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Getting Personal

Nathan Francis Mossell, MD, the first black student inPenn’s School of Medicine, received his medical degree in 1882. On his firstday, he later wrote, he was “accompanied by a storm of protest” as his fellowincoming students sounded their displeasure. “I was not perturbed in theleast,” wrote Mossell. Instead, he worked harder and ended by graduating fouryears later in the top quarter of his class. His dedication and perseverancewere appreciated. At the graduation ceremonies, the same classmates who hadobjected to his attendance greeted him “with almost deafening applause.”

According to Ana E. Núñez, MD, the lecturer at the 31stAnnual Mossell Lecture last month, Mossell remains a role model and atrailblazer, especially as someone who fought against health disparities. Asshe made clear in her talk, despite the many advances in the years sinceMossell dared to apply to Penn’s medical school, much remains to be done. Thetitle of Núñez’s talk, “Personal Enough? The Quest for Personalized Medicineand Health Equity,” suggested the directions she encouraged the currentstudents to take.

Núñez, a professor of medicine at Drexel University College of Medicine who was recentlyappointed associate dean for urban health equity, education, and research, gavefair warning that she had a lot of ground to cover. Her talk, she said, would not be “a sedate and luxuriousstroll.” Indeed, although she was born and raised in Pennsylvania, she said, “Italk like a New Yorker” –- and she maintained a fast pace and flavored her talkwith many humorous asides.

In an era when personalized medicine (with its near-synonymsof individualized medicine and precision medicine) has gained much supportamong both health-care professionals and the general public, Núñez asked heraudience to take a closer look at what it means –- or should mean. As generallyunderstood, personalized medicine will be made possible because of the landmarkachievement of the International Human Genome Project in completing a blueprintof the human genome. Being able to know patients’ genetic, metabolic, andproteomic makeup would allow physicians to tailor their medical care.

Although in the course of her lecture Núñez cited the needfor effective information systems and the need for “the right diagnosis andtreatment of the right patient at the right time,” her focus was not on thiskind of personalized care. Instead, she seemed to be urging the students in theaudience to pay very close -– personal -– attention to the patients they will betreating in a few years. The nature of medical education, Núñez argued, is thatit must teaches stereotypes rather than individuals –- “but then you get topatients,” she added, and the individuality becomes so important.

Health disparities exist, Núñez asserted, but “we have anopportunity to make a difference.” One important step is to understand that“one size fits all” does not work in the real world, where the socio-economicand cultural backgrounds of individual patients can differ tremendously. “Weneed systems where people can be human,” said Núñez –- in other words, systemsin which the practitioner recognizes those differences among patients and triesto see “who is this person in front of me” and takes into account sex,heritage, experience, and other important factors. During her own training as aninternist, Núñez recalled, she knew to ask questions about a patient’s homelife, but didn’t ask, for example, whether anyone in the family wasincarcerated. As she put it, research has shown that “trauma actually has aninfluence in changing genes.” In the same way, she pointed out that the familiesof some patients may play a significant role in how patients are treated andhow they fare.

“We have multiple subcultures,” said Núñez, and physiciansmust be aware of how these subcultures intersect with medicine. Physicians musthave cross-cultural efficacy, seeing what is both the same and what isdifferent about their patients. “We are not experts in the lives of ourpatients,” which is why we need cultural humility.

Núñez also spoke briefly about what she called “personalizedpublic health.” One telling example she gave relates to the kind of food andthe amount of food students in West Philadelphia’s public schools eat. As shenoted, there are no school lunches for such students in during the summer,which their doctors should be aware of.

The “playing field” is not level for all players, said Núñez.The implication, then, is that the presumed benefits of the high-technologypersonalized medicine may not be available to all patients, at least at first.But that does not mean that doctors and doctors-to-be can’t providepersonalized treatment. If they see their patients as complex individuals and“ask the right questions in the right way,” they can make a significantdifference collectively.


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