the medical decoder fall 2014

MDTHE MEDICAL DECODER

Produced byPhi Delta Epsilon

IL Gamma Volume 4

“May I Have your attentIon?” The Misconceptions Among College Students

Surrounding Adderall Use

Establishing A Nexus Between Public

Health and Clinical Practice

The Anti-Vaccination Campaign: A

Retrospective Look

Hippocrates, Not Hypocrisy: Practice What You Preach

IN THIS ISSUEHuman Interest

Hippocrates, Not Hypocrisy: Practice What You PreachNicholas MartinRutgers University ‘16

Early Intervention for Autism TreatmentSarah LaudonUniversity of Wisconsin-Madison ‘16

Science & Technology

The Drug Development Odyssey Kevin ZhaoNorthwestern University ‘16

The Misconceptions Among College Students Surrounding Adderall UseElbert MetsCornell University ‘17

The Fusion of Medicine and TechnologyElizabeth ZborekNorthwestern University ‘16

Health Care and Policy

Establishing a Nexus Between Public Health and Clinical PracticeJane WangNorthwestern University ‘14

The Effects of the Anti-Vaccination Campaign: A Retrospective LookDanielle YinIndiana University ‘15

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38

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2 ■ The Medical Decoder ■ Phi Delta Epsilon IL Gamma

The Pre-Medical ExperienceBlood-Injection-Injury PhobiaStephanie LoNorthwestern University ‘15

The Medical School ExperienceGlobal Perspectives on Health: Treat Patients, Not DiseasesPaulo Tabera-TarelloUniversidad de Monterrey ‘16

Editors-in-ChiefAditya Ghosh

Sarah Smith

Editing StaffAnisha Arora

Brianna CohenTricia Cruz

Andy DonaldsonJay Mainthia

Jenna StoehrAlec Straughan

Jane WangDe’Sean Weber

Creative DirectorSvetlana Slavin

DesignersNicholas Giancola

Lauren KandellCarlos Mucharraz

Lan Nguyen

PhotographersJordan FlemingBryan Huebner

Alexis O’Connor

Online PR DirectorCynthia Stamelos

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Volume 4 ■ Fall 2014 ■ 3


Dear readers,Welcome to the fourth edition of The Medical Decoder (MD). As Editors-in-Chief

of this rapidly growing publication, we wanted to take the time to reflect upon the whirlwind journey that has culminated in the great success of this journal. The MD was founded just over a year ago by three pre-medical students with a vision and a Microsoft Word document. This vision was a powerful one: to help busy students stay aware of the changes occurring in the fields of medicine and health care and to provide an outlet to share concerns, passions, and experiences. The Word document was less impressive; the first draft employed uninspired fonts and simple Clip Art.

As often happens with new ideas, translating our original vision to a reality took time, patience, and hard work. However, the most pleasant realization along this journey was that our vision was a shared one; students were excited to get involved on all fronts, whether through writing, editing, designing, or just spreading the word. Throughout the development of the MD, we have learned that when a diverse group of students shares a vision, they can empower each other to generate a voice that resonates louder than any one could have individually.

As students who plan on entering health-related fields, it is important to express ourselves and connect with others who have similar aspirations. Learning more about our fields and keeping up with contemporary medical practices through easy-to-read and engaging articles empowers us to “decode” information related to health care. This will allow us to become better leaders and doctors in the future. As the world around us continues to change, it is crucial that we fully understand the fields that we will be entering, continue to share our concerns, and advocate for change when it is necessary.

This fourth installment of The Medical Decoder will be the last edition for both of us as Editors-in-Chief. It has been a joy to see how this publication has grown, and we are very excited to see where the next Editors-in-Chief will take the journal. Thank you for your continued interest in our publication. Your support over the past year has been vital to our success, and we greatly appreciate your help in spreading our message. On behalf of Phi Delta Epsilon IL Gamma as well as the rest of the MD team, we would like to welcome you to the fourth edition of The Medical Decoder.

Sincerely, Aditya Ghosh & Sarah Smith Editors-in-Chief, Co-Founders([email protected], [email protected])

L E T T E R F R O M T H E E D I T O R S

humaninterest:

Human Interest ■ Volume 4 ■ Fall 2014 ■ 5

Hippocrates, Not Hypocrisy:Practice What You Preach

By Nicholas Martin

I magine this scenario: you are a smoker sitting in the waiting room

of your doctor’s office because you have been having trouble breathing. You gaze out the window and notice your doctor take one final drag be-fore discarding the ashy remains of his cigarette. When he comes back to his office, you can still smell the smoke on his clothes and on his breath. He takes one look at his notes before stating his expert med-ical opinion: you need to quit smok-ing because it is detrimental to your health. Health care professionals ad-vise patients on how to best main-

tain their health, but what happens when physicians fail to heed their own advice? Doctors often tell their patients to lose weight or to quit smoking. However, a double standard can lead to strain on the patient-doctor relationship and mistrust of future

medical rec-ommenda-tion.1 Re-search has shown that physicians

failing to practice what they preach can negatively affect patient health.1

According to the Center for Dis-ease Control (CDC), a shocking 69% of adult Americans ages 20 and old-er are either overweight or obese.2


Some physicians involved with this initiative could benefit from following the

movement themselves.

“ “


These individuals are at risk for de-veloping complications such as dia-betes, hypertension, arthritis, and cancer. As part of the Healthy People 2020 initiative, a platform designed by the federal government to build a healthier nation, a large-scale plan is being implemented to promote health and wellness in Americans within the next few years. The plan includes health care professionals working to encourage people to be-come physically active and devel-op healthier life-styles.3

Coinciden-tally, some phy-sicians involved with this initia-tive could benefit from following the movement themselves. The CDC reports that 37% of male physicians and 26% of female physicians are classified as overweight.4 Further-more, a study at Yale University identified that obese physicians face a stigma of lacking willpower, disci-pline, and intelligence in the eyes of their patients. The study found that adults are less likely to trust their physician’s medical advice and more

likely to change medical providers if their doctor is overweight.5,6

When it comes to smoking, phy-sicians are much better at practicing what they preach. Between 1974 and 1991, smoking prevalence among physicians dropped from 18.8% to 3.3%. Furthermore, in 2011, 18% of Americans were self-identified as smokers, while only 2% of male and 1.28% of female physicians smoked.4 Physicians seem to be

gaining a great-er understand-ing of either the negative health conse-quences, or the profession-al consequenc-es of smoking. Although the

number of physician smokers is low, patients who are aware that their physicians smoke are still less likely to heed medical advice.7 Because physicians, as health care professionals, are at the front lines of the battle against smoking, it is imperative that they set good ex-amples for their patients. The Med-scape Physician Lifestyle Report stated that approximately 25% of

A double standard can lead to a strain

on the patient-doctor relationship

and mistrust of future medical

recommendation, which can further compromise

a patient’s health.

““


physicians see around 100 patients per week, and many see thousands of patients annually.4 Therefore, it is imperative that doctors practice what they preach, not only so that patients will heed their medical ad-vice, but also to serve as role models. Physicians, however, are only human. With lengthy shifts and packed schedules, it is understand-able why they may occasionally over-look their own health. One of the best examples of this can be seen during a doctor’s residency. Sec-ond-year residents can work for up to 28 consecutive hours.9 This work-load, along with expensive student loans and a salary averaging at about $50,000, can limit both the time and resources one needs to maintain a healthy lifestyle.10 These factors also contribute to stress. One physiolog-ical response to long-term stress is

the release of cortisol, which can lead to excess fat accumu-lation over extended periods of time.11 This added weight could put a physician at a risk for a slew of chronic diseases, just as it could for his or her patients.1

As we continue moving forward with wellness initia-tives in health care, it is neces-sary that the next generation

of doctors is mindful of maintaining healthy lifestyles. There is also an im-portant takeaway for patients: busy work hours, salary, and stress are all contributing factors to why certain physicians may fail to follow healthy behaviors. Like many sensitive is-sues, the importance of physicians practicing what they preach has two sides. Patients should acknowledge the importance of following their doctors’ recommendations regard-less of their doctors’ physical ap-pearance. Additionally, physicians must also recognize the negative im-pact that their actions can have, and their potential to inspire positive behaviors in their patients by lead-ing healthy lifestyles. ÌMDFor references, see page 52.


Early Intervention for Autism Treatment

By Sarah Laudon

A utism spectrum disorder (ASD), according to the Centers

for Disease Control (CDC), is a group of developmental disabilities that can cause significant social, commu-nicative, and behavioral challenges.1 These challenges can range from dif-ficulty maintaining a conversation or eye contact with somebody to struggling with transitions to new things. Autism contains a wide spec-

trum of symptoms that often comes with co-diagnoses of developmen-tal, psychiatric, neurological, chro-mosomal and genetic conditions.1 Because ASD covers a vast array of conditions and symptoms, multiple fields including pediatrics, prima-ry care, psychology, and neurology are involved in the treatment of this disease. Therefore, it is all the more important that future health care providers become cognizant of this disorder and its available therapies.


”

”

Because of the prevalence and

complexity of autism in children today, autism centers are becoming

more common in America.

Due to better diagnostic tools, children with ASD are being diag-nosed at a younger age, some as young as 18 months.1 According to the CDC’s Autism and Developmen-tal Disabilities Monitoring Net-work, it is esti-mated that 1 in 68 children have ASD. 1 Because of the prevalence and complexity of au-tism in children to-day, autism centers are becoming more common in America, offering both in-home and center-based therapies for children and adults with an ASD

diagnosis. Autism centers provide very direct, individualized services, as each child comes with his or her own set of symptoms. The Rochester Center for Au-

tism (RCA) in Rochester, Min-nesota, where I have worked for the past three summers, is a center that prac-tices Applied Be-havioral Analysis (ABA) therapy.

ABA is known to be an effective treatment for in-dividuals with autism, especially young children.2 This method aims

to reinforce positive and ap-propriate behaviors, such as focusing on tasks, engaging in social interactions (i.e. eye contact, playing with a friend), and completing academic pro-grams.3 There are many ways to reinforce desired behav-ior including giving students snacks, letting them play with toys that they were previously engaged with, singing songs or praising them for their great work. Providing the students


with something that they want in-creases the likelihood that these be-haviors will continue.2

All therapy at the RCA is per-formed with one therapist and one student paired together during the day. The training process for ther-apists at the RCA is intensive. Be-fore a therapist and child are paired together, the new therapist must spend several days shadowing an experienced staff member, playing with the child, observing all aca-demic programs and behaviors, and learning the behavior plans. When the new therapist is ready, he or she is observed by a trained therapist and given constructive feedback. An essential component of the pairing

process is for the child to rec-ognize, before he or she is sub-jected to any demands, that the therapist is a fun person to be with. As the relationship builds between the new ther-apist and child, the therapist slowly places demands. This creates a positive relationship and sets the child up for suc-cess. One of the most import-ant skills the center teaches is how to “mand” items. The term “mand” is commonly

used in autism therapy, and it sim-ply means to request. Teaching an autistic child how to request helps develop language and communica-tion skills. American Sign Language or pictures will often be used to ask for items such as a ball, swing, or wa-ter. As the student becomes famil-iar with requesting what he or she wants, the therapist begins to work on developing vocal skills. Many of the students, including one of my own, begin at the center with sign language and later develop vocal skills. Getting a child to mand is not difficult. Before giving a child what he or she wants, the therapist has


him or her request it. An example of this is stopping a swing and having the child request “swing” before giv-ing him or her another push. Most of the students at the center require a daily mand track, where therapists write down their mands and prompt levels. Prompt levels vary for the types of manding - vocal, sign lan-guage, and pictures.

Here are a few types prompt levels:Independent: When the child re-quests the item all on their own; this can be with pictures, vocalizations, and sign language. Vocal prompt: When a child requires the therapist to tell them vocally to request the item; this can be with pictures, vocalizations, and sign lan-guage. Partial physical prompt: Having to assist the child in a sign placement or slightly moving their hand to the desired picture; this can be with sign language and pictures.Full physical prompt: This requires full help from the therapist to select the picture of the item or create the desired sign; this can be with sign language and pictures.

By tracking mands and prompt levels daily, it is easy to see the child’s progress. The therapist records the student’s speech so he or she can monitor the child’s improvement in word clarity. An example would be saying the word “computer” to have the therapist turn it on or play a game. A child might start out saying “puter” and then as time progress-es, will begin saying “caputer” and eventually “computer.” There are many different pro-grams at the center, ranging from so-cial to academic. The style of teach-ing utilized is unique in that it is built into 15 minutes intervals. Pro-grams are designed to be completed in 15 minutes, so that the program-ming can be broken up into smaller time chunks with breaks in between. In order to monitor the progress of a child, a baseline is established by collecting data on how the child per-


””

With the increasing rates of autism, it is critical that future

health care providers, including physicians, PAs, and nurses, have

an understanding of how to best work with these

patients.

forms on their first program of the day, a test that is referred to as a “cold probe.” Programs are targeted throughout the day to continually build a given skill and observe any performance changes. Academic programs can also run off of the table with natural en-vironment teaching (NET). The NET training method allows for a vari-ation of pro-grams to pro-ceed while the child is mov-ing around the center, from counting, shar-ing with peers, imitating a therapist, and kicking a ball. Counting and social skills, for example, can easi-ly be taught while a child is playing on a slide with peers or jumping on a trampoline. The Rochester Center For Au-tism has taught me to always con-sider the best interest of a child and to help them achieve their highest level of potential. While it may be necessary to track a child’s negative

behaviors, it is equally important to acknowledge the improvements and positive behaviors he or she displays. Learning these skills and philoso-phies, working with these children, and realizing the prevalence of ASD today inspired me to pursue a career where I can continue to work with autistic patients. With the increasing rates of

autism, it is critical that future health-care providers, including physi-cians, PAs, and nurses, have an understanding of how to best work with these pa-tients. Not only is it important to provide au-tistic individu-als with the re-

sources that can help them become a productive member of society, but it is also essential to recognize the significant positive impact that in-terventions at a young age can have on a child’s life.


I n order to portray an average morning for a student at the center, I followed around one of my students, Cheyenne, from

9:00am-noon. Cheyenne is 6 years-old and has been at the center for a couple of years. I was put on her team this summer, and it has been a joy to watch her develop!

9:00-9:05am: Cheyenne checks into the center, just like one would at school. Cheyenne takes her lunch box to the kitchen and puts it in the fridge.

9:05-9:20am: After a morning bathroom break, the therapist begins playing with Cheyenne before running morning programs. These games are fun for Cheyenne!

9:20-9:35am: The cold probe is run and Cheyenne takes part in her first program of the day.

9:40am: Cheyenne requested to use the bathroom and because she asked, she gets her highest reinforcement: the swing!

9:55 am: The therapist runs a morning mand track for Cheyenne, and Cheyenne requests the computer. Cheyenne waits in line. She later requests “Care Bears” and watches a video on YouTube. The therapist pauses the video every 20 seconds or so for Cheyenne to mand for “play” or “computer.”

10:15 am: Cheyenne requests to play in the toy room.

A Typical Schedule at the


10:30am: After the mand track is over, Cheyenne’s therapist runs a NET program where Cheyenne must follow instructions. This specific program requests that Cheyenne go to two different therapists on her team and complete two actions. Today, the request was to “give Ashley a hug and Sarah a high five.”

10:45am: A table session is run. Because the cold probe is finished, the therapist runs an errorless session. An errorless session consists of the same program as the cold probe, but if the student is about to make an error, the therapist will interject and prompt the correct answer.

11:00am: The therapist gives Cheyenne an option of trampoline or books. Cheyenne chooses books. The therapist waits before turning each page for

Cheyenne to mand “turn the page.”

11:20am: Cheyenne requests to go to the ball pit, and then changes her mind to go to the indoor swing instead. When choosing activities, it is important to keep the 80-20 rule in mind- 80% of the activities are the student’s choice, 20% are the therapist’s choice. This is to make sure the student is learning to transition and engage in activities that are not always his or her immediate preference. Again, the therapist at the swing waits to push until Cheyenne mands “swing.”

11:40am: Cheyenne and the therapist return back to the table for another round of errorless. While the therapist is

marking down a round of errorless and preparing for the program, Cheyenne reads a story. Noon: Cheyenne heads off to lunch! ÌMD

For references, see page 52.

Rochester Center for Autism


health care & policy :

Health Care & Policy ■ Volume 4 ■ Fall 2014 ■ 17

T he relationship between pub-lic health and clinical practice is

easy to overlook. The former is of-ten associated with an overarching, big-picture approach that addresses issues plaguing populations, while the latter is seen as more individual-ized and personal. However, despite such distinctions, the two are inextri-cably linked. This link is often apparent in the treatment of diseases, a primary duty of physicians. While treating illness-es is an important part of maintain-ing health, well-being stems from a complex web of factors that relate to public health issues, such as access to healthy food, neighborhood safety, exercise, stress, and education.

The mutually dependent nature of the two fields is especially appar-ent in underserved neighborhoods. For example, neighborhoods of lower socioeconomic status are more like-ly to be food deserts, areas where it is difficult to purchase nutritious, healthy produce. According to the United States Department of Agricul-ture (USDA), a neighborhood is offi-cially deemed a food desert if “at least 500 people and/or at least 33% of the census [region’s] population resides more than one mile from a super-market or large grocery store.”1 Low access to healthy food means that residents of these neighborhoods are more likely to resort to fast food for sustenance, a habit that has ad-

Establishing a Nexus Between Public Health and Clinical Practice

By Jane Wang


verse short and long-term effects on health. Food deserts can contribute to an abundance of health issues like cardiovascular disease, diabetes, and certain types of cancer.2

In addition to accessibility to food, another important public health factor that affects overall well-being is neighborhood safety. Underserved neighborhoods typically have higher crime rates. These high crime rates can a direct threat to one’s physical wel l-being , and can be an additional barrier to ob-taining health care. Those who reside in dangerous neighborhoods may not feel safe going out-side, limiting mobility and exercise.4 Unsafe envi-ronments can also place increased levels of stress on its residents. This stress can lead to a variety of health issues such as high blood pressure, heart disease, obesity, and diabetes.3

Areas of lower socioeconomic status are also more likely to be in-habited by people with less access to higher education. Lower levels of ed-

ucation can make it more difficult to find jobs with adequate salaries. With insufficient financial resources, it is harder for individuals and families to afford healthy foods or move out of those unsafe neighborhoods.5

Thus, factors that are often deemed “public health” issues have a direct consequence on both individu-als’ health and the nature of patient populations that doctors encounter in their daily practice.

I was able to observe the re l a t i o n s h i p between pub-lic health and private prac-tice during an internship exper ience. Throughout the spring quarter of my

senior year as an undergraduate stu-dent, I worked at a clinic in the heart of South Chicago, an established food desert plagued by issues like high levels of crime, unemployment, and poverty. Patients who came to the clinic often lacked basic resources to achieve and maintain a healthy life-style. For example, I regularly saw pa-tients who needed assistance locating

””

Low access to healthy food means that residents of

these neighborhoods are more likely to resort to

fast food for sustenance, a habit that has adverse

short and long-term effects on health.


soup kitchens because they did not have sufficient food for themselves and their families on a day-to-day ba-sis. Other patients could not afford transportation to and from doctor appointments; it was not uncommon to see people miss appointments for this reason. To address these issues, the non-profit organization (NPO) that placed me at this clinic forged a partnership with the physicians there. After the doctors saw patients for their medi-cal needs, volunteers from the NPO would speak to patients to address any non-medical resources they need-ed, including food and employment. In this way, fundamental necessities that impact health were addressed in addition to the actual illness. To see people from all areas of the health care sphere – physicians, MBA grad-

uates, college students, and social workers – work together to im-prove the health of pa-tients was humbling. It made me realize that physicians, although immensely important for maintaining health, are ultimately part of a wider web of support for their patients. Health cannot be

viewed through a narrow lens that only focuses on the immediate prob-lems presented by a patient. Well-be-ing is impacted by a myriad of factors and circumstances, all of which com-bine to weave a complete picture of patient health. Choosing to only treat immediate health concerns rather than to address overarching issues al-lows fundamental problems to go un-noticed. Thus, although the domains of public health and clinical practice are often viewed as separate spheres, it is imperative that a nexus between the two be established in order to ad-dress issues that impact both individ-uals and populations. ÌMDFor references, see pages 52-53.

The Effects of the Anti-Vaccination Campaign: A Retrospective LookBy Danielle Yin


The Effects of the Anti-Vaccination Campaign: A Retrospective Look I never enjoyed receiving shots at the

doctor’s office. Although I can handle that painful prick of the needle without causing a scene, I cannot help but feel a momentary spark of anger at my parents and my doctors whenever I have to endure that uncomfortable experience. Still, my dislike for receiving vaccinations is outweighed by my appreciation for what they have done for society, as they have virtually eliminated many preventable diseases. However, not everyone shares my appreciative sentiment. The recent uprising of anti-vaccination campaigns has alarmed physicians across the United States and the United Kingdom. As the facts regarding the harmful effects of these campaigns emerge, it is essential to educate ourselves on the origins of these movements and on the importance of public vaccination.



While skeptics who oppose vacci-nations have always existed, our gener-ation has bore witness to an anti-vacci-nation campaign that could have lasting consequences. The start of the modern movement can be attributed to Dr. An-drew Wakefield, a British surgeon and researcher. In 1998, Wakefield published an article in The Lancet that claimed that the MMR (measles, mumps, and rubella) vaccine could cause autism spectrum disor-ders and bowel problems.1 He insisted that the vaccine led to au-tism symptoms in eight of the twelve children that he studied, and he concluded that the vaccina-tion program was not safe. Wake-field’s assertions raised controversy in the UK, leading to a sharp decline in the country’s vacci-nation rate. Overall immunization rates dropped to 84% in 2002, an 8% decrease from the national immunization rate be-fore the publication of Wakefield’s arti-cle. In London, rates of vaccination for MMR hit an unsettling low of 61% in 2003.1

Wakefield’s research was soon proven to be false, as subsequent epide-

miological studies failed to find a casual relation between the MMR vaccine and autism.1 Unfortunately, this false infor-mation had already taken its toll. Many parents took Wakefield’s research as fact, and soon the anti-vaccination campaign of the 21st century began to spread. Ce-lebrity activists like Jenny McCarthy supported the claim that vaccines could cause autism, ushering the anti-vac-

cination campaign into the public eye. McCarthy used her son as an example of the dangers vac-cinations pose to children. She pas-sionately claimed that one of her son’s vaccinations consisted of thi-merosal, a mer-cury-containing compound pre-viously used as a preservative in

vaccines. She argued thimerosal caused her son to develop autism. Despite the lack of a reputable scientific connection between thimerosal and autism, many anti-vaccine parents protested its use in commonly administered shots. As a pre-cautionary measure, all childhood vac-cines, with the exception of some flu vac-cines, are now created without the use of thimerosal.2

Anti-vaccine parents have chosen

””

The harmful effects of anti-vaccination

campaigns have manifested in the rising

rates of preventable illness. From 2011 to 2012 in the US,

whooping cough cases increased more than

threefold in 21 states.6


to evade the vaccination requirements set by many schools, citing personal or reli-gious reasons. Despite evidence support-ing the effectiveness of vaccines, many parents also doubt the effectiveness of vaccines, calling into question whether or not these immunizations actually pre-vent the diseases they claim to. Studies have found that the chance of outbreaks of diseases such as pertussis, commonly known as whooping cough, is 2.5 times greater in areas that permit personal-be-lief exemptions.3 The decline in vacci-nation rates has also caused an increase in mumps cases. In early 2005, almost 5,000 cases of mumps were reported, a dramatic increase compared to the few cases that were present in the late 1990s.4

While some parents claim that it is their right to choose whether or not their children get vaccinated, they fail to com-prehend the nature of how infectious diseases are spread. By sending their un-vaccinated children into the general pop-ulation, parents damage the concept of herd immunity. In order to protect those who cannot be vaccinated for reasons such as pregnancy, age, or health, 95% of the population must be immunized.5 When this percentage falls, previously avoidable diseases like polio or measles can re-emerge. This has already been seen in California, where only 91% of kinder-garteners were vaccinated in 2010. These lower vaccination rates played a major role in a massive pertussis outbreak.5

The harmful effects of anti-vacci-

nation campaigns have manifested in the rising rates of preventable illness. From 2011 to 2012 in the US, whooping cough cases increased more than threefold in 21 states.6 Looking forward, easily pre-ventable diseases may re-emerge, caus-ing unnecessary danger to both patients and the health care system. It may be time to make changes to the way doctors approach the topic of vaccines with their patients. Instead of waiting until the typical two-month checkup, a pediatrician can address the subject during pregnancy so expecting parents can have time to do research and make an informed decision regarding vaccinations. To emphasize the necessity of vac-cination, doctors should share facts as well. For example, recent studies involv-ing children in Colorado showed that unvaccinated children were nine times more likely to contract chicken pox and six times more likely to end up hospital-ized with pneumonia.7 Parents need to be reassured of the quality of testing uti-lized in vaccine safety studies, a system that operates independently from the pharmaceutical companies that man-ufacture them.7 As the next leaders in health care, it is our responsibility to ed-ucate future parents in order to prevent the anti-vaccination trend from causing lasting harm. ÌMD



science & technology:


The Drug Discovery Odyssey

The Drug Discovery Odyssey

a Glimpse iNto pHarmaceutical aNd academic druG developmeNt

By Kevin ZhaoEndorsed by Professor Richard B. Silverman

Penicillin. Ibuprofen. Aspirin. These are just a few examples of drugs that have benefited our

society. It is incredible how far drug discovery has come; we can manip-ulate biology and use organic mol-ecules as vehicles to treat and cure various diseases. With these advance-ments, we can selectively target var-ious symptoms and extend the aver-age lifespan. While these treatments have greatly contributed to society, they also are tremendously costly to develop and produce. This ap-plies not only to consum-ers who purchase these drugs,

but also to the researchers and phar-maceutical companies that spend years trying to develop effective med-ications. The process of discovering and developing pharmaceuticals is ex-tremely complex. It encompasses fundamental understandings of hu-man biology to recognize how the body’s functions can be modified,

utilizes organic chemis-try to seek a man-made


cure, and requires biochemistry to develop the various properties and mechanisms of a drug. Drug discov-ery begins by first utilizing a biologi-cal model that reflects the properties of the disease or condition of interest. Then, the model’s activity is probed with various chemicals from a large chemical library. This enormous ar-ray of compounds is selectively fun-neled throughout the development process to an end product of one FDA-approved drug. One of the most common mod-els used in this method is a cel-lular-based drug assay, in which cells that mimic the main condi-tions of certain diseases are cul-tured and run through a large chemi-cal assay. After running this chemical test, scientists are able to select a few com-pounds that show potential in treat-ing the disease. These compounds are the ones that appear to reduce symp-toms of disease in the biological mod-el. The compounds are then sent to the organic and medicinal chemists who modify the compounds’ chemi-cal structures in various ways. Many

times, this involves making minute structural adjustments, like changing a fluorine atom to a bromine atom. Next, the chemists send the com-pounds back to the biologists who run another assay to see if the new chemical has any effect. This is one of the most time-consuming steps in the entire drug development process because of the many possible changes that can be made. Sometimes, a single carbon can be the difference between a toxin and a cure.

Advancements in technology have had major im-pacts on drug dis-covery. Chemists often use com-puterized model-ing programs to

predetermine how certain structural changes may affect a compound’s activity. Howev-er, many properties of the targeted protein or enzyme must be known to perform such a study. If the neces-sary data are available, the program is able to visually plot the protein and fit various chemical shapes into a tar-geted pocket. This will predict chem-ical interactions with the protein. Although this technology has been extremely helpful for researchers, it is

””

Each stage brings a new layer of complexity,

progressing from a single cell model, to an animal,

and eventually to a human being.

still developing. Sometimes, the pro-gram may predict activity, while in re-ality the chemical is inactive. The pro-gram might also fail to predict certain chemicals that could effectively treat a disease. Even with this technology, hundreds of chemicals still need to be synthesized before finding the one that has the desired activity in a bio-logical model. When a drug has shown prom-ise, it is tested in animal studies to further examine the properties of the compound. One important step to-wards achieving a better understand-ing of the compound’s characteristics is determining the pharmacokinetics of the drug, which means determin-ing what happens to the drug once it enters an animal’s body. To compre-hend the pathways a drug follows, researchers must inves-tigate its absorption rate into the blood-stream, distribution to the various tis-sues, degradation, and elimination from the body. It is also important to note that even if the drug shows activity in the initial biological model, this does not guarantee that the compound will show activity in the animal model.

Each stage brings a new layer of com-plexity, progressing from a single cell model, to an animal, and eventually to a human being. If the drug is successful in the animal models and is shown to be nontoxic, it is then moved on to clinical trials. From the hundreds of thousands of chemicals in the ini-tial chemical library, only a hand-ful of compounds actually enter this stage. However, many do not make it through the clinical trial. With each phase, the number of patients tested increases, and the drug has to pass more rigorous tests. While drugs may have shown promising results in the animal studies, they may fail to pro-duce similar results in human trials. For example, some drugs have ap-

Science & Technology ■ Volume 4 ■ Fall 2014 ■ 27


Success stories in the realm of academic drug development do exist. Dr. Richard B. Silverman’s discovery of LyricaTM, also known as pregab-alin, serves as an example of academic drug research that made the leap into industry. Silverman’s path to successful drug discovery highlights the time, effort, and potential payoff of academic drug research. Silverman joined the chemistry department at Northwestern Uni-versity in 1976 and began researching various small molecules that af-fect the level of gamma-aminobutyric acid (GABA) in the body. It has been shown that “when GABA levels fall too low in some people, it can trigger epileptic seizures.”3 Therefore, Silverman’s lab developed various compounds to increase GABA production in the body. However, the drug that brought acclaim to Silverman and his re-search did not actually alter GABA levels. In fact, the discovery of Lyri-caTM was a surprising one. According to The Chicago Tribune, “Silverman’s experience suggests finding a chemical that turns into a billion-dollar drug takes as much luck as winning the lottery.”4 While it did not affect

peared to “cure” diseases such as ALS in animals, but fail to have the same effect in clinical trials. The process of drug discovery can be long and tedious, with count-less obstacles prior to introduction into the market. Unsurprisingly, such a process requires a great deal of money to fund the work and time it entails. A recent Forbes study has shown that larger pharmaceutical companies spend up to $6.3 billion

per drug, while smaller companies spend up to $2.8 billion.2 Due to the extremely high cost in researching and developing med-icine, most of the research is per-formed industrially, as opposed to in an academic environment. Large pharmaceutical companies such as Johnson & Johnson and Pfizer, Inc. dominate this industry, as they pos-sess the money to fund this type of research.

Developing LyricaTM: Silverman Strikes Gold


GABA levels as was initially hypothesized, LyricaTM still showed incred-ible efficacy in the treatment of epileptic seizures as well as other ill-nesses, such as neuropathic pain and fibromyalgia. In November 1990, Silverman applied for a patent, which was not approved until March 2001. When Silverman first noticed a few com-pounds that showed great results in affecting GABA levels, he began to look for companies that would be interested in partnering with him to continue the study of these chemicals. Two companies demonstrat-ed interest in this study: Upjohn Pharmaceuticals and Parke-Da-vis Pharmaceuticals.6 Upjohn only asked Silverman for the compound with best activity, whereas Parke-Davis asked for all of the compounds. The drug initially thought to be the best candidate was not effective when studied further. However, one of the compounds in the library of chemicals sent to Parke-Davis showed high potential. Though its official mechanism of action was not yet fully understood, the performance of the compound proved to be so convincing that Parke-Davis and Northwestern proceeded to sign a patent option agreement in December 1991. Over the next six months, Parke-Davis used the compound to per-form many animal studies such as pharmacokinetics and metabolism experiments. Afterwards, another two years were spent on studying an-

Dr. Richard Silverman of Northwestern University

imal toxicology and on synthesizing a specific enantiomer. In December 1995, Parke-Davis filed an investigational new drug application, which allows for clinical studies on a compound before approval by the US Food and Drug Administration (FDA). Phase I of clinical trials started in late 1995 and lasted for two and a half years. A combined Phase II/III trial was then performed from 1999-2003, which involved 100 different clinical trials and tested over 10,000 patients. In 2000, Pfizer bought

Warner-Lambert, which had ac-quired Parke-Davis in 1970, so Pfizer continued studies on the compound. It was also around this time that the compound started being referred to as “LyricaTM”. When Pfiz-er took control of the research, they pushed aside Silver-

man, the initial inventor. As Silverman said, “I became an outsider...There was no longer the possibility to talk with their scientists. No com-ments. They had a launch party for the drug, and I asked to come. Nope. No party for me. They take your stuff and tell you to go away.”4 This is where academic and industrial research part paths and utilize different ideologies. Large pharmaceutical industries are able to research new


The Richard and Barbara Silverman Hall for Molecular Therapeutics and Diagnostics at Northwestern University.

medications as long as they have exclusive profit rights, which requires secrecy about what they are doing. In academia, innovative science, which includes collaboration and publication, is the principal driving force. After continuous success, Pfizer filed a New Drug Application in October 2003 to request approval for LyricaTM to become a commercial product. This was approved by the FDA in 2004. In 2006, during the drug’s first full year on the market, LyricaTM had $1.2 billion in global sales. The next year, Northwestern sold a sizable amount of the royalty interest of LyricaTM to Royalty Pharma for $700 million. With this, Sil-verman donated part of his royalties to Northwestern to help build a new building for molecular therapeutics and diagnostics. His goals were to broaden the research environment and continue to bring great pro-fessors from around the world to the university. Although Silverman hit a scientific jackpot, he continues to perform outstanding research on drug development and hopes to help find treatments for various neu-rodegenerative diseases such as Parkinson’s, ALS, and Huntington’s. In a competitive research environment dominated by major pharmaceuti-cal companies, Silverman’s development of LyricaTM serves as a source of inspiration to other academic drug researchers. While few drugs go on to become blockbuster drugs like LyricaTM, advancements in technology and a greater understanding of the hu-man body offer promising developments. Drug development, whether academic or industrial, offers hope for the future of medicine to cure disease and even extend longevity. With creativity, imagination, hard work, diligence, and perhaps a little luck, major drug discoveries can be made in an academic setting. ÌMD



“May I Have Your Attention?”The Misconceptions Among College Students Surrounding Adderall Use


“May I Have Your Attention?”By Elbert Mets

Photo courtesy of flickr.com/sterlic

The Misconceptions Among College Students Surrounding Adderall Use



“Finally! Schoolwork that matches his intelligence,” reads the tagline

to an advertisement for Adderall, fea-turing a young, smiling boy in the back-ground. Another ad reads, “In the man-agement of ADHD, reveal his potential. Adderall XR® improves academic per-formance.” Pharmaceutical companies and popular media often characterize Attention Deficit Hyperactivity Disorder (ADHD) medications such as Adderall as wonder drugs that can supercharge patients’ academ-ic and social lives. Because these drugs can enhance performance in ADHD patients, many people, es-pecially college stu-dents, incorrectly assume that these drugs should work in undiagnosed individ-uals too. It is import-ant for students to gain awareness of the misconceptions surrounding the use and abuse of these drugs in order to avoid health and legal risks. In recent years, the rate of ADHD diagnosis has risen sharply.1,2 ADHD, a condition marked by inattention, hyper-activity, and impulsive behavior, often appears during childhood and can con-tinue into adulthood.1,2,3,4 In the US, the rate of ADHD diagnosis in children ages 4 to 17 has seen more than a 40% increase

from 2003 to 2011.1 By 2011, at least 6.4 million, or 11%, of American children in this age group had been diagnosed with ADHD.2

The prevalence of ADHD treatment has mirrored the rising rate of diagno-sis, with 60% of diagnosed children re-ceiving treatment.4 The disorder is typ-ically treated using stimulants such as Adderall (amphetamine-dextroamphet-amine), Ritalin (methylphenidate), and Dexedrine (dextroamphetamine).5 A

controlled trial com-paring stimulant medication, com-munity care, behav-ioral therapy, and combined medi-cation-behavioral therapy revealed that stimulant medication was a very effective method in mit-igating ADHD s y m p t o m s . 4 , 6 , 7

However, it was also observed that com-bining stimulant medication with medi-cation-behavioral therapy resulted in an even stronger social and behavioral im-provement compared to the medication alone.7 Despite these observed benefits, pharmaceutical companies have large-ly disregarded the study’s results, mar-keting medication alone as the superior ADHD treatment.8

ADHD symptoms are thought to result, in part, from a shortage of dopa-

””

Despite the consequences of the

illegal distribution and possession of these

drugs, students report that prescription

stimulants are readily available on college

campuses.


mine, a neurotransmitter important in the nervous system’s pathways responsi-ble for producing feelings of satisfaction and fulfillment.4,9 This shortage in ADHD patients is caused by a high density of ac-tive transporters that remove dopamine from the brain. Prescription stimulants raise dopamine levels in the brain by in-

hibiting the ability of the transporter to remove the

dopamine, thus improving focus in ADHD patients.4,10

Unfortunately, these med-ications, touted to bolster

concentration, are frequent-ly abused by nonprescription

users. Improper use of ADHD medications, like Adderall, is especially observed among college students. Misuse of prescription stimulants on college campuses is a major concern.4 Abuse rates range across colleges; 6.9 to 34% of undergraduate students re-port illicit use of prescription stimulants during their lifetimes.5,12,13 Frequent-ly cited reasons for stimulant misuse include improving concentration and alertness when studying and attaining a

“high” akin to that of cocaine.4,13 De-spite widespread use in universi-

ties, many illicit users of pre-scription stimulants are

unaware of the effects of these drugs.11 Students who use

stimulants often rely on friends’ testimonials

rather than medical literature in their as-sessments of the drug’s risks.11 Further-more, the prescription of these medica-tions for ADHD patients by doctors can lead people to falsely believe these drugs are safe for anyone to consume.11

The United States Drug Enforce-ment Agency rates medications and rec-reational drugs on a scale of Schedules


from 1-5. Schedule 1 drugs (e.g. hero-in, LSD) have the highest potential for abuse and no accepted medical use, while Schedule 5 drugs have defined medicinal purposes and lower potential for abuse.14 Despite the drugs’ benign portrayal, the Drug Enforcement Agency classifies prescription stimulants as Schedule 2, grouping them with the likes of cocaine and methamphetamine.14 This classifica-tion underscores the fact that stimulants have a “high potential for abuse” and can lead to “severe psychological or physical dependence.”14 Additionally, the penalty for distribution or possession of these medications without prescriptions can be up to twenty years of imprisonment and up to one million dollars in fines.15 In practice, a conviction for small-scale distri-bution or possession of these stimulants would likely be less se-vere, though such a conviction can still be damaging to aspiring professionals. Despite the consequences of the illegal distribution and possession of these drugs, students report that pre-scription stimulants are readily available on college campuses.11 Surveys indicate that over 20% of undergraduates with prescriptions for stimulants have sold them to their peers, and more than 50% of these students have been asked to do so.4,12 Students use prescription stimu-lants largely for their perceived academic

benefits. A survey of 689 undergraduates from the University of Michigan revealed that 58% of stimulant misusers do so to enhance concentration, 43% to increase alertness, and 43% abuse the drugs to achieve a stimulant-induced “high.”13 A Brigham Young University examina-tion of tweets mentioning Adderall use showed an increase in stimulant-related tweets during December and May – col-lege final exam periods.16

Among college students, prescrip-tion stimulant misuse differs across de-mographic groups. It is highest among Caucasian fraternity and sorority mem-bers who are struggling academically and attend selective colleges in the northeast-

ern United States.12 Students who abuse stimulants are also more likely to abuse drugs and alco-hol.12

Although popular culture often portrays ADHD medica-tion as harmless, prescription stimulant misuse can have significant health con-sequences. Side effects include seizures, heart problems, and trouble sleeping.4,11 Additionally, the effects of Adderall on the heart are similar to those of cocaine.17

Both drugs can injure the endothelium, the inner lining of the blood vessels, and in combination with several other harm-ful effects, can cause heart attacks.17 In addition, alcohol consumption coupled with Adderall use can further increase students’ risk for heart attacks.4,17 The

””

The effects of Adderall on the heart

are similar to those of cocaine.


Brigham Young University study also found that the most frequently reported adverse effects of Adderall use on stu-dents were sleep deprivation and loss of appetite.16

Nonprescription consumption of stimulants for academic advancement is also of questionable integrity. For this reason, the use of stimulants to height-en performance in academic settings is now seen as being comparable to the use of anabolic steroids in professional sports.11 In line with this thinking, Duke University recently listed “the unautho-rized use of prescription medication to enhance academic performance” under “cheating” in its classification of academ-ic dishonesty.4,18,19 This ban could reduce the incidence of these medications’ mis-use and in turn limit the frequency of negative side effects. So, does using stimulant medi-cation without an ADHD diagnosis re-ally improve academic performance? The short answer is no. The majority of studies exploring stimulant use by non-ADHD patients have shown little to no performance gains. Recently published research has demonstrated that stimu-lants are effective primarily in patients with ADHD and serve to bring patients back to “baseline” rather than bolster already normal performance.4 Addition-ally, studies have shown that there is a placebo effect among nonprescription users of Adderall. According to a 2011 study published in Experimental & Clin-

ical Pharmacology, certain students be-came more attentive after receiving a placebo, because they believed they were being given stimulants.4

However, a lot remains unknown about the effects of stimulants in non-ADHD patients, largely due to the fact that stimulant abuse for the sake of en-hancement has been stigmatized in med-ical circles.20 There seems to be a common misconception between concentration and performance; while stimulants may increase alertness or concentration, ex-periments have failed to show a clear correlation to increased performance. Furthermore, the dangers incurred by stimulant abuse seem to far outweigh possible benefits. While possible gains from drug abuse remain hazy, the risks, both medical and legal, are real. Ultimately, the nonprescription use of ADHD stimulants such as Adder-all is not effective in improving academic performance in individuals without the disorder. Misusing these medications ex-poses students to medical and legal risks with minimal benefit. It is important that students gain insight into the misinfor-mation that circulate on college campus-es regarding the use of ADHD stimulants in order to protect their health, avoid po-tential legal problems, and maintain aca-demic integrity. ÌMD

For references, see pages 53-54.


The past decade has seen a rise in the use of electronic health records

(EHR), electronic referrals to special-ists, and e-prescriptions to pharmacies. This transition towards a more electron-ically-focused approach to health care demonstrates the growing influence of health information technology (HIT). HIT encompasses any technological ad-vancement that is employed to collect, store, analyze, and share health infor-mation.1 HIT has manifested through many technological innovations, such as the digitalization of medical diagnos-tics and the advent of mobile health ap-plications. The HIT era emerged as a means to address the issues of health care costs, medical errors, and the disconnect be-tween health care providers.2 Its growth can be traced to the 1960s when the Medicaid and Medicare programs were enacted, and the need for an organized

billing process was met with mainframe computers and centralized processing.3 Smaller and more affordable microcom-puters (PCs) emerged in the 1980s, and became increasingly used for clinical in-formation systems and for maintaining billing information.3 The 1990s saw the dawn of the Internet, and health care workers took advantage of it as a po-tential form of communication between providers.3

More recently, The American Re-covery and Reinvestment Act and The Health Information Technology for Eco-nomic and Clinical Health Act (HITECH) of 2009 introduced financial incentives for professionals who demonstrated proficiency in a certified EHR program.5 These incentives were offered in hopes of achieving improvements in care de-livery, enabling patients to be engaged in the health care process, and helping providers avoid preventable medical er-

The Fusion of Medicine and Technology

What can we envision for the Future of Health Care?

By Elizabeth Zborek


rors.9 Consequently, many clinics and hospitals have made the transition from paper health records to electronic health records. The transition can be laborious, but once health care workers learn how to operate the EHR systems, they can appreciate the benefits that moderniz-ing offers. Moreover, the implementation of electronic health records directly bene-fits patients in addition to providers by assisting patients with their own health management. Patient portals, secure on-line websites that allow pa-tients to ac-cess their per-sonal health records, have become com-m o n p l a c e . These portals provide patients with more control and a better understanding of the health care process overall by allowing them to manage their appointments and medi-cations all in one place. Most important-ly, these sites improve patients’ health literacy by providing them with more information about their diagnoses and treatments. The transition to EHR programs is reflective of a larger shift towards tech-nology in the field of medicine. More creative and accessible ways to improve patient health are constantly being in-vented, and the next phase of the HIT

era will likely entail the widespread im-plementation of health care apps. New health care apps are being de-signed to help physicians provide better care and increase patients’ involvement in the health care process. Such apps in-clude iTriage, HealthTap, Doctor on De-mand, palmEM, and InQuicker. The iTri-age, HealthTap, and Doctor on Demand apps connect patients with information about local doctors and clinics, while also providing patients with more infor-mation about their symptoms. Doctors

and residents can employ palmEM as a quick refer-ence for clinical decision mak-ing; InQuicker helps patients and doctors save time in the

emergency room by allowing those with non-life threatening illnesses to check into the emergency room from their homes. Although these apps have already improved the care patients re-ceive, there are still opportunities for further development. The HIT era has also led to the cre-ation of the telemedicine industry. Tele-medicine is the utilization of telecom-munications technology such as email, Skype, and smartphones to assist in im-proving a patient’s health.7 A combina-tion of health information technology and electronic communications, tele-

What can we envision for the Future of Health Care?

””

The HIT era emerged as a means to address the issues of health care costs, medical

errors, and the disconnect between health care

providers.


medicine is increasing health care cover-age in underserved areas. For example, the residents of the Chakrajmal village in India were able to consult with a doc-tor via telecommunications technology in 2008.6 Telemedicine is already being em-ployed to transmit diagnostic images amongst providers, share medical data between providers and patients, moni-tor patient vital signs from various lo-cations, and educate patients remotely.4 As of now, most of these transmissions are taking place via computer, but in the future, we will see them oc-cur via apps on mobile devices, thus streamlin-ing the patient and provider communication process.6

Despite all of the potential benefits of fusing med-icine with technology, there are also drawbacks. As observed with EHRs, adoption implementation and mainte-nance costs exist.10 Furthermore, fail-ure to learn how to correctly utilize the technologies can lead to interrupted workflow, reduced productivity, and in-creased medical errors.10 Another op-posing argument to health information technology is the risk for patient priva-cy violations.10 Technology users face sophisticated malware and hackers, who

can attempt to access personal health information.11 While these issues must be addressed, the potential that health information technologies have to rev-olutionize and improve the health care system will very likely outweigh these costs. Health information technology has greatly influenced health care during its short existence, and new ways to utilize it are constantly being invented. The US electronic medical record market alone is predicted to grow from $2.177 bil-lion in 2009 to $6.054 billion in 2015,

illustrating the rising demand for health in-f o r m a t i o n t e c h n o l o -gy.8 Though there will al-ways be an adjustment

period when new technologies are being standard-ized, advanced health information tech-nologies can increase both quality and efficiency of health care. With this im-mense potential comes a responsibility for the next generation of health care professionals to invent, implement, and utilize technology in ways that improve patient experience.

””

The transition to EHR programs is reflective

of a larger shift towards technological advancement

in the field of medicine.


Recently Developed AppsiTriageiTriage helps patients narrow down the cause of their symp-toms, identify local providers, clinics, and hospitals, and stay up to-date-with latest health news.

HealthTapThis app helps doctors and clinics attract and educate new pa-tients while improving the quality of health information online. Additionally, it connects patients with doctors to give them the best health information.

palmEMpalmEM covers hundreds of the most commonly encountered conditions in emergency medicine. The app contains quick med-ication references and helps doctors with clinical decision- mak-ing. Many similar apps have appeared on the market, in order to help physicians and residents quickly and efficiently give a patient a diagnosis.

InQuicker Not exactly a typical mobile app, InQuicker is a site that can be used on all mobile devices, much like Patient Portal. It reduces the time that hospital personnel spend on data input by allowing patients with non-life threatening illnesses to check into the emergency room from home. Patients can wait at home instead of a crowded waiting room until they are called in to be seen by a health care provider.

Doctor on DemandPatients utilize this app in order to get in contact with board-certified

doctors for non-emergency medical purposes. They pay a $40 fee for each video visit, and doctors are able to diag-nose patients and prescribe medications when clinically appropriate. ÌMD


the pre-medical experience :


The Pre-Medical Experience ■ Volume 4 ■ Fall 2014 ■ 43

A research participant enters a room and takes a seat in a reclined chair.

She gazes nervously at the computer screen in front of her. She is about to be-gin a standard, decades-old procedure for ameliorating fears associated with blood, injection, and injury, referred to as BII phobia. The researcher displays photos on the computer screen for the participant. These images begin with a photo of a syringe and progress to-wards more fear-inducing images, such as pictures of open wounds and surgical procedures. After viewing each photo, the research participant is asked to rate her level of distress and to describe her physiological symptoms. Her palms be-

gin to sweat when staring at the photo of the syringe, she averts her gaze when viewing the open wound, and she feels dizzy and faint when presented with the photo of a scalpel slicing through bloody tissue. This participant was part of a psy-chology research study conducted at Northwestern University by Ph.D. can-didate Nehjla Mashal in order to observe the effects of BII phobia.1 According to the DSM-IV-TR, a manual that health professionals use to classify mental dis-eases, BII phobia is an anxiety disorder characterized by a marked and per-sistent fear induced by the presence or anticipation of blood, injuries, wounds,

Blood-Injection-Injury Phobia:

Unassailable Terror or

Treatable Concern?

By Stephanie Lo


or receiving an injection.2 Although the person recognizes that the fear is ex-cessive or unreasonable, the individu-al attempts to avoid situations that will instigate this phobia. If unavoidable, he or she endures the phobic stimulus with intense anxiety or distress.2 About 4% of the population in the US has the BII phobia.3

U n l i k e other disorders and phobias, which simply re-sult in high levels of anxiety, the BII phobia can actual-ly induce fainting. When confronted with the feared stim-uli, a person with this condition usually un-dergoes a two-phase re-action. In the first phase, the person experiences the sympathetic fight-or-flight response, which is typical in most anxiety disorders and phobias. This response is accompanied by an increase in blood pressure and heart rate. The second phase is unique to BII phobia and consists of a rapid fall in heart rate and a rapid decrease in blood pressure that causes a reduction in blood flow to

the brain.3 This second phase produces the symptoms that can lead to fainting. Slightly more than 50% of peo-ple with needle phobias and 70% of people with blood phobias have a his-tory of fainting during an injection or during exposure to blood, respectively.4 Although the BII phobia includes fear of blood, injury, and receiving an in-jection, the specific triggers depend on the person. Additionally, studies have shown that not all patients with BII phobia have identical physiological re-sponses.3

According to Mashal, those with BII pho-bia “come to as-

sociate stimuli, like needles and

blood, with that un-pleasant physiological

response, which potenti-ates the phobia.”1 Although

the phobia may not immedi-ately interfere with one’s life, suffering from BII can cre-ate substantial problems for individuals as they get old-

er. “One of the motivations for people to get help is that

it’s getting in the way of getting medical care. It may not be a big

deal in your twenties, but it’s a big deal when you get older and need more reg-ular tests,” Mashal explained.1 In addi-


tion to causing the avoidance of regular check-ups and important surgeries, BII phobia may also cause people to avoid pursuing health-related professions. It is therefore crucial to understand this phobia and discover ways to overcome it, whether you are a student pursuing a health care-related career, a person try-ing to avoid injections and surgeries, or a physician treating patients who have BII phobia. For students who fear blood but still want to pursue a health-related career, North-western Uni-versity Health P r o f e s s i o n s Adviser Nancy Tapko empha-sizes the impor-tance of clinical experience and exposure. Tapko advises students who are afraid of blood but are considering the pre-health track to “talk to health care professionals and volun-teer in the field. Different health profes-sions will have different levels of [expo-sure to] blood and bodily fluids. A lot of times exposure to something helps you get over your fears of it.”6 Additionally, these students can work with psycholo-gists who have experience with treating anxiety disorders.6 Dr. Thomas Ritz, a psychology pro-

fessor at Southern Methodist Univer-sity, conducts research on the psycho-physiology behind and the autonomic nervous system response to BII phobia. Ritz says he encountered difficulties in recruiting participants for the stud-ies because people who have the pho-bia attempt to avoid the feared stimuli.7

“Many people have the phobia but don’t see it as something they need treatment for,” said Ritz. “They will avoid it at all costs, but sometimes the cost is so high

that it would benefit them to seek treat-ment.”7 Peo-ple with the phobia often e n c o u n t e r intense anx-iety from the antic-ipation of

the feared stimuli in addition to the sit-uation itself. “Patients are relatively dis-tressed after fainting,” Ritz said. “After the psychology study, we need to de-brief them and help them find follow-up treatments.”7 According to Mashal, the most well-known treatment for BII phobia is the “applied tension” technique com-bined with exposure to the feared situ-ations and stimuli.1 The applied tension technique consists of the patient tensing up the muscles of their arms, legs and

””

The BII phobia is an anxiety disorder characterized by a marked and persistent fear

induced by the presence or anticipation of blood,

injuries, wounds, or receiving an injection.2


trunk when encountering the feared stimuli.5 Next, the patient releases the tension slowly, which elevates and then maintains elevated blood pressure to counteract the slow heart rate and low blood pressure that lead to fainting. Mashal said that this specific tensing and releasing technique can impede the secondary response of BII phobia and prevent the person from fainting.1

Although research has focused on the applied tension technique, Ritz points out that it might not be ef-fective for all pa-tients. Because researchers do not understand its precise mecha-nism, it is difficult to know exactly when the applied tension technique will work. Addi-tionally, this technique is not effective for all aspects of BII phobia. Other treat-ments, including respiration-focused techniques, are currently being studied to help people who suffer from various permutations of the phobia. Respiration-focused techniques aim to counteract hyperventilation by slowing breaths rather than breathing deeply.3 Ritz claims that these tech-niques are focused on the subgroup of patients who hyperventilate when they

are exposed to the feared stimuli. “The applied tension technique would not really help against hyperventilation,” he explained. “Hyperventilation is prob-lematic for this patient group because it constricts the cerebral blood vessels so the blood flow to [the] brain is reduced. It makes patients dizzy and could con-tribute to their fainting, so we have tried to evaluate an intervention based on reducing the hyperventilation.”7 While respiration-focused techniques seem to

be promising al-ternatives to the applied tension technique, Ritz acknowledges that large clin-ical trials have not been con-ducted to study their effective-ness.7

There is also a cognitive facet that must be ad-dressed to help those who suffer from BII phobia. An important component of treatment for BII phobia is exposure to the feared stimulus, Mashal claimed. With enough exposure, people can be-gin counteracting their intense anxiety. “Repetition is key,” said Mashal, “and you increase the intensity in exposure so that people stick with the treatment. If they’re willing to go straight to the blood draw, it will be equally effective

””

Awareness about the implications of BII phobia

is important for individuals with the phobia who fear

medical treatments and for physicians seeking to help

their patients overcome this phobia.


and more efficient.”1 In addition, some researchers have hypothesized that disgust plays a ma-jor role in BII phobia. “Evolutionary psychologists believe that disgust sensitivity helps us stay away from things that make us sick, like bad food. All these traits are normal-ly distributed on a bell curve and people with BII just happen to be at one end of this spectrum,” said Mashal.1 Although there is a strong association between people’s self-reported dizziness and their actual physiological symptoms, Ritz explained that a major mis-conception of BII phobia is that pa-tients think the condition signifies weakness or fragility. “They are actually well-functioning people who can lead a normal life and are as resilient as anyone else. There’s a bit of stigma around this disor-der and psychological disorders in general,” said Ritz.7 This stigma may prevent people from seeking out treatment for their phobias. Another misconception regard-ing BII phobia is that it is untreatable. “People think that if they’ve had some-thing for a really long time that it must take a long time to get rid of it,” said Mashal. “It’s natural logic. However, eighty to ninety percent of people will respond to treatment such that they

no longer meet [the DSM-IV-TR] cri-teria.”1 Although people who have BII phobia may feel powerless against their

feared stimuli, research has shown that the majority of people overcome their fears through the applied ten-sion technique and targeted expo-sure sessions.5

Awareness about the implications of BII phobia is important for in-dividuals with the phobia who fear medical treatments and for physi-cians seeking to help their patients overcome this phobia. Although the distress and fear of fainting may deter people from seeking treat-

ment, psychological researchers suggest that a two to three hour-long session of exposure is suf-ficient to overcome BII phobia. Though the phobia may ini-tially seem like an unassail-able terror to those who are victims of it, with the proper therapy, Blood-Injection-In-jury Phobia has a chance to be reduced to nothing but a treated concern. ÌMD


the medical school experience :


The Medical School Experience ■ Volume 4 ■ Fall 2014 ■ 49

: A s medical students, it is easy to believe that after years of un-

dergraduate study and hard work, we are ready to be great physicians. How-ever, becoming a successful doctor is not something that can be achieved solely through studying textbooks or scoring well on exams. While these are certainly important components, some of the qualities that make phy-sicians great are acquired through observations and experiences in a hospital. I will recall my time in medical

school as an anthology of experienc-es and clinical tales that will allow me to shape my judgment as a physician. Thus far, I have learned that failure can instruct better than success, and a single bad decision can shape you in a way that fifty good decisions never could. I will look back on these mem-ories, both the good and the bad, when the time comes for me to treat patients on my own. As a medical student in Mexico, I recently had the opportunity to com-plete my surgical rotation. This expe-

Global Perspectives on Health:

Treat Patients, Not DiseasesBy Paulo Tabera-Tarello


””

We start learning how to be doctors without

understanding the patient perspective.

rience was eye-opening and changed the way I want to study and practice medicine. One morning while rotating at a local hospital, my attending physi-cian told me to go assist a resident with a patient examination. In the exam room, I saw a woman wearing an obvious look of discomfort, but I could not immediately ascertain what was causing her pain. The resident in-troduced the patient to me: she was a thirty-eight year-old woman who had consult-ed her doctor be-cause of pain in her breast after a fall two weeks ago. Her doctor prescribed painkill-ers and anti-inflammatories and then sent her home. Three weeks later, she returned to her doctor with worsen-ing pain and explained that she was having difficulty sleeping and breath-ing. She was promptly referred to the surgical department, which is where I met her. After the interview and physical exam, the surgeon found inflamma-tory signs on her left breast and up-per arm, so he ordered a chest x-ray and a biopsy. The x-ray showed liq-uid in her lungs, and the biopsy con-

firmed a diagnosis of inflammatory breast cancer. After receiving the bi-opsy results, the resident informed the woman that she had a rare type of breast cancer, which had spread to her lungs, and that she had approxi-mately six months to live. The woman was understandably devastated; soon she would have to say goodbye to her two sons, her hus-band and all her family and friends. She would be leaving so much behind,

but her doctor never had the courtesy to look her in the eyes, hold her hand, or even say “I’m sorry.”

The resident acted indifferently about the impact that the diagnosis had on his patient. He skipped the sympathy and moved on to options of palliative care. He scheduled an appointment for the woman three days after the initial consultation so that she would have time to decide her desired treat-ment plan. In an almost cruel fashion, he asked the patient to leave, because he was falling behind on his consults for the day. As medical students, we learn to observe, diagnose, and treat diseases through years of medical school, so

that by the end of our education, we are capable of caring for our patients while always trying to achieve the best outcome for their health. How-ever, we learn to do all this from a perspective that can fail to accurately depict the effects that diagnoses have on patients and their families. To a busy doctor, the pain that a difficult diagnosis brings upon a patient and his or her family can all too often be-come abstract and distant. Physicians must realize that when they take the time to truly empathize and identify with their patients’ situations, they can provide more holistic care.

The medical profession is not just a typical nine-to-five job; this profes-sion is about understanding the com-plex systems of the human body in order to ultimately come to the aid of the patient and ease his or her pain. However, throughout all the years of medical school training in Mexico, we still do not have a class where we learn how patients cope with these unfortunate circumstances. We start learning how to be doctors without understanding the patient perspec-tive. Though my experiences as a stu-dent in Mexico may be unique, med-ical students and doctors universally may not fully comprehend the scope of a patient’s experience with illness. When we choose to realize the crucial role that empathy for the patient has in health care, we can start changing the paradigms of the health profession. These changes to the overall mindset of doctors will be essential because, after all, we treat patients, not diseases. ÌMD

The Medical School Experience ■ Volume 4 ■ Fall 2014 ■ 51


R E F E R E N C E SHippocrates, Not Hypocrisy: Practice What You Preach 1. “Overweight Doctors Lose Credibility on Health Advice.” - Amednews.com. Web. 4 Sept. 2014. <http://www.amednews.com/article/20130401/health/130409982/4/>.2. “Obesity and Overweight.” Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 14 May 2014. Web. 10 Sept. 2014. <http://www.cdc.gov/nchs/fastats/obesity-over-weight.htm>.3. “Healthy People 2020.” Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 23 July 2013. Web. 4 Sept. 2014. <http://www.cdc.gov/dhdsp/hp2020.htm>.4. “Medscape Physician Lifestyle Report: 2012 Results.” Medscape Physician Lifestyle Report: 2012 Results. Medscape. Web. 4 Sept. 2014. <http://www.medscape.com/features/slideshow/lifestyle/2012/public>.5. Bleich, Sara N., Wendy L. Bennett, Kimberly A. Gudzune, and Lisa A. Cooper. “Impact of Physician BMI on Obesity Care and Beliefs.” Obesity. Print. 6. Puhl, R, et al. “The effect of physicians’ body weight on patient attitudes:implications for physician selection, trust, and adherence to medical advice.” International Journal of Obesity (n.d.): 1415-1421.7. Foulds, J. “How Many Medical Doctors Smoke?” Medical Information & Trusted Health Advice: Healthline. Web. 4 Sept. 2014. <http://www.healthline.com/health-blogs/freedom-smoking/how-ma-ny-medical-doctors-smoke#3>.8. Nelson, D. E., G. A. Giovino, S. L. Emont, R. Brackbill, L. L. Cameron, J. Peddicord, and P. D. Mowery. “Trends in Cigarette Smoking Among US Physicians and Nurses.” JAMA: The Journal of the American Medical Association (1994): 1273-275. Print. 9. Cohen, I., C. Czeisler, and C. Landrigan. “Making Residency Work Hour Rules Work.” Journal of Law, Medicine, & Ethics. Print.10. Kuther, T. “The Fun Doesn’t End with Med School: About Residency Training.” About. Web. 4 Sept. 2014.11. Greenberg, M. “Why We Gain Weight When We’re Stressed-And How Not To. “Psychology Today: Health, Help, Happiness Find a Therapist. Web. 4 Sept. 2014. <http://www.psychologytoday.com/blog/the-mindful-self-express/201308/why-we-gain-weight-when-we-re-stressed-and-how-not>.

Early Intervention for Autism Treatment1. Data & Statistics. (2014, March 24). August 4, 2014. <http://www.cdc.gov/ncbddd/autism/data.html>.2. Applied Behavior Analysis (ABA). (2014). August 2, 2014. <http://www.autismspeaks.org/whatau-tism/treatment/applied-behavior-analysis-aba>.3. ABA Resources: What is ABA? August 3, 2014. The Center for Autism and Related Disorders: Global-izing Autism Treatment and Awareness <http://www.centerforautism.com/aba-therapy.aspx>.

Establishing a Nexus Between Public Health and Clinical Practice1. USDA Defines Food Deserts. American Nutrition Association. 2010, <http://americannutritionasso-ciation.org/newsletter/usda-defines-food-deserts>.2. The Health Effects of Overweight and Obesity. Centers for Disease Control and Prevention. Decem-ber 6, 2013. <http://www.cdc.gov/healthyweight/effects/index.html?s_cid=tw_ob245>. 3. Stress Symptoms: Effects on your body and behavior. Mayo Clinic. July 19, 2013. <http://www.mayoc-linic.org/healthy-living/stress-management/in-depth/stress-symptoms/art- 20050987>. 4. Janke, K., Propper C. & Shields, M. (2013). Does Violent Crime Deter Physical Activity? Institute for


R E F E R E N C E Sthe Study of Labor: Discussion Paper No. 7545. 5. Haan M., Kaplan G., & Camacho T. (1987). “Poverty and health: prospective evidence from the Ala-meda County Study.” American Journal of Epidemiology: 125:989-998.

The Anti-Vaccination Campaign: A Retrospective Look1. Murch, S. (2003). “Separating inflammation from speculation in autism”. Lancet 362 (9394): 1498–9.2. Frequently Asked Questions About Thimerosal (Ethylmercury). July 30, 2014. <http://www.cdc.gov/vaccinesafety/concerns/thimerosal/thimerosal_faqs.html>3. Shute, N. (2013). Vaccine Refusals Fueled California’s Whooping Cough Epidemic. September 13, 2013. <http://www.npr.org/blogs/health/2013/09/25/226147147/vaccine-refusals-fueled-californi-as-whooping-cough-epidemic>4. “England and Wales in grip of mumps epidemic”. May 13 2005. <http://www.nzherald.co.nz/world/news/article.cfm?c_id=2&objectid=10125382>5. Community Immunity (“Herd Immunity”). November 27,2013. <http://www.vaccines.gov/basics/protection> 6. Changes in Pertussis Reporting by State from 2011 to 2012. <http://www.cdc.gov/pertussis/images/pertussis-graph-2012-lg.gif>7. Daley, M and Glanz, J. (2011). Straight Talk about Vaccination. August 16, 2011. http://www.scientifi-camerican.com/article/straight-talk-about-vaccination/?page=38. Shute, N. (2013). Vaccine Refusals Fueled California’s Whooping Cough Epidemic. September 30, 2013. < http://www.npr.org/blogs/health/2013/09/25/226147147/vaccine-refusals-fueled-californi-as-whooping-cough-epidemic>

The Drug Discovery Odyssey: A Glimpse into Pharmaceutical and Academic Drug De-velopment1. Benmohamed, R.; Arvanites, A. C.; Kim, J.; Ferrante, R. J.; Silverman, R. B.; Morimoto, R. I. Kirsch, D. R. Amyotrophic Lateral Sclerosis. 2011 Mar; 12(2): 87-96.2. Herper, M. (2013) The Cost of Creating a New Drug Now $5 Billion, Pushing Big Pharma To Change. <http://www.forbes.com/sites/matthewherper/2013/08/11/how-the-staggering-cost-of-inventing-new-drugs-is-shaping-the-future-of-medicine/2/>.3. Northwestern University Innovation and New Ventures Office. Lyrica. <http://invo.northwestern.edu/news/2011/lyrica>.4. Van, J. (2008) Drug find worth $700 million. March 10, 2008. Chicago Tribune. <http://articles.chi-cagotribune.com/2008-03-10/business/0803090219_1_gaba-richard-silverman-drug-companies>.5. World Events Forum. Plenary: The Story of Lyrica-Academic Discovery to Commercial Success. 8th Annual Drug Discovery Neurodegeneration Conference. <http://www.worldeventsforum.com/addf/drugdiscovery/notes8/oral-presentations/79-2/>.6. Silverman, R. B. From Basic Science to Blockbuster Drug: The Discovery of Lyrica. Angew. Chem. Int. Ed. 2008, 47, 3500-3504.

“May I Have Your Attention?” The Misconceptions Among College Students Surround-ing Adderall Use1. Center for Disease Control and Prevention., Increasing prevalence of parent-reported attention-defi-cit/hyperactivity disorder among children --- United States, 2003 and 2007. MMWR Morb Mortal Wkly Rep, 2010. 59(44): p. 1439-43.

2.Visser, S.N., et al., “Trends in the parent-report of health care provider-diagnosed and medicated attention-deficit/hyperactivity disorder: United States,” 2003-2011. J Am Acad Child Adolesc Psychiatry, 2014. 53(1): p. 34-46.e2.3.National Institute of Mental Health. Attention Deficit Hyperactivity Disorder (ADHD). [cited 2014 June 29]; Available from: <http://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disor-der-adhd/index.shtml>.4.Lakhan, S.E. and A. Kirchgessner. “Prescription stimulants in individuals with and without attention deficit hyperactivity disorder: misuse, cognitive impact, and adverse effects.” Brain Behav, 2012. 2(5): p. 661-77.5. DeSantis, A.D., E.M. Webb, and S.M. Noar. “Illicit use of prescription ADHD medications on a col-lege campus: a multimethodological approach.” J Am Coll Health, 2008. 57(3): p. 315-24.6. Wang, S.S., ADHD Drugs Don’t Boost Kids’ Grades, in The Wall Street Journal. 2013.7. A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity dis-order. The MTA Cooperative Group. Multimodal Treatment Study of Children with ADHD. Arch Gen Psychiatry, 1999. 56(12): p. 1073-86.8. Schwarz, A., A.D.H.D. Experts Re-evaluate Study’s Zeal for Drugs, in The New York Times. 2013. p. A11.9. Cherkasova, M.V., et al.. “Amphetamine-induced dopamine release and neurocognitive function in treatment-naive adults with ADHD.” Neuropsychopharmacology, 2014. 39(6): p. 1498-507.10. Wilens, T.E. “Mechanism of Action of Agents Used in Attention-Deficit/Hyperactivity Disorder.” Journal of Clinical Psychiatry, 2006. 67(8): pp.37-39.11. Varga, M.D. “Adderall abuse on college campuses: a comprehensive literature review.” J Evid Based Soc Work, 2012. 9(3): p. 293-313.12. McCabe, S.E., et al. “Non-medical use of prescription stimulants among US college students: preva-lence and correlates from a national survey.” Addiction, 2005. 100(1): p. 96-106.13. Teter, C.J., et al. “Prevalence and motives for illicit use of prescription stimulants in an undergradu-ate student sample.” J Am Coll Health, 2005. 53(6): p. 253-62.14. United States Drug Enforcement Agency. Drug Scheduling. [cited 2014 June 29]; Available from: <http://www.justice.gov/dea/druginfo/ds.shtml>.15. The University of Chicago. Table A: Federal Penalties and Sanctions for Illegal Trafficking and Pos-session of a Controlled Substance. [cited 2014 June 29]; Available from: https://commonsense.uchicago.edu/page/table-federal-penalties-and-sanctions-illegal-trafficking-and-possession-controlled-substance.16. Hanson, C.L., et al. “Tweaking and tweeting: exploring Twitter for nonmedical use of a psychostimu-lant drug (Adderall) among college students.” J Med Internet Res, 2013. 15(4): p. e62.17. Jiao, X., et al. “Myocardial infarction associated with adderall XR and alcohol use in a young man.” J Am Board Fam Med, 2009. 22(2): p. 197-201.18. Carroll, L. “Conduct policy changes reflect drug abuse.” in The Chronicle. 2011.19. Duke University Student Affairs. Student Conduct: Academic Dishonesty. [cited 2014 June 29]; Available from: http://studentaffairs.duke.edu/conduct/z-policies/academic-dishonesty.20. Oremus, Will. “The New Stimulus Package.” Slate (2013): n. pag. Web. <http://www.slate.com/ar-ticles/technology/superman/2013/03/adderall_ritalin_vyvanse_do_smart_pills_work_if_you_don_t_have_adhd.html>.

R E F E R E N C E S


The Fusion of Medicine and Technology: What Can We Envision for the Future of Health Care?1. “Basics of Health IT” 15 Jan. 2013. Web. 30 June 2014. http://www.healthit.gov/patientsfamilies/ba-sics-health-it 2. Bates, D., Cohen, M., Leape, L., Overhage, J. M., Shabot, M. M., & Sheridan, T. (2001). Web. 27 Jun. 2014. Reducing the frequency of errors in medicine using information technology. Journal of the Amer-ican Medical Informatics Association, 8(4), 299 -308. http://www.ncbi.nlm.nih.gov/pubmed/11418536 3. “History and Evolution of Health Care Information Systems” Web. 30 Jun. 2014. instructional1.calstatela.edu/prosent/CIS%20581/chapter4.pptx4. Puskin, D. Johnston, B. Speedie, S. May. 2006. Web. 30 June 2014. http://www.americantelemed.org/docs/default-source/policy/telemedicine-telehealth-and-health-information-technology.pdf?sfvrsn=85. “EHR Incentive Payment Timeline” 4 Mar. 2014. Web. 30 June 2014.http://www.healthit.gov/provid-ers-professionals/ehr-incentive-payment-timeline6. “Can Telemedicine alleviate India’s Health Care Problems?” 08 Mar. 2012. Web. 30 Jun. 2014. http://knowledge.wharton.upenn.edu/article/can-telemedicine-alleviate-indias-health-care-problems/7. “What is Telemedicine?” Web. 28 Aug. 2014. http://www.americantelemed.org/about-telemedicine/what-is-telemedicine#.VATVLPldUS4 8. “U.S. Electronic Medical Records (EMR- Physician Office & Hospital Market- Emerging Trends (Smart Cards, Speech Enabled EMR), Market Share, Winning Strategies, Adoption & Forecasts till 2015” June 2011. Web. 28 Aug. 2014. http://www.marketsandmarkets.com/Market-Reports/us-emr-market-401.html 9. Blumenthal, D., Tavenner, M. 05 Aug. 2010. The “Meaningful Use” Regulation for Electronic Health Records. Web. 28 Aug. 2014. http://www.nejm.org/doi/pdf/10.1056/NEJMp1006114 10. Menachemi, N., Collum, T. 11 May 2011. Web. 28 Aug. 2014. “Benefits and drawbacks of electronic health record systems”. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3270933/ 11.Halamka, J. 01 Sept. 2011. Web. 28 Aug. 2014. “The Rise of Electronic Medicine” http://www.technol-ogyreview.com/news/425298/the-rise-of-electronic-medicine/ Images gathered from: iTriage –Accessed 8/15/14 https://www.itriagehealth.com/facilities/il/chicago; HealthTap - Accessed 8/15/14 https://www.healthtap.com/what_we_make/overview;PalmEM - Accessed 8/15/14 https://itunes.apple.com/us/app/palmem-emergency-medicine/id481034047?mt=8;InQuicker - Accessed 8/15/14 https://inquicker.com/; Doctor on Demand - Ac-cessed 8/31/14 http://www.doctorondemand.com/

Blood-Injection-Injury Phobia: Unassailable Terror or Treatable Concern?1. N. Mashal, Personal Communication, June 12, 2014.2. American Psychiatric Association. (2010). Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.). doi:10.1176/appi.books.9780890423349.115473. Ritz, T. Meuret, A.E. & Ayala, E.S. (2010). “The Psychophysiology of Blood-Injection-Injury Phobia: Looking Beyond the Diphasic Response Paradigm.” International Journal of Psychophysiology: 78, 50-67.4. Öst, Lars-Göran. (1992). “Blood and Injection Phobia: Background and Cognitive, Physiological, and Behavioral Variables.” Journal of Abnormal Psychology: 101, 68-74.5. Antony, M.A. & Watling, M.A. (2006). Overcoming Medical Phobias. Oakland: New Harbinger Publi-cations, Inc.6. N. Tapko, Personal Communication, July 17, 2014.7. T. Ritz, Personal Communication, July 20, 2014.

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