Mayo Clinic leader brings patient-focused research expertise to the JAOA

Two decades before the Affordable Care Act established the Patient-Centered Outcomes Research Institute, Robert Orenstein, DO, began to grasp the importance of clinically relevant research.

In 1991, the United States’ AIDS epidemic was near its peak. Dr. Orenstein was an infectious diseases fellow at the Medical College of Virginia in Richmond, training there and at nearby Hunter Homes McGuire VA Medical Center, where saw firsthand the dearth of treatment options for HIV and AIDS patients.

“At the time, we really had no effective therapies,” Dr. Orenstein remembers. “Zidovudine was all that we had. And we gave that horrible drug to people day and night and made them feel worse. Maybe they lived a couple of weeks longer, but it was pretty awful.

“So my interest in research evolved from trying to answer these questions: How do we find solutions for these people who are dying in front of us? What can we do that would be beneficial?”

As the new editor-in-chief of The Journal of the American Osteopathic Association (JAOA), Dr. Orenstein is drawing on his experiences combining research and patient care to reach out to a broader range of potential contributors. He seeks evidence-based articles that are groundbreaking but also practical, with information physicians can leverage to improve outcomes.

After completing his fellowship, Dr. Orenstein served as the medical director of the Richmond VA hospital’s HIV/AIDS program for seven years. At the same time, he helped conduct National Institutes of Health-funded clinical trials related to AIDS. He was the principal investigator for numerous trials, including a study on the prevalence of anemia in HIV-infected patients and a trial comparing the efficacy and safety of dosing regimens for different protease inhibitors.

“Compared to other physicians, Bob was very involved in recruiting patients for studies,” says Melinda Stewart, a nurse practitioner and the HIV/AIDS program coordinator at the VA hospital, who worked with Dr. Orenstein for 10 years. “He was totally committed to helping the poorest of the poor and the sickest of the sick.”

While still a fellow, Dr. Orenstein accompanied Stewart on a medical mission to Peru to provide care in the Amazon rain forest. He saw this as an opportunity to conduct epidemiological research on AIDS, Stewart notes. For Dr. Orenstein, research and patient care are inseparable.

Dr. Orenstein’s experiences caring for AIDS patients had a profound impact on his clinical approach, enhancing his cultural sensitivity and open-mindedness. “It was very eye-opening,” he says. “One day a patient would come to the clinic as a man. And the next day, the same patient would be dressed as a woman. You understand people better when you’re caring for individuals from different walks of life.”

In the early 1990s, a diagnosis of AIDS or an HIV-positive test result equaled a death sentence, so Dr. Orenstein became adept at comforting patients and their caregivers at the end of life.

“During the early parts of the epidemic, we would care for people for relatively brief periods of time and then they would die,” he remembers. “Melinda and I went through a lot with our patients. We were involved in their lives, and we went to their funerals.”

From the beginning, Stewart was taken with Dr. Orenstein’s bedside manner, as well as his medical knowledge. “Because Bob is compassionate and empathetic, patients trusted him,” she says. “He made them feel good. He was also willing to discuss the topic of death and dying with patients so they could make decisions about their end-of-life care and die with dignity.”

Appointed to the faculty of the Medical College of Virginia after completing his fellowship, Dr. Orenstein also earned respect as an educator, receiving awards for teaching and recognition from other faculty members for his lectures, Stewart notes.

“He became known for his grand rounds. But unlike some physicians in academia, he’s not a doctor’s doctor; he’s a patient’s doctor,” she says.

New niche

Today, as the chair of the Division of Infectious Diseases at Mayo Clinic in Arizona, Dr. Orenstein still treats patients with HIV infection, but his research focus has changed over the years.

Due in part to better career opportunities for his wife, Amy Foxx-Orenstein, DO, a gastroenterologist, the Orensteins left Richmond in 2002 to join the faculty of Mayo Clinic in Rochester, Minnesota. Because Mayo already had an experienced infectious disease specialist running its HIV/AIDS program, Dr. Orenstein found another niche for himself, one that had previously intrigued him when he was a resident: preventing hospital-acquired infections.

“At the time we were seeing a lot of Clostridium difficile infection, a diarrheal disease that hadn’t been seen much in the past,” he says. “There were really no good surveillance methods then for figuring out who had it and why.” One of his first projects at Mayo was to build a surveillance network for C. difficile to determine whether incidence of the infection was increasing, decreasing or stable.

The surveillance revealed that Mayo Clinic—like many hospitals across the country—was experiencing a C. difficile epidemic.

“So then our research question became, ‘How do we control the ongoing epidemic?’ ” Dr. Orenstein says. “We needed to be able to develop some tools to be able to diagnose the disease better and disseminate the information to clinicians quickly so that they could intervene.”

Dr. Orenstein worked with Mayo Clinic laboratory scientists to develop new testing that allowed patients to be diagnosed more quickly. And he improved protocols for informing physicians about C. difficile-infected patients.

The next step was to do a better job of preventing the infection. Dr. Orenstein experimented with requiring all patient care staff to wear disposable antimicrobial gloves. The protocol turned out to be logistically impossible to implement, he acknowledges, noting that clinical researchers derive valuable insights from each intervention they test and should not become discouraged.

So Dr. Orenstein tried a different tack. The Clorox Co. had recently developed a high-concentration bleach germicidal wipe that showed promise for hospital applications. Mayo Clinic partnered with Clorox on a project known as “Wipe out C. difficile.” The wipes are used to disinfect hard surfaces primarily in patient rooms and bathrooms.

“Unbelievably, within a very short period of time after starting this project, we had enormous reductions in infection,” Dr. Orenstein says. “We exported the protocol to all Mayo health facilities. And soon, we were getting calls from health systems around the country, asking us about implementation.”

Holistic approach

Surbhi Leekha, MD, MPH, a protégé of Dr. Orenstein’s when they were both at Mayo in Rochester, says she admires his ability to integrate clinical care and research.

“Dr. Orenstein is very thoughtful when it comes to patient care—very detail-oriented,” says Dr. Leekha, the medical director for hospital epidemiology at the University of Maryland Medical Center in Baltimore. “He is also very approachable and has such a wealth of knowledge. You can ask him a question about anything in internal medicine, and he’ll be able to expand on it.”

But it was Dr. Orenstein’s holistic approach that had the biggest impact on Dr. Leekha. “As you go along, a lot of people influence the way you practice,” she says. “With Dr. Orenstein, I was most influenced by his comprehensive, global way of thinking. Whenever there was an outbreak, his ideas for clinical intervention would flow into the development of research projects.”

Osteopathic insights

One of the basic tenets of osteopathic medicine is awareness of the body’s self-healing and self-regulatory properties. In addition, osteopathic physicians traditionally prefer natural interventions over pharmacological ones. A major research interest of Dr. Orenstein’s today draws on these insights: manipulating the human microbiome to improve health.

Dr. Orenstein and his colleagues at Mayo Clinic in Arizona have established one of the nation’s largest programs for fecal microbiota transplantation (FMT)—the transplantation of healthy gut microbes, via a healthy person’s stool, into the gastrointestinal tract of an ill person.

After relocating with his wife to Mayo Clinic’s Arizona campus, located in Phoenix and Scottsdale, in 2010, Dr. Orenstein was startled by the high rate of C. difficile infection cases there, despite preventive measures. He recalled a physician he worked with in Minnesota—infectious disease specialist Johann Bakken, MD, who pioneered performing stool transplants on patients with recurrent C. difficile.

“When we had patients with C. difficile who didn’t get better, we would send them from Mayo Clinic to Dr. Bakken’s private practice. And they all got cured,” Dr. Orenstein notes. “I saw that the C. difficile problem in the Southwest was huge, and we didn’t have enough solutions. That’s when it occurred to me that we should think about doing stool transplants here to help our patients.”

Dr. Orenstein collaborated with a Mayo gastroenterologist to establish a new fecal transplantation program, which now draws patients from around the world.

“We started slowly, first developing a model for how to do it, determining the logistics, the practice, and the standardization and doing some quality assessment,” he says. “Then one day we had a patient who had severe C. difficile and wasn’t getting any better despite every conventional treatment offered. The patient heard about FMT and he insisted, ‘I’m not leaving this hospital until I get one of those stool transplants. I will fly my brother from Florida to be the donor.’

“So we said, ‘Here is our opportunity.’ And we performed our first one on this man, who had been bedridden and couldn’t move and would go to the bathroom 20 times a day. Two days after he had the transplant, he was on a plane flying to Florida, feeling great.”

Mayo Clinic in Arizona now performs three or four fecal transplants a week. Stool donors are first screened for infectious diseases, such as HIV and hepatitis. The fecal samples are processed in a blender with salt water, placed in syringes, and injected into the recipient’s intestine during a colonoscopy.

“It’s unbelievable how quickly people get better when you introduce healthy microbiota into the gut,” Dr. Orenstein says.

A Mayo research team continues to conduct laboratory studies to understand the gastrointestinal microbiome, determining which microorganisms protect against C. difficile and potentially a variety of other conditions, such as irritable bowel syndrome and inflammatory bowel disease.

“I actually think that microbiota replacement might be one of the solutions to the big antimicrobial-resistance problem we have in the U.S.,” Dr. Orenstein says. “You hear on the news that we’re running out of antibiotics and there is no way to treat these big superbugs.

“On the contrary, the way you treat these superbugs is by being an osteopathic physician. You realize that the body has the ability to heal itself, and you look for solutions within the human body that are effective.”

Broadening the JAOA‘s scope

Although he is a subspecialist who doesn’t perform osteopathic manipulative treatment, Dr. Orenstein considers himself osteopathic to the core. “There are people who feel that osteopathic medicine is all about manipulation and people who feel that it is all about primary care,” he notes. “I feel that osteopathic medicine is about being a doctor who looks at things differently.”

While he is trying to bolster the number and quality of the manual medicine articles published in the JAOA, Dr. Orenstein also intends to publish articles by subspecialists who are conducting research of clinical importance to osteopathic primary care physicians.

For example, a few months ago at a grand rounds presentation, Dr. Orenstein heard a urogynecologist at Mayo discuss a new stem cell technology for pelvic floor disorders: “You can inject stem cells into the pelvic musculature to strengthen it and prevent incontinence, the physician was explaining. And I was sitting there thinking, ‘Is this an osteopathic concept or what?’ The physician is not a DO, but he is talking about the kinds of things that we as a journal should be publishing.”

At a time when the federal government is championing comparative effectiveness research, Dr. Orenstein wants the JAOA to publish clinically useful, scientifically valid studies that will lead to improvements in patient care. Submitted articles should reflect osteopathic principles but not necessarily be about OMT applications.

“I’m trying to engage everyone,” Dr. Orenstein says. “We have a very broad profession. I’m trying to bring DO specialists back into the fold, to help them understand that they are still osteopathic physicians, that they went to osteopathic medical school for a reason.”