Building a destination for future doctors and researchers

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We are going look at the state of MCG today. This broadcast being recorded mere hours before the actual State of MCG address is delivered by its dean. We want look at gene editing. We did a story, not too long ago, on CRISPR and the efforts to edit human genes and what that might mean when it comes to diseases and immunity and other health issues. So, we’ll get the dean to break that down for us. And we need more doctors. We talked about that with Georgia’s governor last week and we’ll talk about it with the Dean of the Medical College of Georgia. He is Dr. David Hess. And he is back on the set of “The Means Report.”

Brad Means: Dean Hess, thank you so much for taking the time on this especially busy day.

Dr. David Hess: Thanks for having me here.

Brad Means: Well, it’s our pleasure. Just for the uninitiated, or maybe those who’ve lived here forever and don’t know, when we think of MCG, we think of a medical college, for sure. We think of a place we can go to the hospital and students are likely to observe what’s going on with our treatments, so a teaching hospital comes to mind, but it’s really more accurate to refer to MCG as an academic health center. Tell me about that distinction.

Dr. David Hess: An academic health center is relatively rare. There’s probably only two in Georgia, Emory and us. Other states our population size have more, four and six, in Ohio and North Carolina. But an academic center, academic health, has a tripartite mission, as we always say. Clinical care, research and discovery, and teaching. And the research and discovery is usually a big part of it. And the other important part is that they have large residency programs. And residencies can vary from pediatrics to fellowship programs like interventional cardiology. Or otolaryngology. And to have all those programs, it’s usually only found in academic health centers. The other major part is our faculty that basically take care of patients. They’re mostly all employed by the medical school. A lot of their income will come from clinical income, but they’re really employed by the medical school. And the dean appoints the department chairs and hires the faculty, in collaboration with the CEO of the hospital. But the medical school’s really enwrapped and entwined in the hospital. That’s what an academic health center is.

Brad Means: How are you able to do all three? Clinical, research, and teaching, without one of those three suffering?

Dr. David Hess: Well, that’s the balance. That’s difficult. I think Harvard, and Mass General, was really, really strong in their research. The research is usually getting NIH grants, which is an art in itself, and takes a lot of effort. And you have to have a big research infrastructure. So it’s always a balancing act. And teaching is really the number one priority. We really wanna train good medical students, and good residents. But training good medical students also requires training them in research, right? Otherwise, we don’t advance. We don’t make advances in medicine. Most of the discoveries at advanced health are done in academic health centers throughout the United States. That’s where most of it’s done.

Brad Means: Talk about that NIH and other funding sources that come from the federal level. Does that eat up a ton of your time, trying to apply for that money? And what is the time table when you say, “Hey, I need some help,” until you get to cash the check.

Dr. David Hess: Well, it is a process. Getting an NIH grant is a real ordeal, and I think the average age of getting your first, we call it an RO1, that’s an independent research grant, is now in the mid-40s. So, it takes that long. And it’s usually, you apply, you usually don’t get it the first time, you re-submit it. You have a study section of your peers that evaluates the research. But, the funding levels, for example, in cancer, are under 10%. Single-digit success factors. Now at other institutes, they’re higher. Right now, in Alzheimer’s disease, there’s relatively a lot of money, because the federal government has earmarked money for Alzheimer’s. So, some of those grants may be funded, 30% of them are funded. So it also depends what you’re trying to get funded. And cancer, believe it or not, is very, very difficult, one of the most difficult areas.

Brad Means: We’ll talk about what’s going on at our cancer center a little bit later in this broadcast. First, though, I want to get to the status of our doctors. Especially the ones that we’re graduating and putting into parts of Georgia, especially rural parts of Georgia. That’s a constant struggle, Dean Hess. Are we making any progress?

Dr. David Hess: Very slow, honestly. Very, very slow. We have to do something differently. We can’t do what we’ve been doing. Georgia ranks about 39th or 40th in physicians per capita. But it’s really worse than that, because Atlanta doesn’t have a physician shortage to speak of. There are pockets of Atlanta where there’s a physician shortage, but most of it’s outside of Atlanta. So if you go outside of Atlanta, we have severe shortages of physicians in many areas. And when I go out on the road to alumni dinners, they also wanna know, “Can you get me a rheumatologist? “Can you get me a neurologist?” So they’re short not just of primary care doctors, but they’re short of specialists. So we have shortages in almost every area of medicine. And the shortages are worst in the southeast and the Midwest in the country. The AAMC just did a study of this. And the other thing, I think when they were doing these estimates a long time ago, when they thought we didn’t need physicians, they didn’t probably take in account well how the population has grown. The demand for more access and services. As we increase access, we need more doctors. And then in our class this year, 55-60% or even higher in some medical school classes are women now. And they’re often taking a little break, somewhere in their career, or going part-time. So you factor all these in, we have quite a severe physician shortage.

Brad Means: Is this MCG’s sole burden to bear, or are other med schools throughout the state helping y’all?

Dr. David Hess: Well, everybody’s in this together, but we are the only public medical school, so it’s really our burden. But certainly Mercer helps, Morehouse. Emory I think more is a national look that they help, but we really need to get the doctors out. It’s difficult to get doctors out in rural areas. And we’ll tell you about some of the ways we’re doing that, but they have to flourish. And we talk about medical and physician deserts. If you go out in a small town and you’re the only doctor, who are talking to every day? How are you not getting burned out? How are you financially surviving? Where are your kids going to school? You want your kids to go- Is your spouse happy? These are all factors that are difficult. Generally, the people that are gonna go to rural Georgia are the people that are coming from rural Georgia. So you gotta start admitting them to medical school, and then nurturing them up and giving them exposure and hopefully remitting their tuition to keep their debt down, so that they can go to rural Georgia.

Brad Means: All right, so you’re talking about some of the stuff that falls under the 3+ program. Tell our viewers about that, and how it might help serve as an incentive for would-be rural doctors.

Dr. David Hess: The 3+ program is something we’ve been working on for awhile, but really just the last year though. It came up pretty quickly. It’s the most innovation we’ve had in our curriculum really since 1828. Medical school, for the viewers, is normally four years. But the big secret in medicine is the fourth year could be better spent, usually spent doing a lot of interviews, applying to residency programs. In a competitive program like orthopedics, you may apply to 60 programs, and then do little stints at each of these places, and then interviewing. We think the time could be better spent. For some people, it’s definitely four years is needed. But we want to shrink it to three years for students that are committed to going into a primary care residency in Georgia. And that’s because, this long lead time needed to apply for residencies, we’ll be able to do it if we control the residencies, and they’re controlled by our partner hospitals. Now, primary care is broadly defined. It’s pediatrics, internal medicine, family medicine, OB/GYN , general surgery, and psychiatry, and probably emergency medicine in Georgia. That’s how it’s defined. So there’s a lot of choice for the students, but they’ve gotta do their residency in Georgia. And if you do your residency and go to medical school in Georgia, the chance of you staying in Georgia is about 80%, 70-80%.

Brad Means: Why? Because you’ll fall in love with your job and your community?

Dr. David Hess: Exactly. And you maybe get used to the community. You may marry someone from that community. And then if we remit their tuition, we think that number will be higher. So the idea, now we don’t have this all funded yet, but it’s really resonating with the state and corporate partners, is that if you would go to medical school, we’ll remit your tuition if you practice in an underserved area of Georgia, which is almost all of Georgia outside of Atlanta-

Brad Means: It sure is.

Dr. David Hess: And Columbia County, honestly. And maybe Chatham County. And if you work anywhere from four to six years in one of these underserved areas, then your tuition is remitted.

Brad Means: So four to six, you get your tuition back. Look, when I think about things that I want to be shrunk in my life, my doctor’s training does not top the list. How do you manage to get ’em in and out in three years? I know you said that fourth year is non-classroom primarily. But how do you cram it into three and they’re still good doctors?

Dr. David Hess: Well, there’s about 12 medical schools have a three-year medical school program throughout the country. And they seem to be turning out very good doctors. You have to just be more efficient with your time. And then exhibit B would be Charlie Howell, my colleague who’s AUMA CEO, who went to medical school in three years and then became chair of surgery for… And now is CEO of the practice plan and pediatric surgeries. So he’s a good example that you can do this. But there’s more and more data that you can do it in three years. But you have to be purposeful about it. And we call it more personalized, because most of the students, when we eventually expand up to we think 300 students, probably only 50 will go to medical school in three years and take advantage of this program. So you’re talking about 20% of the class, at most. Most of them will still go traditional. The 3+, we call it, the other thing you would do your last year would be to get an advanced degree. Like, you could also get an MBA, a Masters of Public Health, come out of medical school with an MD/MBA, an MD/MPH. And the last category, which would be the biggest, is the fourth year, they’d be spent doing a year of research or focusing on their area of specialty. So if you want to go into orthopedics, which is very competitive, or neurosurgery, you would spend that fourth year doing a lot of electives in that area. And maybe a research project that would go on longer.

Brad Means: Real quickly on this subject, because it’s important. We need to make sure that all parts of Georgia have doctors. Is there any way to target kids? You said that a lot of the times, these rural doctors are ones that are from those towns. To target kids, middle school maybe, that look like potential physicians and do everything you can to retain ’em and make them come back home.

Dr. David Hess: Well that’s a great idea, starting in the middle school. We have some programs, a SEEP Program here, which has been run a long time, addresses high school kids, particularly underrepresented minorities, to try to get them in the health professions. So that’s worked very well here in Savannah, but I think your idea of even going out to the middle schools is a good one. Our secret sauce, the strength of our campus, besides our academic health center here in Augusta, is our regional campus system. And they’re very tied into the community. Our Albany campus, our Savannah, Brunswick, Rome, and hopefully soon to be Dalton. Dalton will hopefully be in there with Rome, which will strengthen our northwest campus. We really have to start in those early years, and start getting people to come. Fortunately in Georgia, we’ve got a great university system, right?

Brad Means: Mmhmm.

Dr. David Hess: And the University of Georgia, that’s our farm system, and Georgia Tech, and our colleges. And the HOPE scholarship does help keep the debt down at the university level. But now you want to keep the debt down at the medical school level, because still our average debt is $160,000 when you graduate.

Brad Means: Good night.

Dr. David Hess: And that’s low, compared to some medical schools.

Brad Means: You’re pleased with the regional model? We’re not spread too thin?

Dr. David Hess: No, I think it’s, the regional model is the best thing we could have.  The students go out there. They’re not opposed by residents, as we say. So they get to do the procedures. It’s not uncommon to talk to a student who’s been in Brunswick, or Albany, and has delivered 30 or 40 babies.

Brad Means: I think the reason I asked that is because when I hear “regional model,” I get fearful that another town is gonna steal MCG from us.

Dr. David Hess: I don’t think that will happen. Our roots are pretty deep in this town, and a lot’s here. I don’t think you have to worry about that. I think we have that regional campuses because we need more experiences for our students. There’s just not enough in Augusta.

Brad Means: We’re gonna continue this interview with the Dean of the Medical College of Georgia, Dr. David Hess, in just a minute. We’ll talk about gene editing, this cutting-edge research that’s going on at the medical college. Also some other exciting things that are ahead, in advance of the State of MCG Address the Dean has set to deliver, when we come back.

Part 2

Brad Means: Welcome back to The Means Report. We are talking to Dr. David Hess. He’s the Dean of the Medical College of Georgia. He’s about to, as soon as this recording is over, deliver the State of MCG Address, as he does each year to the folks at the medical college. One of the things I wanted to point out, as far as a feather in the cap of MCG, are your Georgia Research Scholars. And tell me Dean Hess if I’m interpreting this correctly. These are folks who do research, who look for cures for diseases, but who also might start companies that flourish from right here at home?

Dr. David Hess: Right, right. The GRA, the Georgia Research Alliance, has I think about 65 Georgia GRA Eminent Scholars throughout the state. At Emory, Georgia Tech. So both public and private universities. We have now seven. We’ve had three in the last year, and exactly like you said, you hit the nail right on the head. They have to be good researchers. They have to be well-published. They have to be well-recognized in the field. And they usually have to be well-funded, and/or they have to be able to start a company. Or provide a service. A core, a core lab, like a CRISPR core, gene editing core, to the state of the research schism. They just had their meeting this week, I understand. They get together annually. So it’s a great program for us. It’s an endowment that the school splits with the Georgia Research Alliance, and then they often buy them equipment, so it’s a program that I’m a big supporter of and thankful for.

Brad Means: That’s gotta be something that attracts people to you all, the possibility of not only helping your medical career, but maybe launching something much bigger.

Dr. David Hess: Yeah, it is. And so we had three the last year. The other thing is, they have to be out of state, so I can’t steal a sheep from Emory, or from Georgia Tech, or UGA. They have to be from out of state. So it is a great resource. We hired three this year. One is Dr. Cortez, who I think has been on The Means Report.

Brad Means: He sure has. The cancer center director.

Dr. David Hess: Yeah, Dr. Cortez joined us from MD Anderson. He has one of the best publication records of anyone in the University System of Georgia, much less just MCG’s. He runs the cancer center. David Mattson is a hypertension expert that we recruited from Medical College of Wisconsin in Milwaukee. He spent his whole career up in Minnesota and Milwuakee, and he’s a hypertension expert. He has a Program Project, they’re really hard to get, around hypertension. So he’s bringing a lot of that with him. And he’s very, very great to work with. So he’s down here. He’s a Georgia Eminent Scholar. There’s no more important disease in Georgia than hypertension.

Brad Means: No, that’s your wheelhouse too. I mean, you’ve been working in that a long time. How are we doing on that front? A lot of people deal with high blood pressure in these parts.

Dr. David Hess: Well, we know more and more about hypertension. We have better and better drugs. But still, if you look at, just nationally, not just in Georgia, about half of people with hypertension still don’t have their blood pressure controlled. Because they’re just, the doctors aren’t aggressive, or they’re not taking their medicine. Maybe they’re taking the medicine at the wrong time of the day. A study just came out that if you take your blood pressure medicine at night, it’s better. You have better control, and less stroke and heart attacks, so there’s a lot we’re learning. We have to get that out into the rural areas eventually too.

Brad Means: Would you say that’s number one on your list of things that you focus on research and treatment, is hypertension? Or is it obesity, diabetes, some of the other big things?

Dr. David Hess: They’re all important, and I don’t want to play favorites, but certainly, to me, hypertension, it contributes to so many diseases, stroke, renal disease, heart attack, and even dementia, that I would say nothing exceeds that. Certainly obesity is important. Diabetes is important. But I think it’s, as a disease that takes the most toll on Georgia, it’s hard to argue anything is worse than hypertension.

Brad Means: It sure is. It’s everywhere. Is there a disease, or sickness, that I just have to leave town to get the best treatment, or can y’all handle everything?

Dr. David Hess: I think we can handle just about everything here. We can’t do heart transplants in Augusta. And we would have to send those to Atlanta, for example, Emory. And we don’t do liver transplants. But short of that, you can get, I think just about everything done. And then a bone marrow transplant in a child. Now we’re gonna change that. We’re hopefully gonna be doing bone marrow transplants. Dr. Cortez wants to do that in children, and we have a plans to do that in the future. But today, we can’t do that. But we can do just about everything else.

Brad Means: I was fascinated when I saw a recent story, you were involved with it, the CRISPR… Program or effort that you mentioned a moment ago. Forgive me for not being able to call it by the CRISPR… Thing. I’m going like, “You’re editing human genes.” It’s amazing. How’s that program going?

Dr. David Hess: Just this past year, we recruited the CRISPR Core from the University of Rochester. There were two of ’em. Lin Gan, who’s another GRM and a scholar, and Joe Miano, who worked with him, who’s a Harrison Distinguished Chair, and he’s a vascular biologist, but they both work closely. Lin Gan is the one that runs the gene editing core. Right now, we’re doing it on mice, but it has a tremendous capability to cure human diseases, like sickle cell anemia, and Duchennes muscular dystrophy, which are tragic diseases. I’ve seen so many sickle cell kids later with stroke, and then painful crises. Wouldn’t it be wonderful if we could clip, like with the scissors, the incorrect part of the gene out of them and replace it with the right gene? So, CRISPR is interesting. This is why we have to do basic science research. It was all found in bacteria. So bacteria, lots of the good information comes from bacteria. Bacteria’s number one enemy are viruses. They’re not antibiotic, so they’re viruses. So viruses infect bacteria, and to defend themselves against the viruses, the bacteria have incorporated pieces of the viral DNA in their genome. So when they see the virus again, it’s as if they were immune to it. They copy that, and they send out this protein called Cas9. And it basically goes and it cuts that virus’s DNA up, and chops it up. Well that’s been basically turned around to basically take that ingenious mechanism the bacteria has, and use a guide piece of RNA, attached to this enzyme, which cleaves the DNA. So it’s basically you cut out the bad piece, and put in the good piece. So it’s got tremendous potential.

Brad Means: Is it working in mice so far?

Dr. David Hess: Oh, yeah. Dr. Gan makes mice for everybody, I think, in the country. Everybody’s lining up. He’s just gotta get down here and get his lab going.

Brad Means: Are human trials years, decades away?

Dr. David Hess: I don’t think decades away. I think it’s coming and it’ll come pretty fast. Now I don’t, people hear bad things. In China there were some CRISPR babies made, and those Chinese scientists are in jail now. So you always have to be careful. We have to watch the ethics of all this. And Dr. Miano, who came with Dr. Gan, I think ran the ethics committee at Rochester. You have to look at this carefully. But it’s not that far away. Some genes, particularly sickle cell anemia, where it’s in the bloodstream, it’s easier to get to those blood cells, through the bone marrow, through the blood. So some diseases will be much more amenable. And diseases with single gene defects are the easiest. The trouble with hypertension and diabetes is there’s many, many genes involved, so CRISPR isn’t gonna cure hypertension, at least right away.

Brad Means: Not right away.

Dr. David Hess: It’s not gonna cure diabetes. It’s not going to cure these polygenic diseases right away, but it’s a great research tool too. You can really study disease processes in mice with CRISPR. It’s a big help there.

Brad Means: The kind of things that you’re talking about sound to me like things that grant-givers, the people with the money would love, and that potential med students would love. Are these things, is this kind of research a big way to attract folks here?

Dr. David Hess: It is. You have to have this kind of research to really attract the best talented students. But the students are also trying to get through medical school. There’s a tremendous amount of information thrown at them. And so, to really do research if you’re a resident or a student, it helps to take an extra year off. So in the 3+ program, they could spend the fourth year doing research. It’s really hard to do a research project in an afternoon, or a couple weekends, or even a couple months. It generally takes a year. So we want to start what we call a T program, to give residents or fellows a year off to do a research project, then go back to residency. And then our young investigators, we’d like to- NIH calls these things K awards. These are awards where we protect their time by paying part of their salary, and hook them up with a mentor. So you have to have a mentor. I’m sure Brad Means had a mentor at one point.

Brad Means: Sure, absolutely.

Dr. David Hess: Sure was. We all have mentors, right, and that’s key. Now we’ve recruited all these great people who are great mentors, so now we have more mentors, and so we can really start doing more of these mentored awards, and then bring the next generation up. And eventually, we want to focus on the bad health of Georgia, really, because Georgia’s a very unhealthy state.

Brad Means: It is.

Dr. David Hess: And if you really look, it’s really sad. You go Richmond County down to the southeast to the southwest. It’s a very sick state.

Brad Means: Well the seeds have certainly been planted under your watch, Dean Hess, and I know great things are to come. Thank you for taking your time to give us an update on MCG.

Dr. David Hess: You’re welcome. Thank you for having me, Brad.

Brad Means: Absolutely, the door is always open. Dean David Hess, the Dean of the Medical College of Georgia.

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