Harvard DO urges profession to question, investigate, publish
Harvard Medical School's Ross Zafonte, DO, is a leading expert in traumatic brain injury. (Photo courtesy of Dr. Zafonte)
The first osteopathic physician to hold an endowed full professorship and the first to chair a department at Harvard Medical School in Boston, Ross Zafonte, DO, is a leading expert in traumatic brain injury, his research published in more than 200 peer-reviewed journal articles, abstracts and book chapters.
The chairman of physical medicine and rehabilitation at Harvard, Dr. Zafonte has made a name for himself in the burgeoning research realm of sports-related concussion, as well as in other aspects of TBI. Associated with many high-profile studies, he is the co-principal investigator of a 10-year project to examine brain injury, chronic pain and other health problems experienced by current and former professional football players.
He served as the principal investigator of a double-blind randomized clinical trial examining the effects of citicoline, a widely administered medication for neurological disorders, on the functional and cognitive status of patients with mild to severe TBI. Published in JAMA last November, his research indicated that citicoline does not improve the cognitive status and function of patients with brain injury when compared with a placebo.
Dr. Zafonte helped oversee the rehabilitation of many Boston Marathon bombing victims as the vice president for medical affairs at Spaulding Rehabilitation Hospital and Massachusetts General Hospital in Boston. He also has been to Afghanistan to advise the U.S. military on caring for soldiers with concussions.
Graduating in 1985 from the Nova Southeastern University College of Osteopathic Medicine in Fort Lauderdale, Fla., he served a traditional osteopathic internship followed by a PM&R residency at the Mount Sinai School of Medicine in New York City. Before joining Harvard in 2007, he served on the faculty of the University of Pittsburgh and, prior to that, Wayne State University in Detroit.
In the following edited remarks, Dr. Zafonte talks about his career and shares insights on what the osteopathic medical profession needs to do to spur more DO graduates to do research.
When did you decide to pursue a research-oriented career?
Although I have always had curiosity about why things happen, I honed my research interests and skills during my residency at Mount Sinai. I had some fabulous research mentors there. Nurturing young researchers is something that large academic medical centers do really well, both in undergraduate and graduate medical education.
Why is that?
Allopathic medical schools have a hierarchical academic infrastructure. Getting research published is essential to rising through the ranks—from assistant professor to associate professor to full professor. The deans of these schools are a product of this system, so they tend to champion research and emphasize it in their curricula and hiring patterns.
“Our DO schools should do more to encourage students to ask critical questions and help them learn research fundamentals.”
Research is about asking questions and designing studies to test hypotheses. In MD schools, there are many faculty members who can mentor young physicians in this regard.
Osteopathic medical schools, in contrast, often hire faculty with a lot of experience in clinical and administrative medicine but not necessarily as much experience in all aspects of academia. They may be leaders in the osteopathic medical profession and excellent teachers but not necessarily leaders in medical research. You see what you look for, and you look for what you know.
Our DO schools should do more to encourage students to ask critical questions and help them learn research fundamentals. Most important, osteopathic medical students need to gain an understanding of levels of evidence so they can interpret, critically assess and later build on the research published in journal articles.
Allopathic medical colleges also tend to have more awareness of programs that can further young physicians’ academic careers. Within a couple of years after residency, I served as a fellow in a research enrichment program through the National Institute of Disability and Rehabilitation. And a few years later, I completed a leadership program for physicians at the Harvard School of Public Health. These sorts of programs are open to DOs, but osteopathic medical educators are not as familiar with them. DOs who train in osteopathic residency programs need to have initiative to seek out such programs to enhance their research skills.
For some 20 years, you have been doing research on traumatic brain injury. As a physiatrist, what aspects of TBI have you been addressing? What questions have you been answering over the years?
Most of my research has been on the post-acute and rehabilitative aspects of traumatic brain injury. One of the things I sought to do early on was to try to understand the recovery process better. What clinical variables could lead to a more refined prognosis, and what biological factors influence recovery?
In the past several years, I’ve been trying to identify individual variations in recovery and learn how we can manipulate those variations to enhance the recovery of particular individuals. This involves understanding imaging-related pattern differences and issues related to the genomic and biochemical markers of injury. We are working to target specific drugs and therapies to particular markers so they aren’t just haphazardly administered.
Is it a major problem that medications are often given without enough information?
Correct. For example, we would like to make sure that we not only do good but that we also don’t do harm. Previously, antipsychotics were frequently given to patients with brain injury. Now we believe that antipsychotics, at least in high doses, may not be the best thing.
Our recent research published in JAMA showed that citicoline, a therapy approved in 59 countries, not only doesn’t work, but it may be harmful in a cohort of people. We have to figure out what doesn’t work and then turn toward things that might work, whether they be certain agents that are more dopamine-based to help with the recovery pattern or other interventions such as neuromodulatory therapy.
Have you ever used osteopathic manipulative treatment in your research?
I’ve not done OMT research, but I use it clinically with some patients. I admire people who do OMT research because it’s not easy. It’s hard to sham OMT and to prevent selection bias.
What did you do when you were in Afghanistan?
I was part of a blue-ribbon panel that looked at the way our nation’s troops should be care for after a suspected concussion. There has been a huge improvement and standardization in how the military approaches concussive care and how they follow those war-fighters over time.
Did you treat many people with traumatic brain injury after the Boston Marathon bombings?
At Spaulding, we received 32 of the more seriously injured patients. It was quite the scene here. We saw some concussive injuries but mostly a lot of people with limb loss and burns. That’s what we’d expect from IEDs [improvised explosive devices] detonated close to the ground.
What do you most enjoy about your career?
I enjoy helping people and answering questions that will make a difference in people’s lives. And I love teaching. I like developing young people who can do better than I’ve done. I’ve mentored both DOs and MDs—residents and fellows who’ve gone on to be very successful.
How has your osteopathic medical education helped you in your career?
The emphasis on treating the whole patient and finding underlying causes has been an advantage for me. Osteopathic medical education is excellent preparation for the specialty of physical medicine and rehabilitation. In allopathic PM&R programs, some 23% of the residents are DOs.
Have you ever found it a challenge to be a DO at allopathic academic institutions?
Years ago more so than now. But, listen, I have been very fortunate. People gave me an opportunity. The reality of the issue is that if you can produce, you know what you’re talking about and you’re a contributor to an institution’s clinical, research and teaching efforts, you will get recognized. These days, there is much less bias against DOs than there used to be.
That said, those DOs who have been successful in the allopathic world tend not to be celebrated within our own profession. I know many other DOs at leading MD schools who have written more than a hundred published articles and have achieved prominence in their fields, such as James N. Weinstein, DO, a professor of orthopedic surgery at Dartmouth, and cardiologist Michael Ritt Jaff, DO, at Harvard. Though they are very well-known in the medical community as a whole, they receive only modest attention in the osteopathic medical profession. Our profession could do more to recognize their achievements and use them as possible mentors. This would open more young DOs’ eyes up to the possibilities and maybe inspire them to pursue research-intensive careers in academia.
In this era of evidence-based medicine, osteopathic physicians have to be not only outstanding clinicians but also part of answering the questions—part of the solution advancing health care forward. If we don’t have the ‘put up,’ we’re not going to be asked to show up.