Researcher Spotlight

Dr. Elizabeth Schoenfeld

Dr. Elizabeth Schoenfeld

Elizabeth Schoenfeld, MD

The Inner Fire: Elizabeth Schoenfeld on Shared Decision-Making, Research, and More

Take two equal measures of dedication and passion, a shot of forthrightness, and stir all of these ingredients well – that’s when you have the distinctive combination that makes up Dr. Elizabeth Schoenfeld, an Emergency Medicine physician living in Western Massachusetts.

It’s not just teaching and working on her research at Baystate Medical Center (Tufts University School of Medicine) that make Schoenfeld such a well-rounded professional. When she’s not hard at work, or spending time with her hand-surgeon husband, she’s taking care of her two “wonderfully energetic” young children. When it’s not that, she’s skiing or rock-climbing with her family, or hiking and biking when the brutal northeast winters ease up. Cheryl Sandberg’s Lean In, and what she hails as a “fabulous” stereotype-defying children’s book called Rosie Revere, Engineer have been her favorites in the last two years (when she has had the chance to read!). But even with her huge life, she still manages to find the time to push forward a very important agenda – research on Shared Decision Making (SDM).

It is in this field of SDM that her passion lies. SDM’s process is a collaborative one that ensures that patients and their families and providers make healthcare decisions together, so that everyone is involved in a patient’s treatment. It takes into account all of the scientific evidence available at that point, but, more important, acknowledges the patient’s preferences and decisions. It’s a method that is fast gaining traction for its emphasis on the patient’s right to be fully informed of all the care options and the potential benefits or harms of them.

Schoenfeld was inspired by the process of SDM for several reasons, the most major being very close to home. “I’ve watched and helped many family members be patients over the past five or so years, particularly the last 10 years of my grandmother’s life (she died a year ago at 91),” she says. When her grandmother needed medical attention after suffering from a stroke, Schoenfeld was glad she was around to help out. “When you’re elderly, you might not always be in the right position to decide and verbalize what kind of medical attention you need or deserve, and I was there to help her articulate those choices,” she adds.

But later that year, when Schoenfeld’s grandmother required medical attention again, she was asked to have several other tests that she didn’t feel were necessary – “she was put through these expensive scans and tests, all of which weren’t really required, and it happened that I wasn’t there to discuss it with her,” Schoenfeld tells us, highlighting the importance of a shared discussion during times like these. “I think we as doctors make a lot of assumptions about what patients want and need, and we could do a better job eliciting these preferences rather than assuming,” she says, adding, “The costs were mostly covered by Medicare, but since Medicare is paid for by our taxes, it was passed onto us in that way. Extra costs like this can be either a burden on individuals or on society, depending on how you look at it.”

While some practitioners might raise an important point ─ that patients might not be trained or well-informed about what they need, and in effect, cannot be relied upon to diagnose and prescribe for themselves – Schoenfeld has a response for them. “The point of SDM is for a patient to know about all his or her options, options that are equivalent to one another, and the pros and cons of each. What it does is to start a discussion and give the patient a chance to add their input, and to put their thoughts and questions on the table. I don’t expect a patient to be trained or have the necessary knowledge,” she says, adding that a collaborative discussion like this benefits everyone in the long run.

She explains further, using her grandmother’s case as a specific example. “In this situation, she just needed something to relieve her pain. The question you’re asked when you come into the ER is, what are the goals of this visit? For her, it was to reduce her pain, but instead it became a case of too much testing. What should have happened is they should have asked her – do you want us to test you to figure out the cause or do you want to just treat this symptom and feel better? She would have probably answered yes to the latter, but here, instead of simply asking her that, there was a presumption that the first was better, which is not always true.”

The field of SDM definitely still has scope for growth, and Schoenfeld hopes to be able to contribute to it. “Most of the research is done in areas of chronic or ambulatory or surgical care – breast cancer, for example, with almost no research in critical care and acute care settings.  But in any area where there is uncertainly, patient preferences could play a role. I’m particularly interested in decreasing resource utilization by keeping patients informed about the problems that come from over-testing,” she states. The field in general, she feels, has a lot of “uncertainty” and that will take time to change, in order for healthcare providers to realize its full potential.

The problems that come from over-testing are numerous, and Schoenfeld provides us with an illustration to elaborate. “A simple example ─ a 50-year-old gets a chest x-ray (maybe it was needed, maybe it wasn’t) and a small nodule is seen. The radiologist recommends a six-month follow-up ─ now the patient is worried about it; the six-month follow up may show that it hasn’t changed, or maybe the x-ray is just different enough that someone says ‘better get a CT,’–and the CT adds cost, worry, and inconvenience. Sometimes it will pick up an early cancer, but other times it will lead to even more tests. Maybe the read on the CT is that it’s still unclear, so the primary care doctor sends the patient to a thoracic surgeon, who has to get a biopsy, which is invasive, to be sure. Then, maybe that biopsy has complications and turns out to be a benign something. Testing begets more testing in our system,” she says.

She realizes that there is a counter argument to this – that if additional testing does show a malignancy, it might be wise to have it done, but she reiterates her previous point in this context. “Some years ago, when you could pay out of pocket and get a full body scan done, very, very rarely would something like that pick up early cancer. What we know about medical testing is this – in a few cases, it does pick up something and that detection might save you, but in most cases, it doesn’t and just leads to more and more testing. There are a number of counter examples to show that additional testing causes more and more problems. So I would say, yes, picking up the incidental thing is sometimes a good thing but that is not always the case.”

Her love for research stems, again, from her family. “My father is a bio-statistician. I believe strongly in evidence-based everything – medicine, parenting, public policy. I could teach my residents my beliefs, but ideally I’d like to prove them first, and teach them as evidence-based,” she says.

Her residents may also benefit from the solid advice she has to offer when asked about what she would say to a young researcher going into the same field. “I would say, ‘get good, solid, experienced mentors early, ask lots of questions and listen to them.’ I can’t tell you the number of times I haven’t heeded advice, only to come back and recognize it was correct. The right way to do things is often the hardest. Looking to get funding, especially, can be very overwhelming. The NIH guidelines can be confusing sometimes, so get help early on,” she says.

But there’s also another piece of insight she offers that is as helpful as the more tangible advice. “Don’t go into research if you’re not passionate about it – there are lots of other things to do with yourself within medicine – for research, you need some inner fire.”

Dr. Katharine White

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Katharine White, MD, MPH

It’s a field that finds itself in the news almost every single day, and for good reason. On the one hand, the Center for Family Planning research reached its 20th anniversary last year, a celebration of 20 years dedicated to research in women’s health. On the other hand, a bill that not only further restricts abortion in Oklahoma, but also makes embryonic stem cell research illegal, cleared a House Committee as recently as February 4. It’s against the backdrop of this ongoing battle between whether or not there should be any research in the field of family planning and contraception, and to what degree, that Dr. Katharine White has to do her job.

White (MD, MPH) is the Chief of the Division of General OB/GYN, and the Director of the Family Planning Fellowship at Baystate Medical Center, Springfield, MA, Tufts University School of Medicine, Boston. The researcher, originally from New Jersey, says she is currently enjoying living and working in Massachusetts, which is perhaps a result of enjoying the research she does, because to say that she is passionate about her work would be a true understatement.

It’s that same passion that drove her into the field. “I love taking care of women, and helping them to maximize their health throughout their lives,” says White, “But I was frustrated by the lack of focus on family planning in my training – pregnancy is one of the most important times in a woman’s (or a couple’s) life, and all too often it happens by accident. I jumped at the opportunity for fellowship training in this field, to be able to perform research myself to better understand how contraception works – or doesn’t – for women.”

It is research like hers that is aiding women to maximize their health, get the contraception they want, and be able to switch to a different method, despite potential barriers, some of which can be put up by practitioners themselves. “Sometimes it’s a financial barrier, and sometimes it’s a barrier thrown up by the doctor. I had a 15–year-old patient whose pediatrician stopped giving her the contraceptive injection, for fear that she would develop osteoporosis later in life….and she then became pregnant. Another woman wanted her IUD removed, but her provider thought it was “too soon” for her to become pregnant again… so my patient removed her IUD herself with a pair of pliers,” she recalls.

However, the barriers exist not just for women who are seeking different kinds of contraception, but also within the research behind it. “This field, like many others, is limited by funding – we have a cohort of new researchers who graduate from the fellowship every year, and we’re all competing for an ever-dwindling pool of grant money,” she explains. That competition, as she tells us, is further increased in abortion research. There is a minimal amount of funding available for that specific area, as it can only come from foundations, not the government or pharmaceutical companies.

It is these biases that seem to truly hamper research in the area. “Family planning research is also limited by prejudice and expectations around sexual health. Many people involved in reviewing research, for an Institutional Review Board, for example, or to award funding, have their own notions of women’s reproductive health – how old women should be to use birth control, what methods should be used by which women, whether or not they should be able to get an abortion – that are not backed in science,” White tells us.

Yet, she powers right through, unfazed by these factors, and continues her efforts. “Politics may influence the funding, but it doesn’t influence the research because a vast majority of it is done by scientists and public health researchers, who look at what’s good for society and the public at large,” she says.

White does it for the women, for the people who are benefiting most from her extensive and dedicated research. “Successfully completing a study lets me have an impact on more women than just the patient in front of me. Having a personal connection to patients is incredibly important to me, but finding something new through research has the potential to improve many women’s lives at the same time.”

Social media, she realizes, is an effective tool to get through to women of all ages about their health, and to push the message forward. White has her own Twitter account, where she answers questions people may have about family planning.

“I think it’s vital for healthcare providers to develop a reputation for honesty and accessibility, and then to use that reputation to spread the facts, in a non-patronizing way, online and through social media. A lot of young women get much of their health information on line or through non-traditional sources. Growing up, my friends and I got most of our sex education from Cosmopolitan and Glamour magazines!” she says. She is now a monthly contributor to Glamour and acts as an advisor to writers and editors on all aspects of reproductive health. “My work with Glamour  has helped me to ‘give back’ and to make sure that the information that’s out there is accurate and relevant,” she adds.

Her perseverance is an inspiring example to young researchers in the field, for whom she has a little piece of advice… “There’s a lot of skilled competition for not a lot of grant funding. Be prepared to hear ‘no’ a lot, but if you have a good idea, don’t let it go. I submitted my first major grant six times before it was funded!”

She signs off on this note—“I tell other researchers going into the field, not every woman has a disease, like cancer, for example. But many women, at some point, might have to think about family planning. It’s why this field has such immense potential, because it affects so many women’s lives.”

Dr. Prudence Plummer

Prudence Plummer isn’t one to sit around and wait for things to happen for her; this go-getter, originally from Australia, where she began her research, has since moved to the US, taking up faculty positions in Florida, California, Massachusetts, and North Carolina, where she is currently an Assistant Professor at the Department of Allied Health Sciences, The University of North Carolina at Chapel Hill. Plummer has been on the move — and all of it is dictated by her passion for research.

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Prue Plummer (r) collects gait data from a participant with stroke, while research staff monitor performance of simultaneous cognitive task.

So it only seems fitting that a person with her energy was awarded a grant by the American Heart Association, “Training Dual-Task Walking after Stroke: Effects on Attentional and Locomotor Control,” and has more recently been awarded an R21 by the NIH, “Real-World Assessment of Dual-Task Performance After Stroke.”

Plummer is hoping to help stroke victims learn how to multi-task/perform other tasks while walking – a dual function so simple that far too many people take it for granted. “During my Post-doc, I became very interested in how people allocate their attention. The area that I developed an interest in is how cognitive and attention deficiencies, and mobile deficiencies, interact with each other. For me, the intellectual stimulation from this kind of research – which the mind is so challenged by – is much more satisfying than working in clinical practice. Working with stroke victims is an especially rewarding experience,” she says, and ”the research is needed to determine whether traditional gait assessments adequately capture the extent of gait limitations in real-world community environments. We may be underestimating our patients’ real-world disability, which could be contributing to their restricted community participation and physical activity,” she explains.

Was there one thing in particular that prompted her to take on such inspiring work? For Plummer, it was the bigger picture, a long-term interest as opposed to one isolated event. “I am mainly where I am today due to a general interest in these research areas that developed while I was still a physiotherapy student.  During my undergraduate honors research and my PhD research, I studied visual attention-shifting mechanisms and disorders of attention after stroke.  During my postdoctoral training, I gained more experience in gait rehabilitation for people with neurological disorders.”

While she does love the big city life, work is always the frontrunner. “My line of work has different challenges and opportunities and I just want to be in the place where the best work is,” she says. She does advise young researchers to take the grant-writing process seriously early on. “I think it is incredibly important. These days it’s impossible to get promoted if you don’t have a considerable amount of funding, so you need to acquire those skills and techniques early in your career.”

Her other advice, too, highlights the enormous amount of dedication that she devotes to her line of work. “Choose an area you are genuinely, passionately interested in. There is no point in dedicating yourself to something unless you really want to study it. Find people you can collaborate with. I was fortunate enough to have wonderful mentoring opportunities.”