“The educator never left”…Teacher, Mentor, Family Doctor and Researcher.
Dr. David Rábago is the Vice Chair for Faculty Development in the Department of Family and Community Medicine at Penn State College of Medicine.
David began professional life as a middle- and high-school teacher in Milwaukee and Chicago. After a nine-year teaching career, he transitioned to academic medicine. He has taught clinical and research-related topics at the medical school and residency levels. One of his goals is to help optimize the relationships between clinical, research and education endeavors of academic family medicine to the benefit of each. David is family physician at Penn State Health Medical Group, with a special interest in prevention, shared decision-making, and patient autonomy.
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“I think that I always knew I’d be a family doc. It has a lot to do with why I got into teaching to begin with. I’m a generalist by inclination and spirit, and family medicine seemed to fit that.”
Today we’re in the US, and I’m talking to David Rabago who has had a fascinating medical career. But what’s most interesting is that you didn’t start off in medicine…
David Rabago: That’s true, a bit unconventional. When I was an undergraduate, I didn’t think that I would have a career in medicine. It wasn’t on the agenda. I come from a family of teachers and I thought that I too would become a teacher. I saw what my parents did; I liked what they did and they seemed to like it. It really was the main choice. And so I became a middle and high school teacher, in Milwaukee, in Chicago, in the US for several years.
DMacA: Not just several years, it was quite a considerable period of time. Tell us about that, and what made the decision to go into medicine?
DR: Yes. It was nine years altogether. I found myself loving the work. The teaching was great. Students liked what I did. Parents really liked what I did. Even the administrators liked what I did, and that’s not always the case. But I found myself running out of ceiling- that’s how I think about it now. I looked around and considered several other science-related careers. I was a math and science teacher and, after eliminating a lot of choices, medicine was left standing. I had a couple of students whose parents were physicians and it was a small school, very friendly, so during one of the conferences with the parents, I asked if I could talk with them later about my own career and, actually, they became mentors for me in a choice that later led to medicine. I was lucky that way in that I had some inside contact.
DMacA: Tell us about medical school.
DR: I went back to academics to complete some courses that I hadn’t done as an undergraduate in a summer post-Baccalaureate program. Then I went to University of Wisconsin which had an interesting program for “non-traditional students”. And I was quite non-traditional- nine years after undergraduate. Essentially it involved taking gross anatomy as a summer student so that I wouldn’t get too clobbered by the first three big classes that were typical when I started medical school in 1993, and it made the transition from my teaching life to student life a little gentler. And indeed, it was a real success-builder. I did fine and the transition was nice. Again, fortunate.
DMacA: And when did family medicine become part of the story?
DR: I think that I always knew I’d be a family doc. It has a lot to do with why I got into teaching to begin with. I’m a generalist by inclination and spirit, and family medicine seemed to fit that. I tried to keep a genuine open mind throughout all my rotations with all my professors, give a fair shake to all of the specialties. I did the best that I could with that but found myself leaning toward family medicine interest groups and hanging out with like-minded students. I found some of my most inspiring professors in family medicine. UW Madison Family Medicine was, and continues to be, a very inspirational place, with national leaders in various aspects of patient-oriented care and primary care research. So, it became an easy choice as a specialty and the Madison program was my first choice as a medical student seeking a residency.
Among David’s other interest is nature photography
“I have been the fortunate and grateful recipient of some serendipity; yes a little bit of hard work and willpower on my part, but also the good fortunate of meeting people who became mentors in my career.”
DMacA: The science and research part of your brain was still active because you did some research very early even as a resident.
DR: That was interesting. Between medical school and residency, I did a one-year NIH internship with the University of Wisconsin Sleep Lab with epidemiologist Terry Young, one of the pioneers in sleep medicine. That was in an effort to get any research experience that I could. I literally shopped around from lab to lab saying- “can you hire or even provide a volunteer position for someone interested in getting a little bit of experience in research?” I caught her on a day where she was frantically producing a grant application that was due almost immediately. And in those pre-electronic submission days the due date question was- “what time does the last Fedex flight leave the airport?” And so she sent me note with a lot of grammatical and punctuation errors saying- “I can’t help you right now; talk to me in two days.” We interviewed later and she said- “yeah, I’d love to have you”. And so I spent a year before residency doing sleep research. Her sleep epidemiology lab was great. I caught the research bug, as they say.
DMacA: Tell us more about this bug, because you went on to do some absolutely fascinating respiratory related research.
DR: I have to say, I have been the fortunate and grateful recipient of some serendipity; yes a little bit of hard work and willpower on my part, but also the good fortunate of meeting people who became mentors in my career. The first person was Doctor Mike Fleming, who’s actually best known for work in alcohol related primary care and brief intervention. He was the director of a fellowship program, a, T32 fellowship program run by HRSA in the US. Early on, he knew that I was interested in research, and when I was a first-year resident, he said- “well, if you ever want to do any more research or just talk about it, let me know.” And I did. He asked what I was interested in and, before medical school I had taken a class in massage therapy. I hung out with people interested in complementary therapies for a little while; while they talked about how great a therapy was, the scientific, analytical part of me mind thought “well, how great is it?” And in fact, we don’t know how effective some of those therapies are, if at all. And it stuck in some brain cell and I thought about having some input in helping determine whether some of the therapies they were talking about were great or not.
It was Chicago. People got colds, a lot. And, one of the most interesting things that people were especially interested in was a therapy called nasal irrigation. It is very old and comes from the Ayurvedic or yogic medical tradition and again. Later some serendipity. I had a rotation with an otolaryngologist who had developed a plastic nasal irrigation cup, or neti pot. And I said- “well, have you ever really tested this?” And, she said- there are some not-great studies but “no, we don’t really have great data”. So that became my first project. And mentor Mike Fleming, who makes no small plans, said, – you should just do a little RCT during your residency. And I didn’t know enough to say no to that! So, I and my wife Aleksandra Zgierska did that, nights and weekends; of course, we didn’t finish it during residency. I did a fellowship with Mike to complete that project. And to start the second area of interest in research.
DMacA: To say you did a little RCT is underplaying it a lot. You did a fantastic piece of work that has international relevance. Tell us a little bit more about that.
DR: Yes, and thanks for that. It was a good thing and it has moved nasal irrigation into conventional care, even in advance of some of the bigger trials that we would like to see. Part of it was hard work and willpower but part of it is great mentorship. It didn’t cost a lot of money. And in those days it was a little simpler to do clinical intervention trials. We needed smaller teams and there was less administrative burden. But the Department was generous and I had some support. It was partly also, I think, about being in the right place at the right time. If I hadn’t done that study, I think somebody would have. There are these moments where the next unsolved question is just right there. We knew that nasal irrigation had been present for centuries, and we knew it had been studied a couple of times in methodologically not such strong ways, for example with airborne environmental issues among woodworkers, upper respiratory infections, and allergy. But nobody had really put in place the randomization scheme that was needed. So, we did that. Most symptomatic people really feel better; for those who have significant nasal symptoms, rinsing out the nose often just feels good. Many love it. It is not for everybody, which is true for many therapies, but I think that patient interest drove a lot of this. People voted with their feet. And so it has become something that gets used for a lot of sino-nasal conditions. That said, we don’t have the big RCT that has nasal irrigation as one of the arms. But we are now involved in a multi-site study that will enrol over 3000 people in the US with nasal irrigation as part of the therapeutic regimen. We love that it has become part of that. You can now buy it in any drugstore and that was not true in 2002, when we did that work.
“It wasn’t really called translational research as much then, but it turned out to be an idea that was ahead of its time because now we’re all about translational science and translational research.”
DMacA: Now, I’m not going to buy this understated approach, David, because while good researchers have one good idea that they run with throughout their career, great researchers have more than one idea. And you’ve had more than one research idea. Tell us about prolotherapy.
DR: That’s very kind. And, again, I have to credit a terrific mentor who sadly passed away long before his time in 2014, Jeff Patterson.
He was one of these guys that you love to work with because he’s so enthusiastic, so optimistic, and he so adored patient care that you just want to do things like he did. And one of the things that he advanced was a technique called prolotherapy for chronic pain. Chronic pain, as you know, is a very big deal and it’s getting worse. And he picked up this therapy that was developed in the 50s, and brought the teaching of it to a much higher level. It’s not typically taught in med school or residencies that have programs that deal with chronic pain. But he used as a family doc and taught people how to do this in conferences, and in service-learning projects in places that need this, and organize it in that way. He taught people the fundamentals and then took it on the road and taught it real-life settings (https://www.hhpfoundation.org/). He was so enthusiastic. But again, early on I said, what’s the evidence that prolotherapy works? I knew the patient outcomes were good anecdotally but that’s often not enough to convince a third party payer or a health system. He said that, frankly, the research could be better. In fact, it could be a lot better. We had those conversations when I was trying to decide whether or not to make research a bigger part of my career and I talked with him about the possibility of assessing prolotherapy as part of a career development plan. And he was enthusiastic. Mike Fleming said -absolutely, you could establish this study and maybe include some basic science work as part of a career development plan. So, I wrote that application. In the US we have a series of grants that fund early career researchers. And I was very fortunate to receive a five-year career development grant that covers time, which is the scarcest resource for research docs, especially early career docs. And I learned how to conduct randomized controlled trials better. And the first one that we did in prolotherapy was something that I remain really proud of.
It was a nice study that involved Jeff. It involved Mike Fleming as my research mentor. And, it involved Tom Best, then one of our faculty in sports medicine. He was instrumental in helping translate my clinical understanding of prolotherapy, bridging it to the research side with Mike, and adding a basic science component. It wasn’t really called translational research a s much then, but it turned out to be an idea that was ahead of its time because now we’re all about translational science and translational research. I think that was part of why I was awarded that grant. And we have tried to keep that going in both the nasal irrigation and prolotherapy research.
“But I think the academic family medicine department functions best when everybody knows a little bit about all those three things, at least what’s going on in those three things, and buys into the mission of each. That’s the passion for me. That’s the joy. This is part of how we win in academic medicine.”
DMacA: We talked about areas that are really pioneering. We’ve talked about randomized controlled trials in two particular fields and also about translational work, really exciting, interesting research. But I’d like to take it back to something else, because you’ve now moved on to Penn State. And your responsibility is with faculty development. So, it almost brings you back to your teaching career with mentorship and support. Tell us about that.
DR: Well, you know, the educator never left. When I transitioned to medical school from being a teacher, friends and colleagues thought it was such a dramatic shift. But I didn’t ever really see all of it as a very big shift. I have always referred to it as a lateral move. You’re a student for some time when you’re young. And then in my case, I became a teacher of people who were young. And then I became an adult learner. Eventually someone tasks you with teaching the medical students and then the junior residents. I was a chief resident in the family medicine residency at UW so I was more involved in teaching; and that never really went away. And then as a junior faculty, I was responsible for teaching residents in inpatient and outpatient settings. And I always have loved all three of those things, clinical care, teaching, and research. I’m a real believer in academic medicine. When people ask what I do, I typically say “I am an academic family physician, and it involves three things: treating patients, teaching learners, and conducting research.” I buy into all three of those, and try to have all three of those as part of my work life. Not every day. But, a good day in any one of those things is a really good day. Later in my career, with my wife, Aleksandra Zgierska (MD PhD), who also works across all three mission areas, we had an offer to come to Penn State. We have supported one another’s careers from the beginning. We were not looking to move but a couple of things happened. They made a strong offers. We were at a point with our family life that the children could endure a move. They were not initial fans at first but they understood, and the move went well. It was not easy and raised interesting questions. We had what is sometimes, with professional couples called a “two-body problem”. Whose career do you move for? And, how does the partner deal with that? The magnet for the move was actually her career because she was in place to assume the vice chair for research role. Penn State was looking for that leader. They were also planning for a vice chair of faculty development. Penn State family medicine is a large department and no one was tasked with helping clinicians move through their career across all three core missions. When they saw Aleksandra’s CV and discussed options, she mentioned my interest in teaching advanced learners, they wanted to see mine. And the chair eventually discussed leadership positions with both of us, and solved our “two-body problem”. It was another example of right place, right time. And, faculty development has become my responsibility, in addition to work in the other areas, helping to grow an environment in which development happens across our missions areas on a per doc basis, as not everybody is interested in all three mission areas in the same way. But I think the academic family medicine department functions best when everybody knows a little bit about all those three things, at least what’s going on in those three things, and buys into the mission of each. That’s the passion for me. That’s the joy. This is part of how we win in academic medicine.
“When patients feel good about seeing their family physician and they are demonstrably healthier by objective metrics, then you’re winning. Of course, we don’t always win; but that’s the goal and a driver for me.”
DMacA: You’ve mentioned the three components. We’ve spoken about the academic, and we’ve spoken about the teaching, and you’ve won a number of research awards and had some fabulous publications. But there’s a third component, and that’s the clinical care of patients. And you’ve also been recognized for your clinical care of patients. That must have been very rewarding.
DR: As you know, we don’t we don’t have great ways of assessing this. Patient satisfaction is one of them and of course I like to receive good feedback from patients. We’re getting better at outcomes-based assessment and I certainly try to facilitate good patient health outcomes. I think that the combination of those two things is the “win”. When patients feel good about seeing their family physician and they are demonstrably healthier by objective metrics, then you’re winning. Of course, we don’t always win; but that’s the goal and a driver for me.
And both of my research areas (nasal irrigation/antibiotic stewardship and treatment of chronic pain) come directly from the patient’s perspective and challenges in the patient care. Pain and upper respiratory infections are things that patients really care about, and they’re things that have a big societal impact. So, it was easy to say yes to those areas for research.
DMacA: I think that’s a particularly important note to end on, with the focus on patient care. It’s been terrific talking to you. It’s been wonderful to have you as a friend and a colleague for so many years. And thank you very much for talking to us today
