Lucas Smith (lrs001@ucsd.edu)

Graduate Program:  Bioengineering
Lab PI: Dr. Richard Lieber
Undergraduate Institution: University of Washington
Clinical training area in Med-into-Grad: Orthopedics
Main clinical mentors: Dr. Henry Chambers hchambe1@san.rr.com
 

Quote:  “I would highly recommend the med-into-grad program at UCSD and think it will be a defining experience of my graduate studies here.  It may not be for everyone, but those whose research is centered on understanding a disease, there is only so much you can learn from books and papers.  Working first hand with patients deepens your understanding and also is a great motivator for continuing your research back in lab.  It can be a lot of work to keep up with the busy pace of life at the hospital, but one that I would recommend to those who really want their research to have an impact on medicine.”

Rational for Med-into-Grad training:  I am in a muscle physiology lab and started off on a study of cerebral palsy muscle.  My thesis research is centered on the question of how an inherently normal muscle becomes pathologic in spastic cerebral palsy.  Initially I was not very familiar with cerebral palsy, having known a few people with it from my past, but it is actually quite common and the 2nd most prominent disability among children behind autism.  Obviously my thesis pertained to this large clinical population and I was interested in learning what cerebral palsy really was from a patient’s perspective.  It was also important to learn about it from a physicians perspective because being able to develop new therapy often requires a solid understanding of current techniques.

Medical training and identification of medically-relevant research issues:  I was able to participate in a variety of clinical settings during my training.  It generally starts in the clinic where we see patients for the first time cerebral palsy, or teenagers that have been coming to these clinics since they were toddlers.  I was able to learn from the patients and their parents what was most important to them.  It varies a lot with severity of the disability, for many it is the ability to walk without any support, while for others it is just the ability to sit comfortably. 
The operating room was another area I spent a lot of my time, as I witnessed a variety of surgeries for children with cerebral palsy as well as orthopedic surgeries for normal children.  This experience allowed me to get a first hand knowledge of how the musculoskeletal system was altered in cerebral palsy.  I can visualize the deformities and pathologies that hide under the skin and also learn about how surgeons attempt to correct them.

While surgery and clinic took up most of the time, there were other aspects that I was able to incorporate into my training.  Monday and Friday always start of with a preview or review of surgeries with the group were plans are discussed and differences in opinion often arise.  Didactic sessions were included with talks on cerebral palsy, reading gait analysis, or a number of medical journal articles.  The gait lab was also an interesting place where they are able to delve into the details of the way a person walks in order to evaluate the need for various therapies or determine their result.

Potential Research collaborations:  In my case we were already in the process of opening research collaboration with Dr. Chambers to investigate cerebral palsy muscle.  This project involves the biopsy of hamstring muscle tissue during surgery of cerebral palsy patients and also obtaining control hamstring muscle biopsy from children undergoing ACL repairs.  We plan to use this tissue for a variety of tests to look closely at how the muscle has adapted in cerebral palsy.  Just starting this research I have been able to more fully understand where this pathologic tissue is coming from.  I have thus been able to add records of various clinical measures and severity scores in order to probe the broad spectrum of cerebral palsy.
The experience has also allowed me to come up with a few new ideas that could be incorporated into my research later.  One such idea would be to analyze the gait lab data before and after given muscle-lengthening surgeries.  Data from the operating room on joint range of motion could also be incorporated to correlate to gait changes.  All of these parameters would then be fit into a mathematical model to predict more analytically what changes in gait can be expected after surgery.

Training in diagnostics & therapeutics, and identification of unmet diagnostic & therapeutic needs:  When I first walked into the clinic I had no idea what Dr. Chambers was going to tell a young child regarding their treatment.  By the end of the term I was able to predict his recommendations fairly well from a variety of options.  One of the primary disabilities is muscle tightness and contractures.  Physical therapy and stretching are almost always recommended in his clinics.  When those aren’t enough botox can be used in specific muscles to disrupt the neuromuscular junction and increase the range of motion.  Baclofen is a muscle relaxer that is used both orally and also now with an intrathecal pump, to relax muscle more consistently.  These options often only delay the need for surgery such as muscle or tendon lengthening to enable range of motion around a joint. 
I think that each of these therapies has their place, but there is certainly a need for improvements.  One problem with muscle in cerebral palsy is that it is often weak.  All of these therapies can be beneficial for improving deformities and range of motion, but they also all increase the weakness of muscle.  This functional disability is important to patients and a therapy that could keep or improve muscle strength would be a great step forward.

Diagnostic & Therapeutic collaborations:  We are looking into what stops muscle from growing in cerebral palsy with the hopes that we will then be able to propose a way to remove that inhibition.  Our investigation involves looking at muscle changes on the transcriptional level, protein levels, muscle mechanics, muscle histology, and muscle signaling.  We plan to work with Dr. Chambers in order to conduct this research and refine our ideas about spastic muscle.  We do have some preliminary evidence on potential therapies, but they require more evidence on the levels discussed before further trials are undertaken.  If we are able to provide convincing evidence to support a novel therapy we would hope to work with Dr. Chambers in the future to determine its value in helping children. 

Long term impact:  You certainly gain a different perspective seeing a patient in clinic rather than looking at some homogenized tissue.  I think that this training has enabled me to look more at what the patient needs in terms of therapy rather than always looking at narrow research goals.  For example, spasticity itself is often researched in cerebral palsy with various measurements and such, yet very rarely is a patients issue with spasticity.  This training has really motivated me for my work in the lab and also to continue viewing research from patient’s perspective throughout my career.

Student-specific experiences:  The setting of the clinic and the lab each have their own peculiarities.  One of the advantages of this program is that you are able to pick up on how the hospital works and the jargon used.  Hopefully interactions with physicians will continually be involved in my research and I think this laid the foundation for quality communication and understanding a little bit more about the culture of medicine. 

Advice for new trainees--Autumn preparatory quarter:  Orthopedics was a new program and thus I didn’t know exactly what I was getting myself into.  Someone suggested that I take the extremities portion of anatomy with the medical student during fall and although it took a little bit of work to get in it was well worth it.  From the first day at the hospital I realized the benefit of having an idea what they were talking about when going over surgery for a particular forearm muscle with its bony attachments, blood supply, and nerve.  Anatomy won’t be as useful for every program, but I would strongly encourage asking around and taking any training you can get before hand, people seem more than happy to work with you to make the experience as valuable as possible.

Advice for new trainees—Winter clinical training quarter:  I think it can be intimidating first walking into the hospital and my initial goal was just to stay out of the way, which can be difficult in a small operating room.  I think that the most important thing to do is to ask questions along the way.  Of course you don’t want to be nagging the attending all the time with questions, but take advantage of all of the people on the team.  Some questions are more appropriate for a nurse or physicians assistant, and they often are able to give more complete answers.  Some questions are best for an experienced physician and your questions often help stimulate their thinking about interesting research questions. 
I would also say that you should always be willing and asking to help.  I wasn’t always able to do so because there are many rules on who can do what in a hospital, but hands on training is definitely better than watching all of the time.  I also had an opportunity to go to some unique clinics outside the hospital and to be on call for a night

Take home perspective on Med-into-Grad at UCSD:  I would highly recommend the med-into-grad program at UCSD and think it will be a defining experience of my graduate studies here.  It may not be for everyone, but those whose research is centered on understanding a disease, there is only so much you can learn from books and papers.  Working first hand with patients deepens your understanding and also is a great motivator for continuing your research back in lab.  It can be a lot of work to keep up with the busy pace of life at the hospital, but one that I would recommend to those who really want their research to have an impact on medicine.