When it comes to diagnosing disease and choosing a course of treatment, gender is a significant factor. In a Stanford BeWell Q&A, Marcia Stefanick, PhD, a professor of medicine at the Stanford Prevention Research Center and co-director of the Stanford Women & Sex Differences in Medicine Center, discusses why gender medicine research benefits both sexes and why physicians need to do a better job of taking sex difference into consideration when make medical decisions.

Below Stefanick explains why a lack of understanding about the different clinical manifestations of prevalent diseases in women and men can lead to health disparities:

…Because we may have primarily studied a particular disease in only one of the sexes, usually males (and most basic research is done in male rodents), the resulting treatments are most often based on that one sex’s physiology. Such treatments in the other sex might not be appropriate. One example is sleep medication. Ambien is the prescription medicine recently featured on the TV show, 60 Minutes. Reporters found out that women were getting twice the dose they should because they had been given the men’s doses; consequently, the women were falling asleep at the wheel and having accidents. Physicians had not taken into account that women are smaller and their livers’ metabolize drugs differently than do men’s. Some women have responded by reducing their own medication dosages, and yet that practice of self-adjusting is not the safest way to proceed, either.

Previously: A call to advance research on women’s health issues, Exploring sex differences in the brain and Women underrepresented in heart studies
Photo by Mary Anne Enriquez

One in four adults in the United States has two or more chronic conditions, according to the latest data from the Centers for Disease Control and Prevention. And, findings published in the August issue of Medical Care show that the burden of multiple chronic diseases could explain why life expectancy increases among elderly Americans are slowing.

In the study (subscription required), researchers at Johns Hopkins Bloomberg School of Public Health analyzed a nationally representative sample of 1.4 million Medicare beneficiaries. According to a release:

The analysis found that, on average, a 75-year-old American woman with no chronic conditions will live 17.3 additional years (that’s to more than 92 years old). But a 75-year-old woman with five chronic conditions will only live, on average, to the age of 87, and a 75-year-old woman with 10 or more chronic conditions will only live to the age of 80. Women continue to live longer than men, while white people live longer than black people.

It’s not just how many diseases you have, but also what disease that matters. At 67, an individual with heart disease is estimated to live an additional 21.2 years on average, while someone diagnosed with Alzheimer’s disease is only expected to live 12 additional years.

On average, life expectancy is reduced by 1.8 years with each additional chronic condition, the researchers found. But while the first disease shaves off just a fraction of a year off life expectancy for older people, the impact grows as the diseases add up.

Previously: Americans are living longer, but are we healthier in our golden years?, Longevity gene tied to nerve stem cell regeneration, say Stanford researchers, Study shows regular physical activity, even modest amounts, can add years to your life and TED Talk with Laura Carstensen shows older adults have an edge on happiness
Photo by Marcel Oosterwijk

A few nights after the recent plane crash in Ukraine, I ran into an acquaintance who was heading to Europe later in the week. “It feels weird to fly,” she told me, comparing it to how she felt about boarding a plane for the first time after the 9/11 attacks 13 years ago. I could relate: During my first post-9/11 flight, I was jittery and uneasy the entire way from San Francisco to Minneapolis. (It didn’t help that I was flying alone, in the darkened cabin of a red-eye.)

If plane crashes and tragedies like the one in Ukraine can leave passengers feeling unsettled (or worse), how might they affect people who take to the skies on an almost daily basis? In a piece on The Atlantic yesterday, writer Rebecca Rosen reported on the work of Jeffrey M. Lating, PhD, a professor of psychology at Loyola University Maryland who has studied this issue. Rosen writes:

For flight attendants who worked at American Airlines on 9/11, the rates [of PTSD] were… just over 18 percent. This number is so high, Lating says, it is comparable to the rates seen among people living south of Canal Street in Manhattan, the neighborhoods closest to Ground Zero.

Lating and his colleagues found no statistical difference in probable PTSD rates between West Coast flight attendants and East Coasters, who were much more likely to have known the flight attendants killed on 9/11. For flight attendants, it seems that the trauma they experience following a crash comes not only from the loss and tragedy itself, but also from a deep sense of vulnerability. A follow-up study in 2006 found similarly high rates of probable PTSD at another airline, further suggesting that “it didn’t matter what airline you worked for,” says Lating. “The virulent factor in this was, ‘I wonder if I could possibly be next.’ ”

…

Those fears can make just doing one’s job as a flight attendant incredibly challenging. Many suffering from PTSD try to avoid sights and triggers that recall the initial trauma. But for flight attendants, those reminders are unavoidable, part of the work itself. To have to work through that anxiety, all the while servicing others and maintaining a sense of calm on a flight— “you could imagine how uncomfortable that would be,” Lating say

Previously: 9/11: Grieving in the age of social media and What 9/11 has taught us about PTSD
Photo by epsos.de

Given the topic of today’s SMS-Unplugged entry, during which Moises Humberto Gallegos discusses how things like housing insecurity and financial hardship can contribute to poor health, I was interested to come across this Covering Health quiz on the social determinants of health. Writer Joe Rojas-Burke asks 10 true-or-false questions, and I think some of the answers may surprise you. For example:

Expanding health insurance coverage and access to medical care (the focus of the federal Affordable Care Act) is unlikely to reverse the health disparities caused by the social determinants of health.

TRUE: In countries that established universal health coverage decades ago, lower social status still correlates with worse health and shorter lives. The research on social determinants suggests that progress is likely to require broader social changes, such as improving access to education, boosting economic opportunity and making disadvantaged neighborhoods safer and and more vital.

And:

Food deserts – neighborhoods with few or no grocery stores selling fresh, affordable produce – are a well-defined root cause of obesity and other health problems in disadvantaged communities.

FALSE: There is evidence showing that low-income and minority Americans are more likely to live in food deserts. But it’s not at all clear to what extent the lack of supermarkets and grocery stores contributes to obesity or other health outcomes.

Previously: In medicine, showing empathy isn’t enough, Should the lack of access to good food be blamed for America’s poor eating habits? and Hopkins researchers find place, rather than race, may be greater determinant of health

Last week, we blogged about a Navy pilot whose mysterious symptoms were diagnosed by clinicians here. A just-published Stanford Hospital video shares more of Robert Buchanan’s compelling story.

Previously: Medical mystery solved: Stanford clinicians identify source of Navy pilot’s puzzling symptoms

SMS (“Stanford Medical School”) Unplugged was recently launched as a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.

As a medical student, it’s difficult to face a situation where everything possible is done for a patient, yet due to circumstances (seemingly) beyond our control, the risk of future harm remains uncomfortably certain. The majority of our medical school learning focuses on how to cure illness; unfortunately we’re not always taught how to deal with the real-world issues that face our patients and that threaten the medicine we practice.

This month I’ve been on my neurology rotation at Santa Clara Valley Medical Center, a county hospital with patient demographics quite different from those seen at Stanford Hospital. As I serve a more diverse and disadvantaged socio-economic population, it’s often the case that the information in the patient’s “Social History” section, which I usually quickly pass over, becomes a defining piece in deciding next steps. The 20-something-year-old with daily seizures because he’s so high on methamphetamine that he forgets to take his pills, the 40-year-old with left-sided paralysis who keeps checking in to the emergency department because she feels unsafe living alone in a trailer park, the 60-year-old who didn’t present to the hospital until days after suffering a stroke because he couldn’t physically get to the door to call for help: These patients demonstrate how social situations can make efforts to provide medical care at times seem futile.

In medical school, we’re taught the pathophysiology of disease and systematic approaches to medical management, but not how to deal with social contributors to health. (The latter is a not-so-glamorous aspect of medicine relegated to the hidden curriculum of clerkships.) During pre-clinical years we spend a lot of time discussing how to make empathy a part of our clinical skill-set, but a pitfall to practicing medicine in a way that is sensitive to a patient’s social context is the belief that showing empathy is enough. To express concern for a patient is different from really understanding a patient’s challenges. Things like the fear that drives a patient to repeatedly present to the emergency room for “inappropriate” reasons and the thought process behind not getting an MRI done since it would mean missing work may not fit traditional logic, but they represent an important piece in delivering care.

What can’t be taught in school is an inherent understanding of the difficulties that some patients face, which is why the push for future physicians to be individuals representative of the various backgrounds that patients come from is so important. (It can be surmised that students who have endured these difficulties, themselves or through family, socio-economic or health related, could better relate to patients they come in contact with.) While socio-economic demographics are easily seen on paper, though, what is harder to select for and recruit is the student who has lived the real-world environment characterized by social issues like multiplicity of chronic illness, housing insecurity, and financial hardship. And, of course, many students in this very position never make it to the point of training for a health profession as a result of the very hardships that make them more attune to the social issues that may contribute to poor health.

Medical school recruitment has changed in ways that will hopefully improve diversity of recruited students and contribute to a greater understanding of the background of all sorts of patients among health-care providers. However, more still needs to be done to support students from less-traditional and under-represented backgrounds so they reach the point of applying in the first place. Instead of being discouraged by their less-than-ideal journeys to medical school, students who have endured educational, financial, and social hurdles should be encouraged to use their learned experiences as a frame of reference to positively impact the delivery of health care.

Moises Gallegos is a medical student in between his third and fourth year. He’ll be going into emergency medicine, and he’s interested in public-health topics such as health education, health promotion and global health.

Drawing by Moises Gallegos

Many of us, myself included, use the weekends to pay off the sleep debt we accrued during the work week. However, excessive sleeping can often leave us feeling more fatigued. A piece published today on Wired Science examines this phenomenon and discusses why clocking extra hours of shut-eye doesn’t necessarily benefit our health. Nick Stockton writes:

Oversleeping feels so much like a hangover that scientists call it sleep drunkenness. But, unlike the brute force neurological damage caused by alcohol, your misguided attempt to stock up on rest makes you feel sluggish by confusing the part of your brain that controls your body’s daily cycle.

Your internal rhythms are set by your circadian pacemaker, a group of cells clustered in the hypothalamus, a primitive little part of the brain that also controls hunger, thirst, and sweat. Primarily triggered by light signals from your eye, the pacemaker figures out when it’s morning and sends out chemical messages keeping the rest of the cells in your body on the same clock.

Scientists believe that the pacemaker evolved to tell the cells in our bodies how to regulate their energy on a daily basis. When you sleep too much, you’re throwing off that biological clock, and it starts telling the cells a different story than what they’re actually experiencing, inducing a sense of fatigue. You might be crawling out of bed at 11am, but your cells started using their energy cycle at seven. This is similar to how jet lag works.

The article goes on to explain that past research has shown that, “If you’re oversleeping on the regular, you could be putting yourself at risk for diabetes, heart disease, and obesity.”

Previously: The high price of interrupted sleep on your health, Examining how sleep quality and duration affect cognitive function as we age, What are the consequences of sleep deprivation? and BBC study: Oh, what a difference an hour of sleep makes
Photo by Stephen Poff

There is currently no U.S. Surgeon General. Like everything else in Washington today, a confirmation vote by the U.S. Senate on President Obama’s choice, Harvard physician Vivek Murthy, MD, has been squashed by politics. Last spring, White House press secretary Jay Carney said that the administration was “recalibrating and assessing our strategy on moving forward with the nominee.” In March, The Hill newspaper reported that up to 10 Senate Democrats signaled they would oppose Murthy’s confirmation after the National Rifle Association made it clear Murthy’s support for bans of certain types of firearms and ammunition purchases made him an unthinkable choice.

Now if you’ve forgotten there even is a position called the U.S. Surgeon General post, think C. Everett Koop, MD, or Joycelyn Elders, MD. Koop and Elders were two recent appointees who used their bully pulpit to raise a national discussion about AIDS and teen pregnancy. (Both were  lightening rods within their respective administrations – Koop in Reagan’s and Elders in Clinton’s. Elders was eventually dismissed by the White House after wading into too many contentious issues.)

Does the position even matter anymore? Associated Press medical reporter Mike Stobbe thinks it does. He’s written a fascinating book (Surgeon General’s Warning, University of California Press) about the history of the position and those who served. The book explains how the surgeon general became the most powerful and influential public health officer in the country and how those powers were later stripped away. An excerpt from Stobbe’s book appears in the current issue of Stanford Medicine magazine, where he catalogs the ups and downs of the individuals who held the position. The strong ones and the weak ones. Those who made a difference and those who faded away in controversy or without making a mark on the nation’s public health dialogue.

He writes, “Surgeon generals have played that crusader role better and more often than any other national public health figure. Absent such a crusader, the public’s health is prey to the misinformation and self-interest of tobacco companies, snake-oil salesmen and other malefactors.” Listen to my 1:2:1 podcast with Stobbe to hear more of his thoughts.

Illustration, which originally appeared in Stanford Medicine, by Tina Berning

In case you missed it, the San Francisco Chronicle ran a story over the weekend on migraines – and researchers’ ongoing search for a cause and universal treatment. Robert Cowan, MD, director of the Stanford Headache Clinic, was one of the people featured and told writer Stephanie M. Lee:

Headache care is 50 years behind things like diabetes and cancer… It just hasn’t had the attention, hasn’t had the funding, in order to get to the answers we need.

Previously: Director of Stanford Headache Clinic answers your questions on migraines and headache disorders and New Stanford headache clinic taking an interdisciplinary approach to brain pain

Prior to becoming a mom, I felt fully confident that caring for a newborn would be less demanding than, or at least equal to, the physically grueling trainings from my college soccer days or my sleepless year of graduate school. But I soon learned that both of these experiences paled in comparison to the exhaustion I encountered after the arrival of my 8-pound-plus bundle of joy. So I was interested to read a recent Huffington Post blog entry from the Stanford Center for Sleep Sciences and Medicine examining how mothers in other countries cope with postpartum sleep deprivation.

In the entry, Mara Cvejic, MD, a neurologist at the University of Florida and former sleep medicine fellow at Stanford, notes that although sleep deprivation can profoundly affect cognitive function and mood, the brain of a postpartum mom is actually growing. She writes:

… despite all the formidable evidence of sleep deprivation in the everyday person, the scientific evidence of what happens to the postpartum brain is positively astounding — it thrives. A study published by the National Institutes of Health in 2010 actually shows that a mother’s brain grows from just 2-4 weeks to 3-4 months post delivery without any significant learning activities. The gray matter of the parietal lobe, pre-frontal cortex, hypothalamus, substantia nigra, and amygdala all form new connections and enlarge to a small degree. The imaging study confirms what animal studies have shown in the past — that these brain regions responsible for complex emotional judgment and decision-making actually bulk up with use. Rationale to the study shows that mothers who have positive interactions with their offspring — soothing, nurturing, feeding, and caring for them — are performing a mental exercise of sorts. Their learned coping skills in the face of novel child-rearing actually muscularize their brain.

She goes on to outline how new moms from Bulgaria to Sweden, and everywhere in between, turn to “hammocks, spa treatments, hired help, warm foods, arctic cradles, and cardboard” to cope with a lack of sleep. Personally, I’m in favor of Americans adopting this Malaysian tradition:

Food and warmth are also a focus of the Malaysian confinement of pantang. Steeped in the belief that the women’s life force is her fertile womb, she undergoes a 44-day period of internment to focus on relaxation, hot stone massage, lulur (full body exfoliation), herbal baths, and hot compresses. Typically a bidan, what can only be described as a live-in midwife and nanny combined, is hired to attend on the new mother. This is sometimes a family member, such as her mother or mother-in-law.

Previously: The high price of interrupted sleep on your health, What are the consequences of sleep deprivation? and Study: Parents may not be as sleep-deprived as they think
Photo by sean dreilinger