Throughout two decades of significant growth and change, the Montefiore Einstein division of general internal medicine (DGIM) in the department of medicine has remained true to its original mission.
“Our goal has always been about bending the system to meet the needs of our patients, prioritizing where the greatest need is,” says Julia Arnsten, M.D., M.P.H., chief of the division since its inception in July 2004.
The DGIM was created to bring together primary-care clinicians and establish a research program with a small group of investigators studying addiction and HIV in the Bronx. It has grown into a thriving hub for clinical care, research, and education, with 75 full-time faculty and more than 50 staff members. The scope of its efforts has widened to include work on hepatitis C, COVID-19, diabetes, obesity, high blood pressure, substance-use disorders, and chronic pain—all conditions that disproportionately affect groups that have historically been marginalized.
“I don’t recall one meeting with Julia where she asked for anything for herself,” says Yaron Tomer, M.D., the Marilyn and Stanley M. Katz Dean at Einstein and chief academic officer at Montefiore Einstein. “It was always for the division, the faculty, the residents. And she pushes hard.”
As the DGIM marks its 20th anniversary, Dr. Arnsten, who is also a professor of medicine, of epidemiology & population health, and of psychiatry and behavioral sciences at Einstein, ticks off a few accomplishments with pride: a primary-care and social internal medicine residency training program; fellowship programs in addiction medicine; and diverse research activity supported by an annual budget of more than $20 million in extramural grant funding.
Julia Arnsten, M.D., M.P.H., chief of the division of general internal medicine since its inception
Matthew Akiyama, M.D., M.S., embodies the DGIM philosophy of prioritizing patients who have the greatest need. He remembers feeling excited when a new oral medication became available about a decade ago that could cure hepatitis C. As an infectious-disease fellow, he treated people who were brought from New York City jails to Bellevue Hospital. People in prisons and jails are disproportionately affected by the viral liver disease. An estimated 10% to 20% of people incarcerated in the United States are infected with hepatitis C.
But his hopes were dashed as the initial high cost of the drug put it out of reach for his patients. “Here was an area of extreme need where we had a solution, but that solution was unattainable for a lot of people,” Dr. Akiyama says. “That stark reality galvanized my interest in making healthcare access more equitable.”
Now a DGIM associate professor of medicine at Einstein and an internist and infectious-disease specialist at Montefiore, Dr. Akiyama has received global recognition for his commitment to improving the care of marginalized groups. Since joining Montefiore Einstein in 2015, he has received National Institutes of Health (NIH) grants totaling $7.4 million as the principal investigator for research focused on preventing and treating hepatitis C, HIV, and COVID-19 in populations that have historically been marginalized.
“One thing that’s unique about the division of general internal medicine is the strong focus on mentorship of junior investigators,” he says. “It’s that atmosphere of collaboration and camaraderie that helped me develop a research career.”
In the early 2000s, Montefiore and Einstein physicians and clinical researchers were treating people with conditions such as addiction and HIV, but their work lacked an academic home.
“We envisioned a grant-getting division,” recalls Victor Schuster, M.D., chair of medicine at the time. “We needed funding that could drive cutting-edge research so that we could improve the care of our patients in the Bronx. We also needed to recruit top talent.”
The natural choice to helm the new division, Dr. Schuster says, was Dr. Arnsten. She had already garnered several grants for her HIV research as well as a sizeable award from the NIH to develop a training program for clinical researchers.
Dr. Arnsten was hesitant. “I was already busy with research and clinical care, and I was pregnant, with another baby at home—there was a lot going on,” she says. But she wasn’t alone. “I partnered with Einstein’s clinical research training program,” she says. “And all these people agreed to be mentors to junior investigators.” With that support, she says, she was able to convince the NIH to renew the training grant annually for the next 15 years. “And that’s really how we built the division,” Dr. Arnsten says.
“Julia had this vision of growing junior people into senior people who would then mentor others and expand the work that is done,” says Joanna Starrels, M.D., M.S., professor of medicine and of psychiatry and behavioral sciences at Einstein and the DGIM associate chief of research, who joined the division in 2008. “And that’s exactly what happened.”
Dr. Starrels, who is also an internist and addiction-medicine physician at Montefiore Einstein, credits the growth and success of the division to two elements: community building and mentoring. “We bring people together in an intentional way to collaborate and learn from one another,” she says.
Early on, Dr. Arnsten established 90-minute weekly meetings of people with a stake in DGIM research, including those from other divisions. A few years in, the “Big Group Meeting” officially became the Research, Innovation, and Shared Expertise (RISE) group. These days RISE focuses mainly on workshopping grant applications at all stages, from developing ideas to responding to reviewer critiques, with participants getting valuable feedback.
“It’s a structured approach to mentorship that has been built into the way we think about our careers,” says Aaron Fox, M.D., M.S., professor of medicine at Einstein and an addiction-medicine physician at Montefiore. “You don’t just put your head down and do your project; you also help early-career investigators get their work off the ground.”
Julia had this vision of growing junior people into senior people who would then mentor others and expand the work that is done.
— Dr. Joanna Starrels
That shared commitment to advancement has paid off. More than 20 of the division’s junior investigators have received career-development awards from the NIH, effectively launching their professional lives as researchers.
Drs. Arnsten and Starrels also rely on their colleagues to help them with grant proposals because, in addition to being committed to their leadership duties, the two doctors are also passionate about their own research.
They were instrumental in landing $10.2 million in NIH funding to establish a multidisciplinary research center for people with both chronic pain and opioid-use disorder (OUD): the Integrative Management of Chronic Pain and OUD for Whole Recovery Research Center at Montefiore Einstein (IMPOWR-ME). Dr. Starrels directs the IMPOWR-ME center and serves as its co–primary investigator, along with Dr. Arnsten and Vilma Gabbay, M.D., adjunct professor of psychiatry and behavioral sciences and in the Dominick P. Purpura Department of Neuroscience.
One of only four such centers in the United States, IMPOWR-ME has enrolled patients in three clinical trials: one studying the impact of offering yoga and physical therapy at methadone clinics; another testing a novel strategy for starting hospitalized patients on buprenorphine to minimize symptoms of opioid withdrawal; and a third exploring the effectiveness of acceptance and commitment therapy (ACT), which promotes mindfulness, acceptance of emotions, and commitment to behavior change for people receiving buprenorphine treatment in primary care.
Until recently, Dr. Starrels points out, alleviating pain in people with OUD has been a neglected area of research. “The throughline in these studies—and really, in all the division’s research—is how to best bring effective care to people where they are.”
When Einstein magazine spoke to Dr. Arnsten, she had just returned from walking the Moses campus with a clinician-researcher whom she is recruiting to join the DGIM. She realizes that careers in academic medicine can involve dealing with bureaucracy and may not pay so well as those in private practice.
If you find the place where what’s important to you intersects with the needs of society, that’s how you build a sustainable career.
— Dr. Julia Arnsten
“But you’re doing something to feed some part of your soul,” says Dr. Arnsten. “If you find the place where what’s important to you intersects with the needs of society, that’s how you build a sustainable career.”
Looking forward, she’s most excited about the trajectories of investigators who continue to expand their research and care into new areas of community need.
To find out more about how they are reaching populations pushed to the margins of the healthcare system, we sat down with Drs. Akiyama and Fox and another DGIM investigator, Andrea Jakubowski, M.D., M.S. Here’s what they told us.
Matthew Akiyama, M.D., M.S., center, with Einstein colleagues and members of the Fortune Society team.
In June, the NIH awarded Dr. Akiyama a five-year, $6.5 million grant to study strategies for preventing and treating HIV in formerly incarcerated people. Two-thirds of people who are incarcerated meet the criteria for substance-use disorder, and many more are at risk for HIV infection. Some people may receive treatment while in jail or prison; once released, however, most face barriers to healthcare that are often insurmountable, Dr. Akiyama says.
He is collaborating with the Fortune Society and its Center for Research, Inquiry, and Social Justice, a nonprofit organization focused on helping people successfully reenter their communities after incarceration. The research team has assembled a community advisory board composed of people who have experienced incarceration, substance-use disorder, and HIV. Their lived experience and expertise will help inform the design of the study’s interventions.
Being Black, LGBT, and formerly incarcerated and having the opportunity to work with communities that I intersect with around the touchpoint of HIV is a dream come true.
— Community health advocate
Community health worker Jamile Torres, left, talks with her client, Kim Kuchler.
A key component recommended by the community advisory board is the use of a peer navigator, someone with a history of incarceration who can not only help coordinate HIV care and prevention but also help clients navigate other services, such as assistance with employment, housing, and food.
A community health advocate at the Fortune Society who contributed to the initial phase of the project says that being involved with the study was particularly gratifying. Since childhood, he says, he has been interested in medical research, but a journey through substance use and incarceration took him in a different direction. Services from the Fortune Society and other organizations helped him on his path, he says, and he was eager to give back.
“Being Black, LGBT, and formerly incarcerated and having the opportunity to work with communities that I intersect with around the touchpoint of HIV is a dream come true,” he says. Release from incarceration can feel like being cast adrift, he says. “It’s revolutionary to bring HIV intervention to those recently coming out of jail.”
In the first year of the study, Dr. Akiyama says, the Einstein and Fortune Society teams will co-develop and pilot a program locally. In years two through five, they will expand the DEST2nation model to other regions heavily affected by HIV. “One goal is to make it flexible enough to be effective in as many jurisdictions as possible,” he says.
“One of the strong focuses of research within our division is partnering with community-based organizations,” Dr. Akiyama says. “In the next five to 10 years, I hope to conduct research with increasing levels of community participation and engagement.”
Andrea Jakubowski, M.D., M.S., right, discusses her current research project with her mentor, Aaron Fox, M.D., M.S.
Dr. Fox graduated from Einstein in 2004, found his calling, and never left. “The start of my career overlapped with the establishment of the division of general internal medicine,” he says. “The social mission of the institution and the division reflected what I was looking for in medicine.”
Dr. Fox directs the Bronx Transitions Clinic, which provides a medical home to people with chronic health conditions who were recently released from incarceration. He has published several studies on how the clinic’s model can improve outcomes. Another key area of his research is focused on integrating addiction therapy into harm-reduction settings—for example, providing buprenorphine for opioid-use disorder on-site at syringe-service programs.
Last year, Dr. Fox received a five-year, $924,000 midcareer investigator award from the National Institute on Drug Abuse to conduct research and to mentor six early-stage clinical investigators about OUD, HIV, and people who have been historically marginalized.
For his study, he is collaborating with researchers at Weill Cornell Medical College and the nonprofit organization NEXT Distro to research an innovative Internet-based program that mails supplies such as syringes and the overdose-reversal drug naloxone to people lacking harm-reduction facilities in their communities. Dr. Fox and colleagues are studying whether the mail-order service can be expanded to include HIV-test kits.
Dr. Fox credits his success to the mentorship he has received at Montefiore Einstein, so he’s particularly excited to have funding to mentor others. “It’s rewarding to see your mentees have a brilliant idea and then to help them shape it into a feasible project and an effective grant application,” he says.
Ultimately, says Dr. Fox, it’s not just about publishing a paper or getting a grant, but about improving the health of patients. “DGIM research addresses social determinants of health in a real way that involves the perspectives of people with lived experience,” he says. “It has a real impact on reducing disparities, and I’m proud to be a part of it.”
As a clinician, Dr. Jakubowski, assistant professor of medicine at Einstein and an addiction-medicine physician at Montefiore, works with a harm-reduction program at OnPoint NYC, the first publicly recognized overdose-prevention center in the United States. That work led to her research interest in long-acting injectable buprenorphine.
“We have strong evidence to support the effectiveness of buprenorphine for treating opioid-use disorder as well as for reducing mortality and the transmission of HIV and hepatitis C,” Dr. Jakubowski says. And, unlike with methadone, any doctor with a license from the Drug Enforcement Agency can prescribe it, she notes. “It’s a lifesaving medication.”
Long-acting injectable buprenorphine has advantages over the daily oral formulation that people dissolve under their tongues, Dr. Jakubowski says. The weekly or monthly injections provide a consistent release of the drug into the bloodstream, reducing cravings. And the convenience can make it easier for people to stick to the drug regimen. “Although it’s been on the market since 2017, long-acting injectable buprenorphine is still reaching relatively few patients,” she says.
In December 2023, Dr. Jakubowski received a four-year, $783,000 grant from the National Institute on Drug Abuse to study ways to get the long-acting treatment to people who need it. She’ll be developing and testing strategies to deliver the drug in a primary-care clinic and at OnPoint NYC.
The goal is to use everything the researchers learn, including feedback from patients, staff, and providers, to create a road map for other organizations. “We’d like to be able to scale this up across a network of primary-care or harm-reduction clinics,” she says. “That’s what I’m really excited about.”
Dr. Jakubowski says that she couldn’t have gotten to this point without the support of the RISE group, and particularly the mentorship of Dr. Fox. “He has been there every step of the way,” she says. “He must have read my grant a thousand times before I submitted it.
“The DGIM is an amazing environment that tries to lift up everyone, especially early-stage investigators like me,” she continues. “I feel incredibly lucky to be here.”
