New Year

Suffice it to say that I, David William Royal, [skateboarder, computer programmer, ex-professional tennis player, ex-neuroscientist, beach-lover, sketch artist, and NAVY brat] am experiencing culture shock - and loving every minute of it! Although it's only been a few weeks since moving from Nashville to Hanover, I've already fallen in love with my new surroundings. I've even caught myself referring to Hanover as 'home' on more than one occasion. And this is a complete surprise considering that I had had some concerns that I would find it difficult to understand 'Northerners' and their peculiar accents and traditions. For example, what's this stuff these Northerners call 'soda'? I'd swear it's what we Southerners call 'coke', but I'm too much of a Southern gentleman to correct them. Besides, "when in Rome...".

I could go on for paragraphs about how charming and wonderful Hanover and New England are, but I want to focus this blog entry on my early experiences as an applicant and a graduate student at The Dartmouth Institute (TDI). First, I can't praise TDI's faculty and staff enough for making the admissions process the most transparent and painless I've ever experienced. TDI's emphasis on the human element makes its admissions process unique among all of the public health programs I investigated. To put this opinion in context, I spent two consecutive months last year driving across America in search of the best public health programs available, visiting each one multiple times in order to find "my place". What impressed me the most about TDI's admissions process was how thoroughly it emphasized "fit" over raw statistics. My conversations with the Head Recruiter, Alex Thorngren, and the Program Administrator, Karen Tombs, made it very clear that TDI was in the business of creating a balanced class of students from a wide variety of backgrounds and skillsets, and that the professional development of its students was high on TDI's list of priorities. Based upon the résumés and profiles of my classmates, I have to say that TDI absolutely hit it out of the park in terms of their constructing a class rich in experience, character, and personality.

Second, my first weeks at TDI have been absolutely amazing! To set this up, Dartmouth just went through a changing-of-the-guard with the appointment of a new President, Dr. Jim Yong Kim. For those unfamiliar with President Kim's accomplishments, he's a human dynamo who's a veritable poster-child for the term "change agent" in the realm of health care. In fact, President Kim was awarded a MacArthur Foundation "Genius" Grant in 2003 for his work with Partners In Health to lower the cost of treating multidrug-resistant tuberculosis among the poor. Suffice it to say that President Kim is now on my "Hero List", along with the likes of my Dad and Abraham Lincoln (as well as Optimus Prime, but that's a story best told over drinks). Now then, I had the privilege of joining representatives from a cross-section of Dartmouth's many graduate schools at a formal dinner hosted by President Kim. The purpose of the meeting was to share with President Kim our impressions of what makes Dartmouth great, and more importantly, where and how we feel Dartmouth can be improved in the realm of graduate education. Like most universities, Dartmouth considers itself primarily an undergraduate institution. Hearing President Kim formally declare his commitment to elevating the status and quality of graduate education at Dartmouth was profoundly satisfying.

Dinner with President Kim was certainly a thrill, and I was honored to have the opportunity. Given President Kim's passion for healthcare reform, I wasn't at all surprised when he made an unscheduled visit to TDI the next morning to share with the incoming class his long-term vision for TDI, and for the important role we students were about to play in the movement to reform healthcare. It's difficult to convey just how uncommon and unique it is for a president of a university, any university, to make time to personally thank students for joining a university's family. I can't speak for the rest of my class but for me, this was one of those rare moments in my life where I recognized, in the moment so-to-speak, that I was exactly where I was supposed to be.

Third, the classes have been incredibly satisfying, full of healthy discussion and engaging debate. Because Dartmouth is on a quarter system, each class is a little longer in duration (typically 4 hours), but the classes don't drag on endlessly. Each class period is organized into discrete sections that flow seamlessly together, helping create a very dynamic and exciting classroom/community experience. You can tell that the course administrators and teaching assistants have put a LOT of time and effort into creating an environment conducive to learning, and more importantly, to exploration of ideas and concepts about which each of us is passionate. While the material comes at us at a pretty good clip (again, it's a quarter system), the workload is completely manageable, and most of the work is performed in small groups to allow each student an opportunity to offer personal insight on the topic of discussion. What's more, the material is presented and organized in a way that blends theory and practice, ensuring that new information is always presented in its proper context. And this last point has been a source of great relief considering that a number of public health programs focus too heavily on theory and rote-memorization of names and dates, in my opinion. I'm angling to help reform health care, and to do that effectively I need the ability to hang ideas and concepts on a more practical framework, and TDI's professors are experts at this. Of course, I don't want to give you the impression that the work's a cakewalk. I'm now in my third week and already I've pulled 5 all-nighters, but that's mostly because I just happen to enjoy working.

Having said that, please understand me correctly. A TDI experience is so much more than just work; it is definitely about the personal and professional relationships formed with one's professors and classmates. Even though it may sound like we (or I?) work 24/7, we are all having a blast outside of the classroom as well. For example, although Hanover is a healthy distance from major metropolitan areas, there are plenty of adventures and activities here and nearby. Within the last week I've: 1) attended a ballet performance at Dartmouth's Hopkins Art Center by the incredible Santa Fe Company, 2) attended an open lecture by an eminent Dartmouth neuroscientist on how the human brain uses a 'physical vocabulary' to interpret music, 3) danced my shoes off at the weekly Swing lessons sponsored by Dartmouth's Student Activities Board, 4) relaxed at The Dirt Cowboy coffee shop in downtown Hanover where I had the most amazing peppermint tea ever, 5) got lost in the woods behind my house while trying to locate The Appalachian Trail, 6) got lost in Vermont while searching for a swimming hole, and 7) volunteered my time at David's House, a guest house for families living far from a primary care facility and whose children are being treated at Dartmouth Hitchcock Medical Center.

In short, I am excited and proud to be at TDI. I can't imagine taking this journey at any other university, or in any other setting. This is shaping up to be a fantastic experience, top-to-bottom! If any readers would like to contact me for further information, please feel free to reach me using the contact information provided below.

Cheers,
David Royal, Ph.D.
MS Candidate, 2010

email: david.w.royal@dartmouth.edu
mobile: 615-294-6051

Thanks!

The 2009 school year is over and a new group of students will soon take over the TDI student blog. Before they do, I want to thank the students in the class of 2009 that contributed to the creation and development of this blog. In addition to publishing blog posts, these students achieved impressive goals this year.

Recent updates to Shannon’s list of career paths below include the former blogger that will enroll in Case Western’s MD/PhD program in the fall, and the TDI grad that will work as a special assistant for new Dartmouth president Jim Kim. My next few months will include continued blogging on health and health care at Justmeans.com, and starting a job with the health group at a nonprofit think tank.

The TDI staff also deserves credit for developing this blog. Karen Tombs was particularly helpful in creating this forum for students to reflect on TDI experiences and in helping us maintain a publishing schedule. Thanks to all the staff and student blog contributors, and good luck to the TDI class of 2010!

-Sam W.

Internships and Graduation

Now that the year has closed, and we're getting ready for a new one, I thought I would reflect on some of my past experiences and one I did not get to comment on thus far: my internship.

My internship was with the Global Health Council, (they have an office in White River Junction, VT-- http://www.globalhealth.org/) and they hold the premiere conference in global health at the end of May in Washington, DC. Helping plan the conference was awesome, but attending it was even more so. I met Hans Rosling of Gapminder Inc. (www.gapminder.org) who not only gave a wonderful talk, but was a lovely funny man to meet... when my boss told him I spoke of him often, he said, "I talk about you too," simply hilarious. I got to hear Gayle Smith, Special Assistant to the President & Senior Director of the U.S. National Security Council, speak, watch Professor Sir Andy Haines of the London School of Hygiene and Tropical Medicine win the million dollar Gates Award for Global Health, and meet the new President/CEO of GHC, Jeff Sturchio. In addition, I got to watch wonderful films, witness excellent workshops, and have breakfast with a legend, Bill Foege, who is a Senior Fellow at the Bill & Melinda Gates Foundation, saved millions of lives by controlling smallpox in Africa and is one of the best speakers I've ever heard! The opportunity The Dartmouth Institute gave me to work at The Global Health Council lead me to more opportunities as the conference that I will never forget.

After departing DC, I flew to Chicago to attend Digestive Disease Week, one of the biggest medical conferences in the U.S. at McCormick Place. Two fellow TDI-ers and myself presented a poster on access to care for Crohn's Disease patients in the DHMC hospital referral region and it was great to see the interest in our poster due to the increased interest in quality and the maps we made using GIS.

Since returning from the conferences, I've graduated along with my classmates and heard the wonderful things many of them will be doing from working at consulting companies, the CDC, and hospitals to going to medical school in Boston, Washington, North Dakota and Arizona, just to name a few. This place really is amazing and so much can come from it, if you want it to.

Thesis Presentations

After just day one (of four) of the thesis presentations, I have to say I am impressed. Not only was it nice to see high quality, well-presented work, but it was even better to finally see what everyone had been up to all term! What was the most impressive was the wide variety of topics that students undertook from program evaluations on the elderly by examining the Bridge program here at DHMC to how to treat malnourished children in Mahipat-Mau, India. Students performed systematic reviews on soft drink consumption and obesity and wrote grant proposals to further explore the maternity leave policy here in the U.S. This session really showed me the great breadth of knowledge we have all learned this year and the innumerable applications for it all. Although everyone chose one track and focused on a specific topic, we all have the skill set to evaluate programs, implement action plans, perform research, write grant proposals and so much more. I can honestly say I am looking forward to seeing more (and the fact we're getting more yummy snacks tomorrow doesn't hurt either.)

-Shannon

Beyond domestic health policy

While TDI is a key player in domestic health care reform debates, and thought-leaders here often focus on comparisons between the U.S. healthcare system and those in other developed nations, healthcare policy and practice in developing nations receives attention as well. For example, we've had speakers lecture on the health traumas facing Sudanese refugees, the ongoing threat of HIV/AIDS in sub-Saharan Africa, and the issue of chronic diseases compounding infectious disease burden in many developing nations.

A number of students built on these lectures by focusing thesis projects on health issues in developing countries. One paper looked at primary care in Afghanistan, another studied HIV/AIDS patients in Ethiopia. Although I focused my thesis on domestic issues, I'm interested in financially feasible solutions to health issues, and a number of health programs in developing nations have recently piqued my interest. I find mHealth initiatives particularly compelling. (As does the United Nations. Check out their report on mHealth projects in developing nations.)

For some of us, using mobile health technology means perusing WebMD on an iPhone in search of a suitably severe – but not too nasty – affliction that will explain an absence from work. In developing nations, a number of projects combine cell phones and health care resources for very different reasons. Indeed, mobile health (mHealth) technology initiatives are helping patients in these countries return to work, avoid disease, and maximize limited health care resources.

Project Masilueke is an example. The mHealth initiative fights HIV/AIDS in South Africa by sending text message reminders of scheduled clinic appointments. Planned developments include “virtual call centers” with highly-adherent HIV+ patients advising others on medication regimens. Early patient outcomes are positive. A beta test showed that the project helped triple call volume at an HIV/AIDS helpline. In a country where HIV prevalence is estimated at 25% but only 3% knows their status, Project Masilueke promises notable improvements in patient health.

Along with individual patients, mHealth initiatives also benefit other stakeholders. These include private corporations. Among the supporters of Project Masilueke, Nokia lends telecommunications services, and National Geographic is documenting the initiative. These corporate entities stand to gain subscribers, licensing revenues, and brand recognition. With the large and growing population of mobile phone users in the developing world – South Africa has nearly 100% penetration – the potential for scaling and profit will continue attracting corporate interest in mHealth, and mobile phones will continue to help some play hooky and others save lives.

The U.N. report also lists other stakeholders that benefit from mHealth projects. These include:

Stakeholder - Benefit
Patient (Mobile Subscriber) - Improved health outcomes
Health Care Provider - More efficient and effective delivery of services
NGO - Advance organizational mission, attract funding
Foundations - Advance organizational mission
Government - More efficient health care provision, more effective government
Equipment Provider - Device revenue generation, improved brand recognition
Service Provider - Revenue from service fees, increased subscriber base
Application Solutions Provider - Revenue from additional applications license fees
Content Management - Increase in volume of readership or revenue
Platform Provider - Revenue from sales

-Sam W.

TDI profs. consulted for health care policy

Here's an update on TDI in DC:
This article describes Elliott Fisher's concept for Accountable Care Organizations. Dr. Fisher is on the faculty here at TDI and will be presenting his idea to the Senate this afternoon.

-Sam W.

The Possibilities at TDI: A Dream Come True

My desire in coming to The Dartmouth Institute (TDI) was to gain the knowledge and skill set to ultimately become an effective health policy researcher and assist in the appropriate reform of U.S. health care. This desire has certainly come true; the opportunities at TDI to begin achieving your career goals are endless. I thought I'd relate one particular opportunity I had while studying here.

As MPH students, we are obviously required to complete a thesis. While the requirements are strict, there are various tracks you can pursue depending on your unique academic/career interests (e.g. Analysis of a Population Health (PH) Problem, PH Intervention Plan, PH Research Grant Proposal, etc.). Since I wanted to pursue a career in health policy research, I chose the grant proposal track and spent the last 6 months working on it. While not required, I wanted to ultimately submit it to the NIH for funding, and so I worked with two orthopaedic surgeon scientists and a biostatistician as my content experts to better ensure its success.

Long story short, after an intense last month of writing and editing according to their critiques, we just submitted it to the NIH last week! It was a very satisfying feeling. If funded, we will be getting $1 million over 2 years to study outcomes of total knee and hip replacement in the United States--the number one cost-driver for Medicare inpatient services. In the end, we hope to generate knowledge that will inform all stakeholders (the orthopaedic community, patients, and policy-makers) and significantly improve these outcomes, while decreasing cummulative costs by reducing the need for revisions (repeat procedures).

I can't wait to see the NIH's decision and hopefully begin working to literally fulfill the motto at TDI to generate "knowledge that informs change."