinical pharmacology at UCSF became chair of good approach: he's been awarded the Medical School's Clinical Sci- medicine at Stanford, he asked Nierenberg to be his chief medical ence Teaching Award twice, in 1986 and in 2000. resident. In 1981, Stanford tried to entice Nierenberg to stay on by of- After class, a few students linger to talk with him. As one asks a fering him either of two positions—one that would be 90% research question, Nierenberg reaches across the table to examine the con- and 10% clinical and another 90% clinical and 10% teaching. But tents of her purple pencil case. "You're not going to make me angry Nierenberg had other ideas. "What I really wanted," he says, "was to with any drug-company pens in there?" he asks. His mock glare is soft- spend about a third of my time teaching, about a third of my time as ened by his unruffled voice and quick grin. "No," she laughs. A fellow a physician, and about a third of my time doing research." He and his student had already warned her about Nierenberg's disdain for the wife also wanted to move back to New England. One night, they won- way many pharmaceuticals are marketed to physicians. dered if Dartmouth might be the right place. They'd always enjoyed "Good. Because I go into anaphylactic shock when I see drug-com- visiting New Hampshire on long weekends and vacations. The very pany pens," he says, feigning shortness of breath. Nierenberg is cre- next day, out of the blue, Nierenberg got a letter from DMS. "It was ative in the way he conveys his strong opinions about pharmaceuti- literally the next day!" he says, still awed by the timing.
cal marketing. For example, he has a "dirty-pen swap," offering stu- DMS needed someone with his kind of training to set up a division dents a chance to turn in the free, often fancy, pens they get at drug of clinical pharmacology, teach a new fourth-year pharmacology company-sponsored luncheons and lectures for a "clean" pen. course, and do whatever else that person wanted. Nierenberg accept- "This is all voluntary and educational. I've never confiscated," con- ed. To his surprise, what he enjoyed most was teaching and designing tends Nierenberg. Is it true that he's broken some students' pens? He courses. "Between 1981 and 1991, we developed the most intensive, explodes with laughter. "Wow, that myth has grown." best, required clinical pharmacology course, almost certainly, of any But the dirty-pen swap is sometimes a tough sell. "See," he ex- medical school," he boasts.
plains, "the drug companies hand out $7 or $8 pens" that are color- ful, thick, and comfortable in one's hand. His are skinny, bright-or- ange, 39¢ knock-offs that say "DHMC Clinical Pharmacology Rx: In 1995, then-Dean Andrew Wallace, M.D., appointed Nierenberg
to the newly created role of associate dean for medical education.
Prescribe the BEST drug!" Ever since, Nierenberg has been helping DMS move to the fore- The message has great significance for Nierenberg. Teaching med- front of medical education. Under his leadership, the school has re- ical students how to prescribe the best medicines for their patients is duced redundancy among courses; changed the ob-gyn rotation to in- what got him interested in course design and educational administra- clude general outpatient women's health; infused more clinical mate- tion. But his interest in medicine goes back even further, to when he rial into the first two years and more basic science material into the was a kid and observed the work of his family internist. "That looks clinical years; and established itself as a national leader in medical ed- like a nice combination of service and science," he remembers think- ucation and medical education research (see page 7). "We are teaching stuff we didn't do 10 years ago," Nierenberg says.
Jennifer Durgin is Dartmouth Medicine magazine's senior writer. "Medical ethics, cultural competency, increased attention on com- 62 Dartmouth Medicine munication skills, whole new cur- search. She helped to develop ricula on how the health-care sys- ClinEdDoc, DMEDS's predeces- tem works, how to work in teams, sor, and has worked with Nieren- how to try to improve what you berg for 10 years. "He has been very insightful about the evolu- But to improve, one must first tion of medical education," she evaluate the status quo. Nieren- says of her colleague. "He's always berg's favorite tool for assessing looking to improve it." medical education is the Dart- Carney is also familiar with mouth Medical Encounter Docu- Nierenberg's willingness to speak mentation System (DMEDS), out on issues he thinks are im- launched in July 2004. He leans portant. "Boy, if he really believes forward in his squeaky office in something, he stands there for chair, opens the DMEDS data- it," she says, in a way that suggests base, and starts reading aloud she's been on the receiving end Dartmouth medical students know that if they use a free drug-company pen like this
from it: "Patient was mentally of his resolve more than once.
one around pharmacologist David Nierenberg, he'll start to pitch his "dirty pen swap."
disabled. Much of the history was And Nierenberg really be- provided by a friend/employer. Patient was 52 years old and had nev- lieves that using pens and other freebies to market pharmaceuticals to er seen a doctor." This is just one among thousands of entries made physicians is wrong. The "dirty" pens he collects from students are by students about patient encounters during their clinical rotations.
relegated to a box on the crowded shelves of his lab. And on the top "That's a really powerful statement of how hard that student had to shelf sits a larger box labeled "Hall of Shame," which contains such work to find out what was going on with that patient," Nierenberg doodads as a colorful "Ene-man" superhero advertising Fleet enemas says. The data in the system is used in the aggregate to see what gaps and a stuffed, talking "stuffy nose" embroidered with "Allegra-D." there may be in students' experiences and to ensure consistency among numerous clerkship sites.
Some of the inspiration for DMEDS, which Nierenberg helped de- Such "crap," he says, is "getting in our way" and preventing doc-
tors from being "clear-headed about prescribing the drug that is velop, came from his work in the late 1990s on a national committee most effective for their patient, safest, and—all other things be- that revised the U.S. Medical Licensing Exam. The committee con- ing taken care of—least expensive." The idea that a trinket could al- verted a multiple-choice section to interactive computer-based case ter physicians' prescribing practices is pooh-poohed by some. But, studies. Now, the exam presents fictional patients. Students can ask Nierenberg asks, would drug companies spend billions of dollars a year for the patients' histories, physicals, and lab-test results and then must on marketing if it didn't work? "It's about name recognition," he in- select diagnoses and treatment plans.
sists. "That's what's in a pen. It alters perspective." Nierenberg reads another DMEDS entry: " ‘Patient's from Liberia His favorite anecdote to illustrate this point is one that a fourth- and spoke a different dialect of English.' This student had to learn to year medical student wrote about for the clinical pharmacology course rephrase questions in ‘a more simple and clear way to facilitate direct he developed. In her paper, the student described the excitement of communication,' " he explains. "That's an advanced communication nailing her first diagnosis—otitis media, a middle-ear infection. When skill. That's what we want our students to wrestle with before they go her resident asked what treatment she'd recommend for the four-year- out and be a doctor." old patient, the first antibiotic that came to her mind was Augmentin.
Other medical schools have computer-based systems that record A few hours earlier, at a drug-company-sponsored lunch, she'd re- clerkship experiences. But Dartmouth appears to be the first to track ceived a pen emblazoned with: "Augmentin: unsurpassed in the treat- its students' acquisition of the competencies now required by resi- ment of otitis media." dency programs; it's expected that these competencies will soon be re- "So what happened?" asks Nierenberg. The resident agreed with quired of medical students, too. They cover six areas: medical knowl- the student and handed a prescription for Augmentin to the child's edge; clinical skills for patient care; interpersonal communication mother. But when the mother went to fill it, she discovered that the skills; professionalism; practice-based learning and improvement; and drug cost $80—and she had no insurance. Too embarrassed to ask for the ability to navigate a complex health-care system. a cheaper medication, she never filled the prescription. Three days lat- The fact that DMEDS is based on these competencies is "huge," er, the child was admitted to the emergency room with bacterial says Patricia Carney, Ph.D., DMS's assistant dean for educational re- continued on page 69 Dartmouth Medicine 63 Faculty Focus: Nierenberg continued from page 63 meningitis—the worst-case consequence of an untreated ear infection. There's a 90% to 95% chance that a generic antibiotic, cost- ing only $10 to $20, would have been effec- Margaret values her tive, says Nierenberg. But doctors all over the friendships. Whenever she country prescribe expensive, name-brand needs a ride, she knows drugs instead of cheaper, often just as effec- tive, generics. A long list of studies in promi- she can count on her nent journals has documented that drug- friends to help. When she company marketing does alter physicians' needed high-quality eye prescribing practices. care, a good friend Yet Nierenberg is not "anti-drug compa- ny," he asserts, just anti-gift. Not accepting recommended DHMC.
drug-company freebies is one way to combat Margaret is so pleased with the rising cost of pharmaceuticals and pro- the care she receives that mote affordable health care, he believes. she decided to be a good His commitment to these causes also ex- tends into the community. For example, he friend to DHMC. She volunteers regularly at the Good Neighbor established a Charitable Clinic, a free clinic that serves the Upper Gift Annuity with funds Valley. He recruits DMS students to volun- from a matured CD. She teer there, too. On a recent busy evening at Good Neighbor, Nierenberg was helping a liked the idea of having a medical student and a resident think through fixed income for life, a each patient's condition before recommend- charitable tax deduction, and knowing her gift will support ing a treatment. If a prescription was needed, medicine and research at DHMC. If you ask Margaret, she'll say he'd prompt them to consider a generic drug.
"It's cheaper," he'd remind them. Doctors she didn't do anything special. After all, that's what friends are for.
must do their part to keep down the cost of health care, he believes—whether by pre- SAMPLE RATES
scribing generics whenever possible or by • guaranteed fixed income for life rejecting that free, fancy pen.
• partially tax-free income Alumni Album: Clark • charitable tax deduction • cash or appreciated assets may be gifted continued from page 65 people about the worldwide AIDS crisis. • income for one or two lives Clark, who has received several national Rates effective through awards for his work, including the Annie June 30, 2004 Dyson Award of the American Academy of Pediatrics, is currently a fellow at the Center Contact us today to learn more about this
for AIDS Prevention Studies at the Univer- and other types of planned gifts.
sity of California at San Francisco. He and Office of Gift Planning fellow soccer players have returned to Dart- mouth several times to help develop oppor- Toll Free: 1-866-272-1955 • E-Mail: [email protected] tunities for undergraduate and DMS students to participate in Grassroot Soccer. And in The Power of Partnership November, he participated in a three-day symposium at DMS on HIV/AIDS, "Great Issues in Medicine and Global Health." For all Clark's worldwide interests, getting back to his own grassroots is nice.
Dartmouth Medicine 69
More than twenty years ago, four college students asked each other: What if we could offer children from under-resourced communities individualized attention before they enter kindergarten, giving them the critical academic and social skills—the ‘jumpstart'—they need to succeed? The idea took hold and by 2015, Jumpstart had trained more than 40,000 college students and community volunteers, preparing over 87,000 children for kindergarten success. Jumpstart's program is replicated across the country in 14 states and the District of Columbia. We leverage partnerships with higher education institutions, Head Start, community-based preschools, and school districts to create sustainable solutions in order to close the kindergarten readiness gap.