Dr. Jay McDonald is an Infectious Disease Doctor and the Chief of Infectious Disease at the St. Louis VA. Dr. McDonald is originally from Oregon but now lives in St. Louis with his wife and 3 sons. He has been working with the VA since 2005 and has been involved in multiple research studies for the past 15 years.
Learn more about Dr. McDonald in the interview below:
What is your background? Tell me more about our education and training:
I grew up in Oregon and went to Duke University in North Carolina. I was an Economics major and didn’t really know what I was going to do with my life. After I graduated, I moved back to Oregon and then decided I wanted to go to Medical school. So, I went back to school at Portland State University and got my biology degree and I applied to my home state medical school, Oregon Health Sciences University in Portland. Once I was in medical school, I figured out pretty quickly that I wanted to do Internal Medicine.
At the time, Oregon was really interested in training primary care doctors for the state of Oregon – and I didn’t want to do that. I knew I wanted to go into academics, and I knew I wanted to specialize. So, I started looking around country and applied for residencies all over. I moved back to North Carolina to Duke University for my residency, chief residency, and Infectious Disease fellowship. I finished there in 2005, and my first job out of training was at Washington University.
I came to Wash U for a couple of reasons, the main professional reason being that Wash U, aside from being a great academic university, has been known for a long time as being one of the leaders in infection prevention, which is part of my niche within infectious diseases.
When did you join the VA and why? What drew you to the VA?
At the time, Vicky Fraser was the chief of ID at Wash U, and she has been a leader in the field for a long time. So, I came to St. Louis mostly because of Vicky, and because of Seth Eisen, who at the time was a Rheumatologist at VA and working with national VA data. So, I came to work with Seth and Vicky and spent the first few years kind of split between the two institutions (Wash U and VA). In 2009 the Chief of Medicine at the VA asked me to become the Chief of ID and wanted me here full time and so I became full time VA at that time, even though I stayed as Wash U facility.
What made you choose this field/Specialty?
I really like general internal medicine and I didn’t want to have to give up a bunch of organ systems to focus on one. A lot of specialties focus on the heart or the lungs, and Infectious Diseases is one of the few specialties that stays kind of body wide. If you want to be a good ID doc you must know about the heart, the lung, the brain, the kidneys, the liver, and everything else. So, I picked ID because of that and I also because I like things that I can fix on a short feedback loop. ID gives me a chance to take care of people who are sick in the hospital and to help them get back to full function and I really enjoy that. I also still attend on general medicine here at the VA which I’ve really enjoyed doing over the years in large part because it allows me to keep working with medical students, interns, and residents. I’m trying to teach them something about what I know and trying to learn from them as well.
Why did you want to be a researcher? What interested you in Research?
I kind of come from a medical research family, my dad and uncle were medical researchers and my grandfather was too. And for me, when it came time to get a job after training, I did look at a couple private practices, but I knew pretty early on that I was interested in staying in academics. And the main reasons for that had to do with being surrounded by smart people, who are always thinking about the cutting edge of medical knowledge and being around people who were learning to be good clinicians, so that I could be a part of their education.
Part of being in academic medicine, which provides this great atmosphere of teaching and learning, is doing medical research. So, I really started in research because I love the atmosphere of teaching and learning that is found in academic medicine. I started out in research not knowing if it would catch or if I would be successful or not. A lot of people aren’t, because it’s just a tough business to make it in frankly. So, I started with the idea that I would do it as long as I could do it, and I’ve been lucky. I’ve been at the right place at the right time and I’ve just latched on to some good projects with good people and here I am 15 years later still doing it.
Tell us more about your different research Studies:
One project I work on is TIDOS “The Trauma Infectious Disease Outcomes Study”. TIDOS in a pretty unique project. We’ve been funded continuously since 2011. TIDOS is a collaboration between a research group at the Department of Defense and our research group here at the St. Louis VA.
The intent of TIDOS is to investigate and understand the long-term infectious complications of combat trauma. The Principal Investigator, David Tribble, works in Maryland at the Walter Reed Military Medical Center and at the Uniform Services University of Health Sciences. He is part of the military’s Infectious Diseases Clinical Research Program. One of the things David realized 12 or 15 years ago as the Iraq war was under way, is that we really didn’t have a systematic way of collecting information on battle field injuries and their downstream infectious outcomes. So, he started working on TIDOS on the DoD side at the same time and I was interested in the same topic from the VA side.
I realized pretty quickly that the VA part of the data is not that interesting unless you’re able to combine it with the information about the early injury and what kind of treatment they got in the field. Because I know how they ended up years later, but in order to correlate that with any kind of process that might help them, you need to link that up with the early information. For instance, what was the nature of their injury? How long did it take them to get evacuated? How many surgeries did they get? Did they get antibiotics early on? What kind of hardware was implanted to fix their fractures? So, I ended up meeting with David and we realized we had two pieces of data that if you put them together and better than either of ours individually.
Over the years, TIDOS enrolled over 1,000 military personnel after severe combat trauma. They enrolled them once they got back to Walter Reed and San Antonio Military Medical Center and then followed them forward through time. The military follows them through their time in DoD care, and then shares their identifiers with us and then we look to see when they enter VA care. So, when they enter VA care, we call them to consent them and collect their VA data and share it back with the DoD. Then, we put all our data together in a huge database and try to understand how the early elements of care they got in the field or early on after injury, affect their long-term outcome, with the ultimate goal of improving the early care in the field of combat trauma.
This research project is unique because nobody else has done it. It’s really hard to do research in the combat arena, because the last priority is ‘how can we help people 10 years from now?’ So, it’s really gratifying because all these years of hard work are really going to pay off, and we’re going to have some really cool data that comes out the next few years.
We are now winding up data collection and sort of in the wheelhouse now of starting to be able to look at the whole cohort of information and starting to publish some really good stuff out of the data set.
This was about 350 patients followed for several years. But our subsequent data, is going to be more than twice that size in terms of the number of patients and a lot longer longitudinal follow up.
In additional to the main TIDOS project, there is a separate project within TIDOS with the same funding mechanism.
TIDOS focuses on all kinds of combat infections, most of those being skin and soft tissue infections (people who got injured by shrapnel and other projectiles from blast injuries, and infections at amputation sites etc.) but also infections like intra-abdominal infections after penetrating trauma, intra-thoracic infections, even intra-cranial infections. The piece of that that I’ve always been most interested in, is the bone infections because bone infections can really recur over and over again throughout the years.
So, what the TIDOS investigators, including myself, have done, is create a secondary project.
TIDOS was set us as a prospective study, so basically we enrolled patients for several years prospectively and followed them forward. But there is a whole bunch of data that wasn’t included in that because TIDOS didn’t start until the end of the Iraq war. And we enrolled a few people from Iraq but mostly Afghanistan.
There’s a project that starts at the time TIDOS starts and goes backwards. And that project is a case-control study of orthopedic trauma in combat. We call it the Osteo study, short for osteomyelitis. That study looks only at bone infections, and essentially what they did was take all patients that had open fractures and extremities and those that had infections. And then created a control group that had open fractures but did not get infections. And then we try to understand between the two, why did the ones get Osteomyelitis and why did the controls not?
By focusing on just that particular group, they were able to really generate a lot more power to draw granular conclusions than they are able to go with TIDOS. So even though this data is older data, I think it’s going to be every bit of important if not more important than TIDOS. And those studies are just in the final month of data entry. We will be able to say some things about those infections from this data that we won’t be able to from our TIDOS cohort.
I’ve also worked with national VA administrative data. I currently have one project that is funded by CDC which is a collaboration with some investigators at Duke University and at Washington University looking at whether the use of antibiotics in the previous year impacts the risk of infection after surgeries. Over the years I’ve also been involved in several other studies that use similar data sources which are amazingly powerful and also under-used because they can be difficult to get access to.
My projects that used administrative data started back when Dr. Eisen was here and he wrote a grant that ended up getting funded right before he left to be the Director of HSR&D in DC for the national VA, and he handed the merit over to me. I’ve spent several years working on a big data set of VA patients nationally with Rheumatoid Arthritis and how their immunosuppressant treatments influence the likeliness of infection later on. I was working with some people in other specialties, so we used the same dataset, not just look at infectious complications but also cancer complications and pulmonary complications. Through the years, that experience early on has helped me to help other investigators link into VA data and get familiar with it. Because once you have the template of how and what kind of data is available in those data sets and how to access it, there is an incredible amount of information that is under-utilized and not utilized at all.
Tell me more how your studies impact veteran health and wellbeing:
Even though we haven’t even gotten to the end points that I think will be the most important endpoints, the TIDOS project has had a huge impact already on care in the field. David Tribble, the Infectious Disease doctor at USUHS, as a part of getting funding for the project, generated a lot of interest among military operations people about the way that this data could be applied in real time and to help soldiers that are out there now.
The big break with that was that when the British pulled out of Afghanistan, they pulled out of an area called Helmand Province which people called “the Green Zone” because it has really lush vegetation, unlike the area most of the US troops have been, while is more arid. What they found after they moved in, was that they were seeing different kinds of infections after injury, then they were in the desert. In the green zone, after an IED explosion, they would see really nasty invasive fungal infections, and that was unusual because we didn’t see fungal infections in the other areas that we’d been. And so, when that happened, the military medical leadership thought “hey we’ve got this group of people who are collecting this data prospectively and might be able to look at their data and give us some advice”. So, they talked to David and the DoD side of the project put down everything for about 2 years and really focused on this cohort. What they found was, that they in fact had a large number of personnel who, after severe blast injuries, had these fungal infections and they were able to use our data to look at risk factors for fungal infection to try to help predict who would benefit from upfront more aggressive debridement surgery and also who would benefit upfront from antifungals before we even saw if there was fungus in the wound. And very early on they were able to put together treatment protocols that were adopted and used in the field that determined who would get antifungal medication early after blast injury because they were at highest risk of getting these fungal infections. Also, using that same risk factor analysis, were able to tell the surgeons “ok this is a guy who is going to need more aggressive debridement or need more frequent debridement”. A lot of these soldiers after these blast injuries will get a dozen or more surgeries to try to get rid of the infection and spare the limb so that they can eventually be fitted with prosthesis and go on to be functional in the future.
How does that work with your findings? Do they begin to use them in real time?
David would be contacted by the operations side of the military to do these analyses and then he would return to them with their findings and they would be asked to generate treatment protocols. And after we started having some preliminary findings, David and his group took the lead helping the military revise their treatment guidelines after combat trauma while keeping our findings in mind.
So, it has already had a significant effect on how medical care is delivered in the field after polytrauma.
Tell me about a dream study (a study that you have not done yet, but dream about doing)
My dream in research would be to be able to use national VA administrative data to answer whatever clinical questions I wanted, without having to worry about the funding source. There are so many things that fall below the radar of what a national funding source like the VA or the NIH is going to pay for, but which are incredibly important at an individual level to delivering healthcare. One of the things that I’ve come to realize more and more the older I get is, how much we think we know in medicine, that we don’t really know at all or that is completely wrong. And to have a huge resource like the VA national administrative data, at our fingertips that could answer all these questions is just sort of tantalizing thing.
So that would be my dream research project, to have the power to do whatever research I wanted without worrying about writing grants.
What is your advice for people thinking about a job at the VA or a job in research?
For anyone who does research, particularly clinical research, which is my area, I would say that the VA is an incredibly rich source of data and I think that is a relatively underused source of data. Because in this country our healthcare system is fragmented in such a way that it there aren’t many data sets that give you a cross section of a big geographic area, across all ethnicities, across socioeconomic lines. The VA’s national data really combines inpatient and outpatient, every state in the country, everything from the most complex tertiary care hospitals to rural hospitals, and includes an incredible number of patient years with very detailed data. So, I think for people who are interested in using that kind of data for doing research, the VA is a great place to be and I think that the VA over decades has done a great job of supporting researchers, both through its own research funding that it offers, and through supporting the infrastructure for people like us to actually do the research. I think the VA has been a really important sponsor for research in the country for decades and I think it will be for decades to come.
Check out two published articles on the study below: