Virtual Shadowing Session Twenty Three: Research in Medicine

good evening everyone welcome to our 23rd virtual shadowing session research and medicine with dr debra derricks if you have any question regarding our program please contact us on our instagram at virtual shadowing or email us at virtual virtualshadowing gmail.com as always this session is going to be recorded and posted on our youtube channel pre-health virtual shadowing next please after this week we have our upcoming topic specialty spotlight in pediatric endocrinology with a provider from puerto rico we have a specialty spotlight in clinical pediatrics and another specialty spotlight in emergency medicine so be sure to tune in with us on zoom or youtube live at 7 pm central standard time next please these sessions are brought to you by our working group composed of reagan shayan taylor elena myself rachel any ruth miriam rohit and our three physician providers uh dr fowler dr mercede and dr salazar a quick interruption if um to see the slides and to see the powerpoint you need to pin dr derrick's so go into participants search up derricks and pin her screen and you should see our presentation might help it a little bit we will post these slides onto our google drive um and again these sessions are recorded if you have any questions regarding the assessment please wait until the very end we will talk about the assessment at the very last slide and um these sessions are again one and a half hours to two hours and if you have any questions please put it in the chat and our group will collect it for you during the two designated times all right dr fowler take it away well welcome everybody good to have you back almost a thousand of you are online on this very interesting political day in the history of our nation so so glad you could join us as usual our talks will be posted on our youtube site and we look forward to having 5 000 of you once again join us for these terrific presentations this this is our 23rd presentation and we're so glad to have you here we now have almost we have 29 950 people who've signed up through the website in five months representing over 780 universities worldwide so clearly we've touched on something that seems to be important to a whole lot of people worldwide tonight we are so honored to have a very special individual join us dr debra dirks is professor and chair of the department of emergency medicine at ut southwestern medical center she holds the audrey and bernard rappaport distinguished chair in clinical care and research dr dirks is a very special person she's a nationally recognized leader in emergency medicine and she oversees the emergency medic medical programs at parkland memorial hospital and ut southwestern university hospitals which together constitute one of the largest emergency medicine programs in the united states which means in the world um deb is an amazing person after receiving her undergraduate degree in microbiology and immunology from the university of california at berkeley deb dirks attended tufts university school of medicine completing her residency in emergency medicine at the university of cincinnati and where she joined the faculty of the university of california davis and she became a major contributor to the growth and development of its emergency medicine programs she holds a master's degree from the harvard university school of public health deborah dirks is one of the recognized researchers in the field of emergency medicine she's received funding from the national institutes of health among other sources for research on early management of acute coronary syndromes the influence of gender on symptom characteristics and the utilization of cardiac biomarkers she has been one of the great leaders in the history of emergency medicine she was the president of the society for academic emergency medicine where she was presented the society's award for advancement of women in academic emergency medicine she is also a senior associate editor of the annals of emergency medicine she's also one of the finest physicians i've had the pleasure to work with she is my boss she is my friend and i will say deb we are so pleased to have you here tonight thank you for taking the time out to join us and would you please um share your thoughts about a career in research thanks for joining us well it's my real pleasure to be here oh sorry rachel yeah um so a lot of our students are still actually having issues seeing your uh slides so do you think you could potentially stop using the app that you're using and share screen normally i can [Music] uh not really without having to clean up a different powerpoint um why don't we take it away as it is and see how it goes let's give it a few minutes and then a lot of students can't uh can't really see it for some reason so i should be can't they if i'm speaking they should be able to see me so ask them now if i'm speaking it should be popping me up in the main screen correct it is is that helping they can see you it's really blurry for a lot of people i have no idea why um um we'll take it away anyway deb and i can we'll take it a step back for example we can see the map of the u.s here and where you've been and where you're going and that's obviously uh what you're trying to cover here so uh perhaps perhaps we'll take it away and see how it goes all right interesting okay so i'm deb derricks it's nice to be here i'm going to talk a little bit about the history of research why we do it and also kind of some things that have gone along on my path as a as a clinical researcher and then lastly on what you all need to do to kind of get involved in research in general you know as you can see i've kind of spanned the u.s and i got to tell you i'm a california girl and so when i started my journey you know i went up to the northeast for a little bit our north west for a little bit to start my college and then finished out at berkeley i thought i'd be in california and i think that's the challenge of med school applications is that you never know where you're going to be what i do know is having the opportunity to go to bed school in boston do residency in cincinnati i have made great friends that have spanned the us and i think that's been so valuable in my own personal growth it is great to have friends and colleagues everywhere and i think part of the thing if i just have you kind of think about it going to med school get into med school um that's like the gate that's the name of the game and where you go doesn't really matter at the end do your best meet a lot of people take advantage of all the personal growth you get from wherever you go med school is fun uh my some of my best friends i went to med school with residency the same thing um i went back to california where i was from and then had the opportunity to go out to texas um really because of my research career and it was people who i'd work with throughout my career that actually called me and said hey we got this job in texas we'd really like you to apply and so i think it's just the connections you make through research and being in academics that has really been instrumental on my own the fun i've had in emergency medicine and really doing research but we're going to talk about it first the background behind clinical research and really kind of the ugly history that we've had in the us in research in general why this matters to me is i've had a lot of opportunity through my career to get really involved in regulatory matters and research so i was an irb member what that means is i was on what we call the institutional review board it's a group that is that you have to go through to get approval to do any research at all and when i decided to get involved in that it was really first self-serving gain i wanted to be on the inside to figure out what i needed to do to get my research approved and so i joined this group and through being there and i think honestly just showing up at the meetings uh where some people didn't i got to be a vice chair of the irb i then went to go on to be the director of regulatory and knowledge support for a clinical translation research unit that was at uc davis and um left that behind when i moved to texas but now i have started being on what they call data safety and monitoring boards and those are national boards that you're on i'm on one for a large infectious disease study called the petal group and they do a bunch of different studies on infectious disease so um and what you do is you actually have the opportunity to look at the safety of the studies they're doing and give some recommendations on whether you think the study should continue and so at the end i'll share some of my kind of experiences that are really hard to believe a little bit um as you've got to go through and that i've had to the i guess the benefit and the privilege of being involved with to really get to understand how rules and regulations work so kind when we get going on research i really want to talk about four landmark unethical research studies that have gone on in the us all right and the world right so if i had to kind of study all of research out there these are the four that i think really resonate on how we've done research wrong and what has been the foundation on why there's so many rules and regulation behind what we do now those four are the nazi medical experience during world war ii the tuskegee syphilis study the willowbrook study and the jewish chronic disease hospital study and i'm going to go over those a little bit in depth now the first one clearly wasn't in the u.s the last three are though and really goes into the history in our own country that has gone on in research and um it's not something we should be proud of so the mozzie medical experience experiments were well known in world war ii a lot of times it was done to really understand racial genetic differences that they had an underlying in that they use patients our victims and prisoners and concentration camps for a lot of those studies too many of those studies were done in horrific manners and it really led to a famous trial called the nuremberg trial at the end of the war it is really hard to understand how horrific these trials are some of the famous ones that they did one was called the freezing experiments what they wanted to know was how cold a person's body could be until they died so they would put prisoners in vats of cold water they would cool the water down until the person died and then they would dissect the brain and learn from it now the learning and what they gained from that knowledge is we know a human can't survive at 28 degrees below 28 degrees celsius so we have identified where that freezing point probably fahrenheit where that freezing point is other things they wanted to study is the impact of high altitude on the human body also so they would take prisoners create an environment that went up to about sixty six thousand feet and see how they did well they died and as part of that they actually would then do autopsies and understand a look at the physiologic effects of high altitude on patient on prisoners and on the human body joseph meninglei is probably the most vicious unruly unethical physician that existed at the time and he got the name the angel of death he is famous for doing study on twins he would do things like inject chemicals into their eyes to see if they change colors in one experiment he tried to suture twins back together so this man's whole career was really trying to do i don't even know how you could justify them but really torturing twins to figure out what differences can make on genetics now i'm a twin myself and so i find these awful um they resonate really well with me and it was horrific uh as i read about him but just really one of the really most unethical people uh into him research in the history of the world so at the end of world war ii the nuremberg drop doctors trial took place now remember a lot of history doctors were actually well respected they were kind of revered as people who would say them so to have a trial focused on unethical experience by physicians hadn't really been done that much in the past so they took 23 german physicians and tried them all 16 were found guilty right they got 16 7 not so much others actually escaped to argentina to get away from persecution now the nuremberg doctors trial was really important and probably one of the first things that led to some sort of discussion about if we're going to do research we actually need to think about the people we're doing research on so the nuremberg code of 1947 was one of those things it was actually made to say look at patients have right physicians have duties and by if we define that we have to acknowledge that a physician just can't do whatever they want in the name of science they actually have to take a patient's right and actually look at that also and so that's really the premise of the nuremberg code which is patients right physicians duties part of those were voluntary consent is essential a patient has the right to say no avoidance of unnecessary physical and mental suffering right options to terminate the study if they don't like it and the creation of other safeguards need to be present so this nuremberg code really was the foundation and the first time anybody had actually put in writing that patients should have rights huge change in our kind of a change in the trajectory of research at that time clearly different when what they had done in world war two the nazi experiments in world war ii led to the first kind of documented patient right document and code that had existed in clinical research well back now to the us and as i said totally embarrassed by how we've behaved in our our past and what i hope you understand is it's not that long ago so in 19th a tuskegee syphilis experiment occurred between 1932 and 1972 40 years the purpose was to determine the natural course of syphilis as a disease over time they enrolled poor african-american men now this time was a depression right so people were hungry people were starving us and especially this poor area was in financial ruin so they promised them money promised them cigarettes and got a bunch of african-american males to enroll in this study what they did then they gave syphilis right exposed them all and continued to observe what happened to them now when it first started they treated some and then it stopped as a depression occurred and resources and funding for the study decreased deb penicillin had just been discovered around 1928-29 the treatment was available right yep exactly and especially the supply came back in about 1947 but they didn't give it to them right so we have a group of poor african-american men getting some money getting cigarettes for their visits right something that we wouldn't think is a luxury but it was a luxury to them at the time they weren't told there was a treatment available they just continued the study and continued it over 20 years from the time we had a drug called penicillin available and known to be an efficacious therapy for syphilis so what happens a bunch die a bunch of wives and our significant others get syphilis and even some children are born with congenital disease from syphilis now some of the awful things about this are really kind of what the doctor said right they just didn't really care they would say things like it doesn't really matter right as we are we have no further interest in these patients until they die that's one of the quotes of the physicians who participated in this there's a name up there from dr clark who basically said it's our duty to follow these people and dr clark's going to come back later because dr clark had a long history of kind of research unethical process dr heller made a statement the men's status did not warrant ethical debate they were subjects not patients clinical material not sick people the justification he used is they're in a trial that's the matter this gentleman was interviewed and made that comment in 1976 in 1997 some of you were alive most of you were alive president clinton says the united states government did something that was wrong deeply and profoundly morally wrong it was an outrage to our commitment to integrity and equality for all citizens and in that statement he acknowledges right this was federally funded it shows a select group of vulnerable people and it studied them in a way that would be viewed today and should be viewed there as really inhumane we've had lasting effects of the tuskegee study getting this african-american group engaged in research has been traditionally difficult and i don't blame them because they had institutional racism of good lord against them at this time and really lost faith in the medical profession the next study had kind of in that four most unethical research things was a willowbrook school study this was done in 1956 to the 1970s the purpose was to learn about hepatitis and understand the effects of it they studied mentally delayed children and injected them with the hepatitis virus i guess that would have been hepatitis a i suppose would you suppose yep so the study was designed to do one thing is understand how it goes and then to atta eventually what they said was to test the effects of gamma globulin in preventing the progression of the disease so there's a huge ethical issue on this is children were deliberately infected with a hepatitis virus initially they were given stool to eat so they were fed extracts of stool from infected individuals later they made it much more civilized and just injected them with hepatitis but initially they made him eat poop the defense they used and what the investigators said was that you know what willowbrook was having an outbreak of hepatitis they would have gotten it anyways so by giving them hepatitis in a controlled manner we were really helping them and they said look it we followed the nuremberg code we got consent well let's talk about the consent they got parents of children's at willowbrook were told it was full right you can't get your kids here unless you put them on the hepatitis floor and let us do our work so the parents had mentally ill children nowhere in this area to send them and the only way they could get in to a hospital for mentally ill children was to consent to participate in a research study we're going to talk a little bit that's not consent that's coercion and we have to understand the difference between the two all right the jewish chronic disease hospital 1960s purpose to determine patients response to injection of live cancer cells who they study the elderly so elderly patients who are in this chronic disease hospital but they didn't tell them what they were doing so they said they got consent but they never documented it they never told people they're gonna inject cancer cells no one had looked at the study and the physicians responsible for the care weren't even asked if they wanted their patient to participate the researchers said well you know documentation you know isn't really needed we know what we're doing so do you know what if we told them we're giving them cancer cells we may scare them and you know what it we learned a ton by giving them cancer cells because you know what it's going to reject and we'll see with the immune response and science would be advanced so they took elderly people didn't tell them what they're doing and gave them cancer cells not something that should be allowed today so what happened the state of new york actually brought charges against dr sopham who is the investigator and dr mandel the hospital's medical director they suspended the license others doctors and then you know what said uh suspension too much you just need to be on probation for a year dr southam went on to be the american association for cancer research president not much of a hand a slap on the hand not much punishment so even though those regular regulatory bodies knew that it was wrong their actions and the how they handle those doctors kind of raises the question that they really didn't think anything was a big issue at all so those are my four there's a couple other things that have gone on that have shaped our world and and kind of the u.s research just to kind of let you know what we've also done another big study not one of my top four but one that's definitely worth discussing is the guatemala std study done in 1946 to 1948 use u.s researchers took 1500 prisoners prostitutes orphans and mental health patients and gave them gonorrhea and syphilis they treated 87 percent of those infected but lost track of about 13 they didn't trace anybody who could have been exposed the study was actually approved by the guatemalan government so they knew to ask if it's okay but the guatemalan government at that time was poor and in response to approving this study they actually received materials for research starved institutions in return so we gave them money and then we also gave them cigarettes which seems to be a big currency at this time in 2010 the us apologized and said we were wrong we're going to give you a million dollars to actually study research ethics and we're going to give you three quarters of a million to study stds and to fight them because we've given and spread them so much in 2011 there was a class action filed against the u.s government by 700 victims and relatives what happened to these these folks well dr coulter the research coordinator said unless the law winks occasionally you have no progress in medicine so you know what if we don't do the wrong things and people ignore it we're never going to advance science and guess what in 1943 he decided you know what federal prisoners in indiana i'm going to do the same study and he did it again dr coulter then went on to be a key participant in the tuskegee syphilis study and was dean at university of pittsburgh in the 1960s so let's go back through history in 1949 to 1946 to 1949 we have the nuremberg trial in 1963 the new york jewish chronic disease hospital study ended 1966 the willowbrook state school ended in 1971 this tuskegee study ended it wasn't until 1966 that scientists said we got to make this different we actually need to look at ethics before we publish and we need a national policy on institutional review board reviews so we before studies are looked at and started we can actually look at the ethics behind them so i can stop and take some questions there all right we have a lot of questions so far a lot of people are just so shocked that these types of studies happened um was it a common practice to deceive patients before ethics ethical standards were implemented you know i think the scary part is i don't think we know how many people were deceived we know about these because i think they caught the press and someone questioned them but the true kind of extent of what scientists did i'm not sure we know oh man um have you seen any unethical practices and research in your career so far we will be going over one of those at the end so yes okay um why do you think they continued the syphilis study even though there was already a cure i think because people got lost and wanted to understand the disease state and as kind of they made the quotes they didn't view those people as patients they viewed them as research study and in that matter felt no obligation to treat oh man um so a lot of students are interested in research and want to pursue it in the future what can students do now to combat like unethical research or potentially in the future you know i think that's part of writing the irb and realizing that any study you participate in really should be reviewed for conduct and that's even anything that's just done in in a manner of what we call performance improvement which is to make things better for patients that really isn't research but you implement it and so really asking your faculty you work with to make sure that they've they that that has been done and then also if you're going to be enrolling understanding the study itself so you can actually inform patients on what their risks are awesome um hey rachel if uh if i may there's been a lot of different variations on this same question um what do we do with the information that's gleaned from these highly unethical studies that still considered science but the way that it was achieved was certainly questionable what do we do with that information going forward for example now we know the national or at least in part the natural course of syphilis what do we do what do we do with that you know i think you know the sad part is that you know ray brennan and stuff we know those symptoms of neurocognitive syphilis and how what they present with we learned in part from this study and so you know i i know the and and how it was obtained and know how awful and horrific what practices were in place i can also though recognize that at the benefit of having some of that knowledge i just really wish it had been obtained in a manner that doesn't turn my stomach um we've had a lot of other questions too um so a lot of our students want to be doctors and they also want to do research do you have to have an md slash phd to do research as a physician no typically you have to be employed by the hospital or the institution that you're going to do research at and so it can be a bachelor's it can be a masters it can be phd you know pa app all those aspects the regulatory steps you go through though are the same irrespective of what your degree is cool um was it the history of clinical research that made you go into research or really explore research you know it wasn't um i didn't really get to know this until i got on an irb and institutional review board and understood why some of these practices are in place and how important they are to understand and to use them on for to protect our patients my desire to do research honestly um wasn't my spiel going into med school i wanted to didn't have i didn't wasn't interested in necessarily emergency medicine definitely wasn't interested in doing research um but was given the opportunity when i was a resident to do some research and quickly learned that i like asking questions i'm that person that you know i love if somebody tells me this is the way to do it to ask why and in medicine there's a lot a lot of reasons that i'm not sure there's a great why out there and so truly understanding and thinking about ways to answer questions and provide evidence so we can actually treat our patients in a effective way is really what drives me and makes me excited to do research and i really just like answering the questions and i think to me that's what makes research fun is um i feel bad for the residents who work um with me on shift because i can turn anything into a research question um you know if anybody asks a question i'll be like that's great that'd be a good research question you would do it so um to me i just i i just take a lot of enjoyment and um answering the question awesome and so is there any limitations of what you can do in research if you don't have a phd or if you only have an md no okay okay do research yep pas can do research too so the limitations of doing research is having the money to do it if it takes money having the time to do it because it always takes time having the idea which is the hardest part um and then having the perseverance to get it to get it completed do you have any advice for anyone who wants to pursue research right now or like they are thinking about it um i think you really before you go into it decide that's your career i would suggest trying it um it's not for everybody uh it takes it takes it can be tedious it is not glamorous at all sometimes it is sad at times it is rewarding at times and it can be disappointing because sometimes other people don't think what you've done is that big a deal and so getting it published can be challenging so research is not for people that can't take disappointment because there's a lot of it and you have to be willing to bounce back from it and to keep going and find a home for your papers or you know figure out when things just don't work and you just aren't going to get the answers you want um is there any advantage of having a phd for doing research i think phds are really important if you do basic science research i think that's essential to get funding in basic science research to have a phd i don't do basic science research um so it would make no difference for me to have it or not that was same with a pa a nurse typically they don't do basic science research so the phd doesn't add as much value in that setting and then so as you how was your experience as a woman in a male dominated research environment yeah you know i haven't found my sex to be a problem at all um i think it's more what i've done to get my to move my way which is i kind of follow a couple rules and that's um if i say i'm gonna do it i do it if you ask me to have it done by a certain date i have it done by a certain date and i'm gracious and i like the people i work with and so um getting stuff done when you say you're going to get done is not necessarily a common trait and so by doing that it was not hard at all being a woman and a clinical research environment that's male dominated it was um i had just an equal seed to the table as anybody else i'm glad you did or you still do um so how do you deal with the stigma that only successful research gets funded so i think the funding is really based on you know it's federal funding um not all research that's funded is successful good research ideas that people believe in and believe that can answer a question either based on good science behind it or and rigor and a track record to doing research it's what gets funded um we need to publish negative trials matter of fact that's one of my biggest one of the biggest criticisms of kind of our medical profession right now is we don't publish negative trials because they're negative but um those are also important to publish and those are what are really hard almost harder to get published because no one really wants things they're interesting but negative you know things don't working out they should that's also relevant so nobody else repeats it in the future um a lot of students are still you know still shocked that we had such a negative history of unethical research um did anyone try to stop that unethical research like earlier on or was it just you know when it got published in the news you know so i don't it's hard to say i don't know if they did or not it's really difficult i haven't found through reading names of people who vocally tried to intervene that would make kind of history books at this point um so what checks and balances does medical ethics have in place to um prevent something unethical well that's the second half of the talk so i think i am excited for the rest of this talk i think the students are excited for the rest of this talk so i think we can move on all right so the response to these abuses right so we know about the nuremberg code from the nazi atrocities there's one other study i want to mention because i think it was important and you all may have heard of it and that is the thalidomide disaster that flintamide is a drug that was given to pregnant women to kind of combat nausea and it did except for it caused birth defects and so for a period around the 1960s to probably 19 early 1970s there were women who were given thalidomide for nausea and ended up having babies who had limb deformities in particular and these women were never told sorry that the drug was actually investigational they were just told we have a drug that works and so that actually also led to the fda you know a federal drug association really actually for the first time creating an act to address drug use too and so thalidomide although wasn't a as it wasn't as atrocious as some of the other things really hit the public hard because they'd show pictures of deformed babies and so that really also brought a ton of public kind of response and knowledge to some of the research going on and so brought a lot of press to some of the areas because these were regular women right they didn't do these studies weren't done in groups that people could dismiss they were done in everybody and so even institutional bias and racism couldn't excuse it so thalidomide itself had an impact they just weren't told it was a study so after kind of 1964 the declaration of helsinki was created and we're going to go over that because that was one of the other foundations that built on the nuremberg trial that was really done in response in part to the willowbrook and the jewish hospital the last thing that came out after the tuskegee was the national research act and that really instilled some core principles that as a person who reviews research to be approved you had to look at so we have the nuremberg we have the fda's code we have the helsinki declaration and then we have the national research act all kind of a response to the atrocities that had gone on so the declaration of helsinki it addressed some core principles it addressed patients right to respect self-determination and informed decision-making and it said the investigators duties primacy of the subject's welfare and ethical consideration should take precedent over laws and regulations so the investigator even if someone doesn't say explicitly it's wrong has to have some idea that ethics have to come into play it also allowed surrogate consent which means if someone is unable to consent because they're too ill or don't understand that someone else can consent for them the national research act was again because of tuskegee went into effect in 1974 and mentioned some basic ethical principles that should underline all research biomedical behavior anytime there's a human subject and it gave and it had a name called the belmont report now the belmont report is what every person who does research has to know about and we have to study it and that there's some kind of forms we have to go through and training and it's all built around understanding the belmont report and that is really what's the difference between clinical practice and research what are some basic core ethical principles and how do we apply them on the research we do one of the things was that practice so the actual practice of medicine and research are absolutely different one should be based on standard of care so what we know is best and one stretches and questions and advances what we think standard of care is an institutional review board has to know the difference and distinguish what's standard and what's not and what's research and we actually need to make sure that that's clear to patients when we do it so the three key components though of the ethical principles are respect for persons beneficence and justice respect for persons really goes around people are individuals and should be treated as such and if they have limited capacity to make decisions we need to protect them and there needs to be protections in place benefits is the same thing do no harm maximize benefit minimize risk and then justice is we need to ensure that everyone who could benefit from research should be able to participate so respect for persons this is really sometimes hard and actually raises some controversy you need to treat individuals as in a person who is capable knowledgeable to make their own decision that sometimes is hard for doctors to do especially if they think and believe that what they're doing and their research is good we need to protect also people with limited capacity even them to the point of saying you should not participate and we actually need to reassess that capacity in people now capacity is really the ability to understand and this is where mentally ill patients get involved this is where depressed patients get involved this is where mentally ill patients get involved this is where patients elderly dementia or too sick to make their own decision are included and that capacity can change throughout the disease process it can change with time if it's a longitudinal study and so the respect for person says look you just got to keep revisiting this so you've got to reassess it and we want to know how why and when you're doing it beneficence the irb should determine whether the risks to subjects are reasonable in respect to the potential benefits and as a member of an irb we spent a ton of time talking about this so one of the things that the researcher now has to do is list the risks they had to inform the patients of as risks for me i do a lot of biomarker studies so my risk of most of my studies are needle puncture right bruising from a needle if i'm not going to tell patients the benefit i have to tell them there is no direct benefit to you but the results from this study may help the future so part of an irb and part of that consent process needs now to include telling people what could happen to them and some decision about whether that long-term benefit and risk profile is equitable and appropriate justice treat people fairly don't exploit those who are readily available are malleable we're going to show i'm going to show who we think are vulnerable patients but when you talk about do not exploit those who are readily available or malleable they're talking also about students right you as a group are at risk you could be exploited your professor says hey come participate in a study you know what may not be appropriate so we have actually a lot of scrutiny that goes in to research that involves students trainees anybody you supervise to make sure that you're not they're not being exploited and the last point is fair distribution of the risks and benefits based on the problem under investigation and that really is meant to say look at we have to include everybody at risk in our studies it's why we can't use language as an excuse to exclude people from research usually it's why we actually can exclude by race in most studies now so we actually can if a disease is common in a broad base population that's diverse we have to include everybody application of these principles is tough and we do it a couple ways we have informed consent process that all these are listed in we discuss the risk benefit ratio and we actually make them specify who is going to be a target for a study when it's done so who are the people going to be selected and those are the ways we address a lot of these issues so members of the institutional uh boards like i was really have to consider all these things and i gotta tell you these discussions usually can go on for hours they are long discussions sometime especially if it's unclear if you don't have if you don't understand fully exactly what they're gonna study or it's going to involve a vulnerable patient population another patient population that we consider vulnerable right now are prisoners so prisoners also are in that group that we really have to have extreme caution of whenever we include them in research so respect for person self-determination no coercion right what does coercion mean it means i'm going to make it such a good deal for you to participate that you're going to say yes no matter what i do and that can be done by a couple of ways that can be done by me promising you something if you're a student i'm going to promise you a good grade that's coercion it can be done by me offering a ton of money right so if i'm going to pay you an amount that seems unreasonable for the time you spent that could be you just coercion so everything's got to be voluntary and people should be able to make decisions to participate without external forces going on now when i was a med student i participated in a research study i got 900 dollars to do a right heart cath and at the time that 900 was my flight home and so um the irb clearly thought it was reasonable as far as what i was doing to get paid but in a way the money is why i did it i don't really care about the science it was more the money and so in a way you could you could consider that coercion at that time where i was making my decision not really based on probably thoughtful thorough discussion around the risk benefits but i needed airfare flights for my husband and i to get home violations of respect for persons again offering large incentives not telling people what you're going to do and collect misinforming people about the true purpose of the study right those things can happen and sometimes it's okay usually it's not beneficence freedom from harm freedom for exploitation and again looking at the risk benefit for every study we do harm not knowing anticipated events temporary discomfort is how we categorize these these are all how we look at them so you know what nothing out of the ordinary is going to happen temporary discomfort needle stick right you may have a bruise it may be uncomfortable level three is unusual levels of temporary discomfort four is permanent damage and five can be certainty of permanent damage i've never seen a category five be approved but risk of permanent damage can be if the risk of a disease is such that without treatment or any study that patient will die and so there are some ways that we do some risky stuff under an irb it is hard to do though and are carefully carefully scrutinized exploitation we won't use right information against people some examples of that are we're not going to enroll people with holistic drug use and hiv status and say look at you i'm going to tell your employer right if you're hiv to get them to participate and then the relationship should remain professional and this really is kind of a theme that has it kind of gone through medicine itself is that we really need to separate learner teacher researcher participant and make sure those relationships are always professional in nature justice treat people fair right to privacy and confidentiality so those we think have diminished capacity are minors they can be people who are elderly they can be people who are mentally ill there are definitely groups that we link and they're all on here what you really need to know about it is there are groups that just we think are high risk for being taken advantage of and again minors prisoners mentally ill institutionalized are those groups of patients that we look really hard on at when we look at their studies and students are in this group so have we learned from the past right a lot of those studies i showed you were before 1970s right most of you weren't even born all of you weren't even born except for the old farts so in 2009 right not that long ago 2009 a government office goes undercover what they wanted to say was we have all these rules in place how are they working so they did two things the first thing they did they created a fake irb right and said hey send this to this irb that doesn't even exist says the pharmaceutical companies and then they sent created a fake device company and sent a research proposal to an irb thinking that as part of due diligence as reading some of the information someone should question whether these existed or not and you know what no one did so they've got all these rules and regulations but what they found was is that even though they had these in place there were loopholes and there were ways to get around it and there was a way that people didn't have to go through all the checks and balances and so about 2009 they ratcheted it down again more kind of more protocols more oversight and really kind of increase the scrutiny on the irbs themselves but the other thing that happened because of the in the kind of the implementation of an irb and the fact that what this did was it made drug companies inventors innovators go through a longer process to get approved we saw something called the globalization of clinical trial and that's especially when we talk about pharmacy and what we see is that pharmaceutical companies said you know what us you are way too difficult we're gonna go somewhere else we're gonna go overseas right and so instead of taking at-risk u.s people we're going to go to india and enroll at-risk poor indian people because we can do it easier faster and more and get our answers quicker through that and you know what this is from scientific grounds it was presented and talked about the fba fda and what it says here is you know what maybe going overseas is the answer we can do things cheaper by going elsewhere to do our research so instead of going through and trying to get through the studies that we had in the us and the process that we had in the us the answer to the industry the pharmaceutical industry would say uh uh i don't want to wait that long i got billions of dollars at risk i'm going to go somewhere else and that's where i can get my stuff my research studies to to look at pharmaceuticals so i can do that and what we saw over the years if you look at from 1990s to late 2000 and the number of trials done oversea exponentially increased as the rigor and the requirements for doing research in the u.s increased also so what we came to is about 80 of drugs are now approved based on data from foreign clinical trials over half of clinical trial subjects and sites are not in the us and one third of trial investigators are now from foreign sites so we have pushed a lot of companies a lot of clinical trial design outside the u.s to escape some of the rigor and the time it takes to get things done in the u.s it reduces cost speed and regulatory burdens but it also led to some more unethical principles so in 1997 there are nine u.s government-funded studies of pregnant women in africa asia and the caribbean half of those women in these trials were treated with azt a therapy known to prevent hiv transmission to a fetus the other half receded placebo received placebo why were these done outside the u.s because at this time azt was known to be an effective way to prevent the spread of hiv to fetuses from hiv infected moms and so what they said in this write-up is look at you know what the u.s trials that did it there were two that looked at the same thing but everyone could get azt the foreign studies used a placebo so what we saw what they collected from all these studies that were done out is that exactly what we expected and should have been expected occurred that women who got act their babies did not get infected are sorry in the red and women who did not got placebo had a higher rate of transmission of hiv to from the pregnant mom to the fetus couldn't be done in the u.s because the u.s would say no because you're taking a known standard therapy and denying it to people which cannot be done according to the belmont report again going back to look at overseas is our solution issue that came up is denying the use of surfactant which is a drug that gives given to babies to help their lungs mature if they are born prematurely we couldn't do those studies in the us because it was standard care so they went over to some areas where it wasn't and did a randomized trial to really determine the magnitude of difference between those who did get it and those who did not a study we could not do in the u.s so what really needs to be done and how can we address this there actually needs to be just a lot more oversight we need to address conflict of interest who's going to benefit from a drug being shown to work or not work and are they making too much money and is that really what's driving some of the research and then tying that in with some high-profile third world justice causes to make sure that access to medicine is equal no matter where we live so kind of questions on that and then we'll go on just to why this matters to me and kind of tell you my story and what i've kind of experienced so i already told you i've been a member of irb i was a member of the irb at davis for a lot of years kind of went through kind of leadership and now i'm on some data safety monitoring boards so i've had some interesting stories of my time one of them was my research study so this is naturocore naturocore was a synthetic kind of natural peptide naturonic peptide makes you kind of pee for better kind of simplicity and it was given to heart failure patients so i got a grant to do a study using nature core and comparing it to not giving it in observation unit patients when i started the study it was easily argued that nature core was a standard therapy well i got about six months into my research enrolling patients and getting things going and two studies came out and they were retrospective that questioned whether this drug actually caused harm and so as a result of those two papers there was a lot of discussion that you know what this wasn't standard care and it shouldn't be standard of care and so what i did is i stopped the study gave the money back right never completed the child because what was i was doing research was under the assumption that everybody was going to get a medication that should help them right either standard care that should be good because that's what we do are an investigational agent on top of standard of care because everyone got standard of care and once that investigational agent is no longer beneficial the question of whether the risk of participating in this trial in my mind outweighed the benefit and i stopped it and you know and i was only irb so i didn't even have to wait for them to look at it i just made the decision but it was a hard pill to swallow to give back grant funding that i had worked hard to get and it was just had to happen so this is headlines zac b uc davis doctors infected brain cancer patients with bowel bacteria resign this was a tough one i knew both these guys matter of fact one of them dated the sister-in-law one of my best friends so these people i'd seen good guys they were taking care of patients who had glioblastoma multiforming and that is one of the most awful diagnosis to get because it almost is universally fatal so they had some patients that were really at that point where there was nothing that could be done for them they were terminally ill no treatment available and they had done research that showed that an inflammatory response in the brain can actually in lab animals in the lab setting reduce the tumors and actually make an impact on the outcome of these patients so they decided to talk to these patients and consent them and let them know what they were doing so all the patients knew and went in and put stool in the brains of these patients and everyone died not unanticipated right they were gonna die that was that was the course that was going on and there was no treatment but they did it as standard care and didn't do it as research and so it never got to the irb to look at and so it was never reviewed the risk benefits were not actually thoroughly discussed all the principles of the belmont report were not addressed and ultimately these two lost their jobs because of it it was probably one of the more memorable discussions we've had most of us i couldn't believe that people would put stool in people's brains um secondly these doctors actually adamantly argued that they felt that it the patients were appropriately informed they argued that it wasn't research unfortunately the box they brought the stool into said for research use only and so that was videotaped and had clearly been documented and it was just excuse me a bad situation to be in all together and uh was horrible so this is another one from the news this is actually about two months ago nih damn can i stop you one second yep you think that there was a i mean you knew these guys was there an element of the fact that the disease was so horrible i mean john mccain died of this that they were trying to do anything they could that might make a difference on a terrible disease i do i really thought i think they thought that their they had a potential kind of foundation of a cure or at least something that could mediate the disease process they just decided to do it outside of every ethical principle had they done it provided it got through irb heck we may have allowed it if it you know if the risk benefits radically explained there was good science behind why they wanted to do it they just went around every road every check box kind of thing perhaps an emergency use authorization from an fda or something like that yeah so they can there's there's actually some provisions for what they call hud which is really kind of um as you kind of mentioned it it is used for rare cases and people with terminal diseases where you have to get approval it really is kind of a short course for an irb that can be done and some of those kind of rare diseases um rare instances they they will use an alternative to an irb approval to get that um they just didn't do it and it just it hurt their careers which is pretty sad so this is another one this is nih halts clinical trial of hydroxychloroquine this is um recent it is hydroc hydroxychloroquine was a treatment for um thought to be a good treatment for copen and um this was a multinet it was a national trial multi-center run out of vanderbilt they had you know gone through the process they had randomized people to receiving it or not um well done study i served on the dsmb and was part of that group that halted it and as a data safety monitoring board one of the things you have to look at is futility and what it came down to on hydroxychloroquine wasn't that it was harming people but it wasn't helping them either and we got to the point in that trial where there was no way had they continued it that it would show a benefit to patients and so that risk benefit ratio changed because there was no benefit and so instead of continuing a trial that was futile um the decision was made to halt it and that was a big deal this was a 5 p.m friday night to 9 p.m friday night discussion on really were we certain that the recommendation to the nih was to stop it because the last thing you want to do is stop a trial that actually could help people and so morquin actually seemed to have physiologically for example alkalinizing of endosomes and so forth some compelling things that might have worked yep but uh this was a uh this was a big decision uh the nih did you know took the recommendation from the data safety monitor board and halted it um i think you know our results were also looked at and there was what we had also when we made this decision were the results from all the other clinical trials that had shown that it really didn't work that well so um again this is kind of where research goes this is what part of it is um it's been an interesting process there are many coded studies that they're looking at right now that were you know i have to look at make some decisions on or at least provide my input but that's really part of research and that is having safety monitoring boards that are separate from the researchers they know researchers part of it this is a independent group that's goal is to look at it even that though is not done with scrutiny this is a letter sent to the nih by a public group that questioned the overall kind of safety of the network that i'm part of the safety monitoring board on and they raise concerns about consent and so this has been going on since 2018 before i got engaged um but definitely there's scrutiny on even the overall network that uh and all the studies are looking at that the public is engaged with so these are kind of my kind of experiences um i'm going to be dealing with this one for a while but definitely really makes me appreciate uh what can happen looking at why things happened and also all the thought and the carefulness and the extensive discussions that go on when you actually evaluate the safety of a study so on that cheery note if you still want to do research which i do i think is really fun and i love it um how do you get involved and these are kind of my five steps and um my nf2 which are my kids it's worked so far um but these are kind of the rubrics that you know we walk through trying to when they ask the same question is what do i do and first is do your research and what i mean by that is if you have an area you like google that department in your school google that department in your school of medicine go through each of the faculty in there and look to see what they're doing most faculty profiles have a list of the research they're interested in when you find one email them and say i have looked at your profile you are doing work in x write the title down so they know you work and i would like to talk to you about getting involved in your study so my older daughter was interested in sports and so she looked up a kinesiologist and got involved in some research on orange juice hydration and got engaged in that my younger daughter also interested in sports emailed a sports medicine person and got engaged in some sports medicine research the key is it may not take just one email and you need to email again so if you don't hear back from somebody don't take that they just aren't interested sometimes your emails are in amongst of 30 to 100 people get a day and when people are going through and cleaning your email they may put a flag by it and just not get back to it so email again once you make contact go talk to them and this is the hardest thing research is not sexy you as a undergrad or as a high school student or even as a medical student you aren't going to get to do all the cool stuff because most research isn't all cool it's just fun to find the answers and accept anything they want to do and they they give you it may be entering data you can learn a lot from entering data if you especially if it's medical terms or anything and that's just part of it i enter data matter of fact in the last three weeks i spent probably 40 hours doing chart reviews to help one of my colleagues out because they weren't going to get it done so anything they give you is a foot in take it the one thing that'll help you get more is to continually do it we're all busy and so don't go into a you know don't go into research if you're gonna get engaged it's not a quarter thing it's a year thing it takes that long and so really if you're going to get engaged in research make it a commitment medical schools like long-term commitments right show perseverance you can also get a heck of a better letter of recommendation from somebody you've worked with for a year than somebody you met four times so if you're getting get engaged in research it's an investment it's an investment of your time which will pay off with a great letter of recommendation and saying something that you didn't you don't have to get published the reality is most research projects about 50 percent of them never get published anyways you do have to know what you did you do have to know why the research is being done so know the question being asked being able to talk about it be able to talk honestly about your role part of the med school committee although i'm not on it now i've been on it in the past we don't expect you to be you know the person doing everything we understand if you're doing chart reviews we understand if you're entering data we understand if your job is to type stuff or to do menial stuff that's okay we've all done it and so really you don't have to do everything so really accept anything and understand your value you're a part of the team you may be working for a postdoc right who's got the p that the other person they work for and it's okay your value is getting stuff done and helping them get their answers and that really is what you are you're gonna do at this stage of the game you probably aren't going to develop your own research study and take it from beginning to end that's going to take time it's going to take time to get to know somebody and if you do that it's because you made a longitudinal investment with the person you're working with and you've developed that relationship where they trust you to to support your own research and so again no do research figure out who you want to look you know to talk to and then email and be persistent email them again make this a long-term investment right doing it for a semester is fine doing it for two is better so longitudinal showing dedication is going to get you much further along as far as getting things done getting things published and understanding what you're doing and so i think those are some of the keys to really getting engaged and with that i am happy to take questions yep all right well thank you dr derricks for just telling us about research and i'm sure you've inspired so many students tonight to do research um we have a lot of questions coming in um first students want to know more about the irb like how do you get onto it and like what does the irb specifically do all right so the institutional review boards are made up by members of these usually school of medicine or other people within the health system campus there can be pharmacists on there nurses kind of research coordinators most of those people are selected to be on it there is a community member on it also and if a study is going to discuss prisoners there is a prisoner representative that comes in and so what they do is any study that is deemed to be more than minimal risk has to go through an irb and be presented to a committee to review all those aspects of the belmont report they consent the protocol to make sure the risk benefits are there looking at the safety and making sure that their participants are all encompassing of those who are at risk for the disease awesome and then is there someone that keeps the rb in check so the person that keeps the irb and check there is an up there's a national office that actually kind of will come in and audit and do audits and so there are and then different policies that an irb has to go through each year to get re-credentialed so they're kind of two different offices that look over the irb to make sure they're following rules and regulations so deb let me interrupt with one so you're an acute coronary syndrome heart attack research person we know that there's some question as to whether for example adrenaline epinephrine is a benefit in cardiac arrest but these patients who have dropped dead and we're trying to resuscitate them cannot consent so how do you go about doing such a study like that right so about 10 years ago the government passed something that allowed exemptions from informed consent and that was absolutely made to address research in the area that ray talked about where you can't can't actually consent people so those are pretty darn tough to get through what has to happen to get a study like that through is you actually have to prepare a community awareness plan so for and what you do on that is you actually take your study and you take it out to populations that are relevant to your study in general so patients you know if it's a cardiac arrest group you could take it out to community groups and deal with elderly because they're more likely to have cardiac arrest or just general public groups and you inform them about your study and you give them the opportunity to opt out so they can either email the principal investigator and say i never want to participate in this or or not now that itself is not fail proof we've had some press for some of our investigators that have done cardiac arrest research and still had it challenged even though it was done under the exemption from informed consent the public still will question the validity but there are certain policies that have to go through for community awareness if you're going to do a study that is exempt from consent for the initial enrollment all those patients who are already treated with cardiac arrest if they survive they will be consented and their family will be asked to consent at a later time i remember one time after speaking to a city council about something that jim atkins and i were going to work on uh one of the council members came up after it can you make sure i get the real drug son rachel uh yes so if you see that there's any type of unethical research or research that doesn't look like it's going to be beneficial what is the process to stop those research practices so every every research project has to go over an annual review that's when a lot of those discussions are kind of brought up the kind of the more at risk the study the more extensive it is reviewed uh it has to go back to the full committee where you look at what they've done before you've looked at kind of what the results they've had there is a mandatory reporting if someone has what we call a serious adverse event and that can be either a re-hospitalization or something that's already named a serious side effect of a treatment or an intervention so those have to go to the irb within 72 hours so that also can cause a study to be halted or we looked at if there are too many serious adverse events if there are not then it gets an annual review to look for these same kind of principles all right cool um so in light of the rush to develop the covid vaccine what precautions are put in place to make sure that marginalized communities aren't being tested on like in the past so most of the code the copa vaccines itself are not community they're actually people have to be consented i think we've seen actually the irbs work uh when you saw them halted right so those are halted usually because of a serious adverse event um one gut halton didn't review and that's probably because the irbs looked at all these side effects and said this won't go too much risk and so one of our companies has already dropped out another one restarted what some of the side effects were looked at and they can may have been deemed not related to the in vaccine itself but the current vaccine trials undergo the principle of of consent they undergo the review of serious adverse events and they also undergo annual review is that the same uh process for looking at uh like new drugs for trials right yep cool um do you think there are any other regulations that need to be made for research that's happening today i think we need to be really careful when we look at more underserved um countries um just because they don't have access to a drug doesn't mean that they shouldn't have access um and really question the use of placebos which is a drug no like no intervention a fake pill uh in those groups and i think that is where i hope things are going um but we did see it in the hiv trials where that's what they had done and then do you uh can you tell us more about the process of approving uh say animal drug trials to go to human drug trials so animal studies are all reviewed by a separate irb though they aren't they don't aren't reviewed by humans irb they are actually also scrutinized pretty extremely as far as what's been done same principles of safety risk benefit to the animal how they're cared for who care who's caring for them the environment they're in so they look a little bit more of the environment than a human trout going from bench to kind of research there are kind of three phases of drug development the first is a phase one and that's just we're going to try it and make sure that there's no serious harm the second is a phase two and those are usually dose uh escalating trials where a drug will be started and they are trying to figure out the exact dose that actually has a good side effect benefit profile and most of those are kind of phase two so early on and a phase two three trial is really when you get into the randomized doesn't work better than standard of care so there are kind of three phases for drugs to go through uh until they get actually um into market wow and then do you know how long that kind of process would take about five years wow five years that's crazy um while we're talking about you know all this different kind of research can we hear more about your research sure so i as as dr feller mentioned i do cardiovascular research and so a lot of my work has been on looking at different biomarkers that detect heart injury or looking at how we can risk stratify people to figure out who actually needs additional testing and that's either from symptoms to protocols to how we can use biomarkers with risk kind of ways to stratify to make the most efficient manner of getting the right diagnosis and putting resources to those who need them and not doing stuff to people who don't and that has been it's a fun fun work it clearly involves working really closely with lab people so pathologists to cardiologists to emergency physicians and that's been really uh kind of beneficial and fun to have that kind of multi-disciplinary approach to my work i always like to say deb that research is where you find it you know we pulled all the charts on all of our heart attacks for one year we had 104 at parkland er and we found that if they arrived by ambulance or arrived by car that more or less the outcome was about the same it just took longer to get an ekg done but deb we found that non-english speaking folks were 600 percent more likely to arrive by car than arrive by ems so so we found a social issue and how in the world to deal to deal with that it's funny that you just turn a corner and you find something very interesting yep so we have a lot of high schoolers in our program with that same you know method of reaching out to uh professors or you know researchers be the same for them to get involved in research you know i think most people especially if they're if they're a college professor will try to reserve their extra time to work with college students so i getting involved in high school is a little tough just because there's a lot of people asking everybody for their time and they're going to probably invest in people who go to their college um i think there are probably some programs but i think at that level i think it's really more doing i just would spend my time on community service and building that kind of arm of your kind of multi-faceted uh personality and experience i probably don't research until you get to a college just because that's where all your resources will be and people be more willing to kind of and have more time to invest in you i think they're just really excited to do research um are there any consequences for researchers who fake data and publish unfounded results uh yeah so it's interesting so there's two approaches one the journal will take an approach and so there are there have been and and i've been part of um you know because i'm on editorial boards looking at some of these kind of fake data or more importantly copyrighted data or plagiarized data so we actually have the ability for every manuscript submitted to actually run it through and see if it's ever if there's match up from other articles so we can actually look to see how much things have been plagiarized we've had a lot of discussions about what percent uh is is a problem because some words just are the same but we look for that in in manuscripts to make sure they're not plagiarized from others the fake data is a little harder um every manuscript that's submitted gets reviewed by you know two content experts who know the subject but also a statistician and so hopefully a lot of those questions about methodology are caught um usually fake data is tough to glean um and typically that's been found by competitors or other people who are knowledgeable in the field who say look at this can't be right uh and that's kind of happened in the past awesome well i'm glad that people are always looking now to see like what's incorrect and whatnot so as a researcher and a doctor how do you balance both of those hats slash roles um i i think balance is in is in my it balances in the eye of the beholder and so i think that um there are many who would say have no balance and and i'm okay with that because i think i'm fine my balance is my balance um and you know research when you're into it you love doing it and so it's not work it's kind of fun and i think that balancing my clinical shifts with research really you kind of go in different phases of your life when you start out as an attending if you don't have any funding you're a big clinical doctor and a little researcher until you get funding or get support to do research um that clinical piece decreases and your research piece can increase but it really is based on funding and protected time to do that work and when you start research in most instances you're going to put a lot of sweat equity in before you get the time to do it because you've got to show that you can get it done yeah above all the research you've done what study is one that stands out to you most of a very interesting finding you know i think i think the one that stands out for me most was um jeff you know working with jeff klein on uh the use of tnk for pulmonary emboli for moderate pulmonary and it stands out for me most because it was a negative trial right we it showed that really not much benefit but um that was an interesting study because we were going to give this clot buster to people with pe and at my institution that clot buster was only given in the icu and these patients had to be observed and so the irb said this is one of the benefits of being on it said look at you can do this study but you have to observe that patient just like we would in the icu and so on that study um i spent some nights sitting in chairs in hospitals beds you know in the patients hospital rooms absorbing them and uh one of my most memorable kind of things i think will probably haunt me for the rest of my life was um i had the i had the major adverse event um of one in one of my patients in that trial um who ended up getting placebo but it was christmas eve she was enrolled in the trial and i sat with her in the icu for 12 hours and her family had come in and they had seen her and her sons had flown in and it was all happy reunion and i went home and the next morning i went to check on her and she had passed away and that was probably one of the hardest patients because i got to know her i talked to her i saw our family and that was just a hard one and it's not one i'm gonna forget um because it reminded me how how crazy that disease is um that it was somebody who was sitting there laughing and you know a few hours later was dead and so i think that was probably one of the most impactful research studies uh more because it just highlighted why we need a better treatment um and we just don't have it for that disease i have two thoughts you know it was funny about 15 years ago we thought that by giving a sugar water in potassium solution this was the immediate trial to people having a heart attack that we could we could nourish the muscle and and shrink the size of their heart attacks and we did the study and it turned out it didn't it didn't do anything but it was then replaced by the alternative therapy that we all use now which is get the artery open the other thing that i've been able to participate with dr idris of course with the resuscitation outcomes consortium is that it was interesting over about 15 years to watch steadily a little bit how we refined how cardiopulmonary resuscitation was done for example in the old days we thought bagum give them a lot of air that must be good well it turns out it's not good if you over bag them over ventilate them in fact they don't do as well so it's been interesting to be a part of watching things change with the passing years uh rachel um so how do you deal with patients who don't believe in research and the studies and results that have been posted so they they don't believe in the research that's been done patients have the right to make their own determination and i think you respect it and you explain why you believe in it uh compared to it and if they still don't want to participate or don't want the treatment that's really up to them and that's really um the challenge of being a doctor is we can't make everyone's decisions we as a physician though have the right have the responsibility to provide them with the information that's that's a that's very great um i think that that's a lot of questions that we've had uh i think you've been so great about answering all these amazing questions uh can you go to the next slide please and then can you make it full screen yep all right make myself fight away there we are perfect thank you so much uh here is the quiz information you have until next week uh 11 10 at 6 59 pm central standard time to do the assessment it's like it's real easy if you listen um you don't need a quest based account to do this just enter in the pin for find assessment and enter the password derek's and then it should let you in if you have any questions and concerns about the assessment please don't hesitate to email us before the deadline because we can't do anything about it once uh the quiz is done and this information will be sent out on our instagram on our website and in tomorrow's email if you can't see the screen right now so don't worry we got you uh dr fowler can you take it away for any closing notes absolutely uh deborah dirks what an amazing talk there were a thousand kids online listening to you there will be 5 000 that will hear your talk ultimately on the posting on youtube each of those 5 000 kids deb will become a health care provider and see a hundred thousand patients in their career five thousand times a hundred thousand is a half a billion tonight deb you touched a half a billion lives with your wonderful humanity your amazing scholarly approach to the world and the leadership that you've shown we are we are deeply grateful and thank you so much for joining us everybody uh all 600 of you online please put thank you dr dirks into the chat room right now so she can see that okay all right everybody we're going to wrap this up thank you so much for coming we'll have another exciting talk next week we're going to be here as long as you keep coming back and so on behalf of dr dirks on behalf of the whole working group for the virtual shadowing team we want to thank you so much for coming and being part of our family and we wish you a good evening good night

Channel: Pre-Health Virtual Shadowing

Views: 4,863

Rating: 5 out of 5

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Id: bqXYRycJ6BY

Length: 98min 8sec (5888 seconds)

Published: Tue Nov 03 2020