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Harvard DO urges profession to question, investigate, publish

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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.”
Dr. Zafonte

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.

14 Responses

  1. DO Student on Aug. 2, 2013, 2:08 p.m.

    Thanks to the AOA, future generations of DO’s will no longer be able to follow paths like the one that Dr. Zafonte took–an osteopathic internship followed by an ACGME residency.

  2. Paul J. Morris DO, FACOFP on Aug. 2, 2013, 4:44 p.m.

    What “DO Student” wrote is incorrect. DO grads will be able to pursue both osteopathic and allopathic (ACGME) residencies after a DO internship. What might be problematic is doing an ACGME-approved fellowship after completing an osteopathic residency. And that’s only if the AOA and the ACGME are unable to rectify what is hopefully a temporary problem.

  3. Joseph N Bottalico, DO, FACOOG (Dist.) on Aug. 2, 2013, 4:47 p.m.

    As a former faculty member at UMDNJ School of Osteopathic Medicine, now part of Rowan University as well as a member and former Chair of the American College of Osteopathic Obstetricians and Gynecologists (ACOOG) I take exception to Dr Zafonte’s statement that “Our DO schools should do more to encourage students to ask critical questions and help them learn research fundamentals….and gain an understanding of levels of evidence so they can interpret, critically assess and later build on the research published in journal articles”. While further improvements in such training are very important, his statement fails to recognize that such training in research methodology and critical interpretation of the medical literature has been going for many years in our leading DO medical schools as I have witnessed personally. This is also taking place within our specialty college (ACOOG) as evidenced by the burgeoning number of quality abstracts and original investigations of merit from our OB-GYN residents throughout the country. I feel that the DO editorial staff should encourage comment on this misperception from our Osteopathic educational leaders nationwide.

  4. Joseph N Bottalico, DO, FACOOG (Dist.) on Aug. 2, 2013, 5:01 p.m.

    correction : former chair of ACOOG’s Research and Awards Committee.

  5. OMS3 on Aug. 2, 2013, 5:07 p.m.

    As a DO student with an extensive research background and plans to stay within academic medicine, I appreciated Dr. Zafonte’s perspective. It seems to me that the limiting factor for research opportunities for DO students is the isolation of many colleges of osteopathic medicine from larger university systems. This may be less of an issue at UMDNJ and a few other DO schools, but unlike at the majority of MD programs, we have to look beyond the handful of faculty members conducting research at our schools to find a mentor.

  6. Lisa Charbonneau on Aug. 2, 2013, 7:08 p.m.

    As a fellow DO physiatrist, I appreciate and applaud Dr Zafonte’s many contributions to our specialty. He has excelled because of his commitment and academic fortitude. Although years ago, it would have been unthinkable for a DO to hold a Professorship at Harvard, trailblazers like Dr Zafonte’s have paved the way for future generations of academically oriented osteopathic physicians.

  7. Maria F Daly D.O. FACOFP on Aug. 2, 2013, 7:41 p.m.

    Yes, I agree that Osteopathic Physicians such as yourself other Osteopathic Physicians and myself who completed an OB/GYN Fellowship at Stanford University’s affiliated hospital system have not had the recognition nor the support of our Profession. I had suggested initiating an Ob Fellowship program for our Physicians interested in this type of training and even suggested a Women’s Health Fellowship for our profession. This suggestion was not recognized as a priority from one Osteopathic leader to the next. Because of my specialty training in an Ivy league prominent program, I was have been recruited to a large County Hospital affiliated with two allopathic Medical Schools where I am a Voluntary Assistant Professor.It is with hope that the next generation of leaders will be open to those who love our profession and are willing to reach outside the comfort zone for medical training ,stimulation and creativity in order to share with our young Physicians.

  8. Martin Levine, DO, MPH on Aug. 3, 2013, 8:29 a.m.

    Congratulations to Dr. Sarongs on his achievements! Drs. Weinstein and Jaff have also been widely recognized by their osteopathic profession, Mike received an Honarary degree from his alma mater, KCOM three years ago and both have been interactive in helping AOA leadership in many areas of public health, research, and interaction with the allopathic organizations. Dr. Jaff is a widely recognized professor at Harvard and Jim was noted to have been elected to the Institute of Medicine in osteopathic publications. Having sustained PTSD myself after being on the front line at the Boston Marathon bombings, would love for Dr. Zafonte to research osteopathic cranial manipulation as a major part of my rehabilitation.

  9. Martin Levine, DO, MPH on Aug. 3, 2013, 8:31 a.m.

    Corrections: sorry about Sarongs, using IPad spell check. I’m Past President of the AOA

  10. allopath trained DO on Aug. 3, 2013, 10:14 a.m.

    Congrats to Dr. Zafonte!
    Instead of “taking exception” to the comments by Dr. Zafonte, lets learn from what he has to say.
    My experience with DO training is exactly as Dr. Zafonte outlined-excellent clinical training and very little research exposure.
    Some 20 years ago, I embarked on a “black sheep” mission to get the best medical training I could get and completed allopathic residencies in Internal Medicine and Emergency Medicine and obtained board certification in both. Clinically, I feel I am as well trained as my MD colleagues (and possibly better ) but would have have an extremely difficult time being competitive in a research program.
    Every DO that does well in an allopathic program helps DOs in general!
    It broadens our exposure, educates the uninformed, mentors future students and physicians,
    and enhances our reputation in the medical community.
    My wish for the Osteopathic family is to become more inclusive instead of exclusive!

  11. Patrick Woodman, DO, MS on Aug. 4, 2013, 5:55 p.m.

    It is encouraging that high-performing academic DOs are now being recognized in the allopathic community. I am also encouraged that some of the commenters cite the great strides the osteopathic community has made in academic medicine in the last three decades. As an AOA-residency trained OB/GYN, and an ACGME-trained fellow in Female Pelvic Medicine & Reconstructive Surgery, I know what its like to be a DO trying to compete in a DO world. It seems that Dr. Zafonte was able to “escape” the constraints of osteopathic training by switching to an MD-residency, allowing him to sit for his ACGME-approved specialty boards. We have to remember that traditional osteopathic training relies on volunteer clinical faculty who are not reimbursed for their teaching and are expected to “make their salaries” from their busy clinical practices…this is not conducive to great research production. My academic career is due to late nights and long weekends, and working for a Masters in Clinical Research in my spare time. Until our osteopathic schools treat their faculty members as real academics, with grant funding and protected time to complete research, it will be impossible for us to be as successful as Dr. Zafonte has become on such an uneven playing field.

  12. gas passer on Aug. 4, 2013, 7:17 p.m.

    The osteopathic profession needs to continue to support physicians like Dr. Zafonte and future osteopathic physicians who seek out the best post-graduate training they can find. Whether some DOs want to admit it or not, many of the best training programs are allopathic and treating DOs who choose them as “sell outs” will only hurt the profession and drive those DOs away.

  13. Sam Small DO on Aug. 5, 2013, 8:13 a.m.

    I appreciate the opportunity to respond to Dr.Zafonte’s comments. I am a D.O. trained and board certified orthopedic surgeon. I went on to complete a fellowship in spine surgery at UCLA. Joseph Lane MD who was the Department Chair and head of the residency program at the time made me an offer to stay at UCLA. I chose to go into private practice, but did not give up my desire to teach and give back to our profession. It took me 17 years, but I have been successful in my efforts to cajole the handful of DOs and many of my MD colleagues to start DO residencies in Family Medicine, Internal Medicine, and Orthopedic Surgery all of which started 5 weeks ago. We are in the process of making application for General Surgery starting next July. I am not certain how Dr. Zalfonte would like the Osteopathic profession to celebrate his and others accomplishments. Do they take a proportionate number of DO applicants into their residencies? Have they applied for DO accreditation ? Besides being successful in the “MD world”, how have they given back to the Osteopathic Profession? Sam Small DO

  14. James E.Whte, DO, RPh on Aug. 6, 2013, 8:29 a.m.

    Congratulations Dr. Zafonte or your hard work and success, you are doing a great job and staying real busy. I noticed you were very diplomatic about Clinical Osteopahic Research. The MDs are much more opened minded about research even into somatic dysfunction problems. I have had several offers from MDs who I met outside of Academia to read the first draft of the book I’m ciurrently putting together titled, “PTSD A non-drug trreatment”. It uses craniofacial OMT to release the bones of the skull and restore micromotion to them, then uses an acrylic oral appliance to support the new occulsal balance this in turn allows the physician to teach the patient spinal self-manipulation and integrate everything. I have been using this methodology since the Viet Nam era. It seems to be effective in over 80% of the physical symptoms of PTSD. Maybe, Martin Levine, DO, might be interested in this approach. The scientific approach I used were operational definitions of somatic dysfnction, along with predictable models of SD plus two quantifying systems of NIH quality.

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