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Emergency Medicine, Health Policy, Patient Care

Improving patient satisfaction and turn-around time in an emergency department

Improving patient satisfaction and turn-around time in an emergency department

Emergency Room SignWhat could a manufacturing philosophy concocted by a car maker have to offer a beleaguered emergency department staff? More than you would expect.

“Lean manufacturing” is a method used in the 1960s and 1970s by Toyota to improve quality on its assembly lines. The idea was to empower all the workers to have the authority and confidence to stop the line and address quality and efficiency issues. In the decades since, it’s made its way to other industries beyond manufacturing, including software development.

When Amir Dan Rubin, MHSA, MBA, came on board four years ago as president and CEO of Stanford Hospitals and Clinics, he brought the lean management mentality with him.

Marlena Kane, MPH, executive director for performance excellence & medicine services at Stanford Hospital described the process as “looking at things from the patient’s perspective and getting people to talk to each other.”

The hospital’s emergency department implemented the lean methodology, and a year later, wait times dropped dramatically and patient satisfaction shot up. Kane, along with David Pickham, PhD, director of research at Stanford Hospital, and their colleagues reported their experience in a paper in the Journal of Nursing Administration last month. And Rubin spoke about the changes they’ve implemented at this year’s Medicine X conference.

The median length of stay in the ED fell by 17 percent, despite a 7 percent increase in patients. And there was virtually no increase in the cost of running the department. “We all want the same thing, to take care of patients well,” Kane said.

The main change the department made was to teach front-line staff to solve problems as they cropped up. Those front-line staffers were able to have discussions with other groups when they noticed inefficiencies or slow-downs. This required several teams to work together to find solutions – from nurses and residents to transporters, housekeepers and translator services.

Training the teams on the new approach was no small feat. For the day-long trainings, additional staff had to be called in to back-fill staff members who would be away from the emergency department.

She pointed out that the lean approach has to have leadership buy-in and commitment to work. “You have to start with the executive team,” she said. “They have to be invested and give time to let staff do it. It can’t be grass roots.” When the lean approach fails at an organization, it’s often because the leadership team isn’t fully invested in the process.

Kane noted that handing the power to solve problems to front-liners frees up leadership staff to tackle long-term problems. “If we keep solving problems for our teams, they won’t be empowered,” she said. “We are always fire-fighting, not thinking strategically.”

Previously: Speed it up: Two programs help reduce length of stay for emergency-room visitorsStanford’s “time banking” program helps emergency room physicians avoid burnout, and An emergency medicine physician’s take on honoring your emotions
Photo by KOMUnews

Medical Education, Medical Schools, Medicine and Literature, Stanford News

Tiger mother, tiger cub: A Stanford doctor reflects on his upbringing

Tiger mother, tiger cub: A Stanford doctor reflects on his upbringing

Tiger Child Pic JAMA PedsWhen Amy Chua’s book, “Battle Hymn of the Tiger Mother” was published in 2011, Jason Nagata, MD, was in medical school at the University of California, San Francisco. He caught on to the humor (which escaped some of the book’s reviewers), and the anecdotes resonated with him – reminding him of his own strict and intense upbringing. “It was very funny and very controversial,” he said. “A lot of that book stuck with me from the child’s perspective.” He started to share some of those memories with people around him and found that his fellow med school students had similar stories, too. He wrote about his experiences as a “tiger child” in a funny and touching essay (subscription required) published online today in JAMA Pediatrics.

When I connected with Nagata, we spoke over Skype because he was working in Ecuador as part of his global health residency. He noted that despite the negative press Chua’s book received, he believes that strict childhood training helped prepare him for medical school. “The tiger mentality is prevalent throughout medicine,” he said. “It was intense as a child, but it prepared me well for medical training – the hours and the intensity.”

But Nagata had to learn the hard way to make room in his schedule for rest. After a particularly intense time during medical school, he developed an ulcer that landed him in the hospital. His recovery took more than a month. He explored writing as a way to reflect and think through his experiences as a student and later as a doctor. When he came to Stanford, he attended the Medicine and the Muse writing workshops to hone his writing chops. His current essay is just the latest in a series.

Although he makes time for rest, he still has plenty of drive and intensity. He mentioned that he was planning a trip to the Galápagos Islands and to hike Mount Chimborazo, the highest mountain in Ecuador, the weekend after we spoke. After he completes his residency at Stanford, he’ll start a three year fellowship in adolescent and young adult health in July 2016.

Nagata describes his own mother’s unusual path from NICU nurse to graduate student in chaplaincy. “She exemplified the tiger mom and probably works even harder than I do,” he said. “I got a lot of my habits from her.” She doesn’t demand as much from Nagata these days, but her Tiger mom spark isn’t completely gone. When he told his mother about the upcoming essay, she quipped that she was planning to write a rebuttal to JAMA Pediatrics “in her own tiger mother vein,” he said.

Previously: For group of Stanford doctors, writing helps them “make sense” of their experiences
Photo of Jason Nagata as child, courtesy of Jason Nagata

Bioengineering, Cancer, Infectious Disease, Precision health, Research, Stanford News

Stanford scientists co-opt viral machinery to create medical delivery system

Stanford scientists co-opt viral machinery to create medical delivery system

James Swartz

Stanford engineering researcher James Swartz, PhD, and his colleagues have remodeled a hepatitis B virus to turn it into a microscopic taxi for medical therapies. The team stripped the virus of its pathogenic DNA and modified an outer shell so that they could “hang” molecular tags on the outside to help deliver vaccines or other therapies to specific cells. The researchers reported their findings in a paper in the scientific journal Proceedings of the National Academy this week.

They call the engineered product a virus-like particle (as opposed to a real virus with infectious material) or a smart particle. “We make it smart by adding molecular tags that act like addresses to send the therapeutic payload where we want it to go,” Swartz said in a Stanford News story.

The smart particle is a novel way to deliver vaccines or cancer therapies by teaching the body’s immune cells to recognize pathogens or cancer cells. Alternatively, the smart particle can deliver medicine specifically to the cells that need it.

Swartz and his colleagues’ effort is part of a larger field of targeted therapies that aims to precisely deliver therapies to the cells that need them and avoid damaging nearby healthy cells. Current cancer therapies, for example, are effective at fighting malignant cells, but also kill off healthy cells. That’s why cancer therapies often have such devastating side effects. But previous attempts to create virus-sized delivery systems have not been successful. In fact, Swartz’s team had a hard time getting funding for the early stages of this project because of previous failed efforts by other scientists.

So far, Swartz and colleagues have created the self-assembling shell that is invisible to the body’s natural immune defenses and strong enough to weather conditions in the blood stream and get its packaged contents to its destination inside the body. Next, they’ll work on putting specific cancer-fighting tags on the shell.

The most challenging task will be to pack the shell with a tiny dose of medicine. But Swartz sounded optimistic about his team’s goals. “I believe we can use this smart particle to deliver cancer-fighting immunotherapies that will have minimal side effects,” he said.

Previously: A less toxic, targeted therapy for childhood brain cancerIs cancer too complex for targeted therapies? and Working to create a universal flu vaccine
Photo, of Swartz holding an enlarged replica of a virus-like particle, by Linda Rice

Addiction, Anesthesiology, Chronic Disease, Pain, Stanford News, Videos

“People are looking for better answers”: A conversation about chronic pain

"People are looking for better answers": A conversation about chronic pain

2048px-Low_back_painChronic pain limits the lives of an estimated 100 million people in one way or another and costs our country half a trillion dollars per year, according to Sean Mackey, MD, PhD, chief of the Division of Pain Medicine. To address the needs of the many people suffering from back pain, the most common kind of chronic pain, Mackey and other doctors and researchers in the division recently held a free Back Pain Education Day.

The event was popular enough that all seats were filled more than a week ahead of time, and a video stream of the day’s speakers was viewed by almost 1,500 people during the conference and in the week following. Recordings of the day’s talks can now be viewed on the Division of Pain’s YouTube channel.

We don’t have a cure for chronic pain. What we have are exceptional ways [to help] people get back their lives

During a recent conversation, Mackey told me the big turn-out reflects the keen interest people living with back pain have in finding solutions. “People are looking for better answers: why they have what they have and what they can do about it,” he said. “We wanted to provide them with real-world tools that they can use to control their pain.”

Speakers at the event covered varied ground, including physical therapy approaches to pain management, new research in using acupuncture to treat pain, self-management strategies, mindfulness-based pain reduction and the important role of sleep in pain. (Recent research has shown that poor sleep can intensify and prolong pain.) One over-riding theme was the role of the brain, Mackey said, not just in terms how people experience pain, but also how it can help turn down or turn up pain.

Mackey cautions that a quick fix often isn’t possible, so people living with chronic pain need to think about long-term management. “It’s a chronic disease, like diabetes. We don’t have cures for diabetes, and we don’t have a cure for chronic pain,” he said. “What we have are exceptional ways to control the disease and ways [to help] people get back their lives.” Speaker Beth Darnall, PhD, the event co-chair, emphasized that pain psychology techniques can empower people to lessen distress and pain, and begin moving toward meaningful life goals.

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Chronic Disease, Health and Fitness, In the News, Nutrition, Obesity, Stanford News

A conversation about the diabetes epidemic

A conversation about the diabetes epidemic

On this morning’s KQED’s morning radio show, Forum, several doctors including Stanford’s Bryant Lin, MD, discussed how diabetes is affecting the health of millions of people globally.

A recent study in the Journal of the American Medical Association estimated that about half of all adults have diabetes (diagnosed or undiagnosed) or pre-diabetes. Lin and his fellow panelists talked about how changes in our diet and lifestyle have fueled the number of diabetic cases, as well as how genetics can tip the odds against certain patients. Lin mentioned that Asians have a higher rate of diabetes than whites, for example.

Like Lin, I have a family history of diabetes. (Like Lin, I’ve also struggled to maintain my weight). That history has made me keenly interested in staying abreast of recent findings about diabetes – and I surprised to hear that among young people, high rates of liquor consumption is influencing diabetes rates. It’s not just soda intake that we have to watch out for.

Another surprising finding that Lin described was that for pre-diabetics, taking Metformin, a drug that helps control diabetes and blood sugar, can help stave off full-blown diabetes. Eventually, it may become routine to prescribe this medication in certain populations, but Lin said that guidelines haven’t caught up with this aspect of diabetes care.

Other factors at play, Lin noted, include the role of the microbiome in promoting or protecting people from diabetes. And people who undergo bariatric surgery for weight management often find their diabetes is cured, but doctors don’t understand exactly why that’s the case.

Despite the staggering number of people affected, it’s clear that we still don’t understand all the complex factors that influence this disease.

Previously: Faulty fat cells may help explain how Type 2 diabetes beginsThe role of nutrition in diabetes prevention and managementThe importance of regular exercise in delaying and treating diabetes and Examining the role of exercise in managing and preventing diabetes

Aging, In the News, Infectious Disease, Public Health, Research

Does the flu vaccine really help the elderly?

EM_of_influenza_virusMost years, senior citizens are among the groups hit hardest by flu, which is why doctors recommend all people over 65 get vaccinated. But accurately measuring how well the vaccine does at preventing severe disease and deaths isn’t as straightforward as it is in younger populations.

A lot of factors complicate getting accurate information on the number of flu cases among older adults and the vaccine’s role at preventing them, and some have argued that current estimates of the flu vaccine’s effectiveness are overblown because they don’t account for such factors. For example, sometimes patients are left unvaccinated because they are already medically frail and struggling with a lot of other health issues. So simply counting the number of deaths among unvaccinated patients versus vaccinated patients might not paint an accurate picture.

Last month, a study led by Vincent Mor, PhD, of Brown University, looked a little closer at the vaccine to assess its effectiveness. The research team analyzed 10 years of Medicare claims for nursing home residents, taking advantage of a built-in variation.

Because the flu virus changes over time, the vaccine has to be updated every year to fight against the strains that are circulating that year. Some years, the vaccine matches what’s circulating better than other years. (Last year, in the 2014-2015 season, the vaccine strain didn’t match the flu viruses infecting people very well.)

If the vaccine isn’t effective in elderly patients, then we shouldn’t see any difference in flu cases from year to year. But Mor and his colleagues found that the better the vaccine strain matched the circulating viruses, the better the vaccine was at protecting elderly nursing home residents. They argue that this indicates that the vaccine protects people living in nursing homes from serious outcomes associated with influenza infection.

This isn’t an approach we can take with other types of vaccines. It’s only possible because the flu vaccine changes from year to year. “What we’ve used is the randomness of the match,” Mor said in a statement. “Ours is the first study to, we think, come up with an unbiased approach.”

Though this study probably won’t settle the controversy about how well the vaccine works in older people, it does offer a different way to look at the question. A variety of other novel approaches are probably what it will take to get a handle on this hard-to-understand aspect of influenza.

Previously: Science Friday-style podcast explains work toward a universal flu vaccine, Study: Pregnancy causes surprising changes in how the immune system responds to the flu and Gut bacteria may influence effectiveness of flu vaccine
Photo by Cynthia Goldsmith

Chronic Disease, Events, Pain, Stanford News

Stanford expert on back pain: “The important thing for people to know is that it’s treatable”

BackPainSeptember is Pain Awareness Month and later this month, Stanford will host a Free Back Pain Education Day. The event, sponsored by the Division of Pain Medicine, offers community members the opportunity to come to campus and hear about current back pain management strategies and the latest research. The event will also be live-streamed via YouTube for people unable to make it in person.

In anticipation of the Sept. 13 event, I sat down with Beth Darnall, PhD, a pain psychologist at Stanford’s Pain Management Center, and one of the day’s speakers. I was interested to understand why back pain is such a critical health problem worldwide and what people living with back pain can do to manage their pain.

Back pain is a leading cause of disability in the U.S. and other countries. Why is chronic back pain so common?

I think there are many different reasons why back pain is the number one pain condition. The back seems to be the place that’s really most related to the development of chronic pain and debility from chronic pain. Pregnancy can either trigger or flare back pain, but there are a multitude of reasons: aging (there is degeneration of the spine), obesity (when people gain weight, it puts additional load on the spine), activity levels, and influence of posture. Dr. Sean Mackey will be talking about some of the reasons why back pain is the most prevalent pain condition in the world at the event.

[Back pain] is something that almost everyone will experience at some point in their lifetimes, so it’s really relevant to all of us, whether we have pain now or not.

Why have a community event about back pain now?

There has been increasing global and national attention to chronic pain in terms of its impacts and costs to society. In the United States alone, 100 million suffer from pain on a regular basis, and that is associated with costs of $635 billion dollars annually. That includes treatment costs and loss of productivity.

What we also know is that the incidence and prevalence of chronic pain has been increasing, despite the fact that theoretically, we have better treatments. So then the question is why. While we have a multitude of treatments available, we haven’t been focusing on back pain as comprehensively as we really should. We need a broader approach to the treatment of pain. This was recently outlined in the National Institute of Health’s National Pain Strategy (Note: Mackey co-chaired the oversight committee).

Some people may be under the misconception that the best way to treat back pain is simply with a pill… While medication can be one helpful component, the best way to treat back pain is with a comprehensive approach that involves self-management strategies.

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Addiction, Aging, Chronic Disease, Pain

National survey reveals extent of Americans living with pain

National survey reveals extent of Americans living with pain


Yesterday, the NIH announced a new analysis of data that examined how much pain people in America suffer. The findings, published in The Journal of Pain, were based on data from the 2012 National Health Interview Survey (NHIS), an annual survey that asks a random sample of U.S. residents a wide variety of questions about their health.

The survey results are staggering: More than half of the adults in the country (126 million) had some kind of pain, minor to severe, in the three months before the survey. About 25 million had pain every day for that time frame and about 40 million suffer from severe pain. Those with the worst pain were also most likely to have worse health in general, use more health services and have more disabilities.

The survey also looked at complementary medicine approaches people take to dealing with their pain. Natural dietary supplements topped the list, followed by deep breathing and physical exercise such as yoga, tai chi or qi gong.

Joseph Briggs, director of the National Center for Complementary and Integrative Health was quoted in an article about the new study in the Washington Post:

The number of people who suffer from severe and lasting pain is striking. . . This analysis adds valuable new scope to our understanding of pain … It may help shape future research, development and targeting of effective pain interventions, including complementary health approaches.

Another topic the WaPo article touched on, which we’ve written about here at Scope, is the link between chronic pain and prescription painkiller abuse:

The prevalence of chronic pain in America also lies at the root of an ongoing epidemic of prescription painkiller abuse. Since 1999, according to the Centers for Disease Control and Prevention, the amount of painkillers such as oxycodone and hydrocodone sold in the United States has nearly quadrupled.

Here at Stanford, the Division of Pain Medicine is sponsoring a free back pain education day on Saturday September 13. You can find out more details here.

Previously: Assessing the opioid overdose epidemicChronic pain: Getting your head around itFinding relief from lower back pain and Stanford researchers address the complexities of chronic pain
Photo by Steven Depolo

Behavioral Science, Genetics, Neuroscience

Wishing for a genetic zodiac sign: How much can genes really tell us about personality?

Wishing for a genetic zodiac sign: How much can genes really tell us about personality?

Brain MRIGiven all the recent news on how gene expression influences our brain, from Alzheimer’s to addiction and even our personalities, readers might come away thinking that we’re close to breaking the code and using genetics to understand why we behave the way we do. But, things aren’t that simple.

In a post on the science blog Last Word on Nothing, Eric Vance explores what getting your personal genetic sequence means for your personality – something he calls, tongue-in-cheek, “a genetic tarot card.”

Vance delves into an explanation of one specific mutation in the COMT gene. The gene creates an enzyme that neutralizes dopamine, a neurotransmitter. The gene comes in two forms, and the difference in these two forms is just one base-pair, the individual links in our DNA code. One version of the resulting enzyme is efficient at clearing away extra dopamine. But if the gene codes for the other version, “then the enzyme becomes a wastrel… Work piles up and the brain accumulates a bunch of extra dopamine.”

Because dopamine is such a powerful regulator of mood, and by extension personality, Vance then describes, in surprising detail, personality types he expects people with either version of the gene to have. But genetic information like this is meant to be used at the population, not personal, level. In fact, none of the people in his circle of friends who have had their genome sequenced turns out to be who he expects them to be (which begs the question, how many people does he know who’ve had their DNA sequenced?). Disappointed, he laments:

But that’s not how I want it work. While I don’t like the idea of boiling human emotions down to a couple squishy turning gears, I do like how tidy it is. I want to be able to look up my genome and make broad generalizations about myself. I want to have a genetic tarot card that I can inspect and say “ohhh, that’s why I always forget people’s names” or “that’s why I got in that fight in the third grade.”

Vance concludes, “But that’s not what nature gave us. Nature has given us messy, confusing and vastly complicated brains.” We are more, it turns out, than the sum of our base pairs.

Previously: New research sheds light on connection between dopamine and depression symptoms

Photo by deradrian

Aging, Ask Stanford Med, Chronic Disease, Neuroscience, Women's Health

Exploring Alzheimer’s toll on women

Exploring Alzheimer’s toll on women

Julianne Moore AlzheimersIn last year’s “Still Alice,” Julianne Moore’s portrays a woman beset by early-onset Alzheimer’s Disease. It’s fitting that the academy-award winning film (Moore garnered a Best Actress award for her role) about Alzheimer’s features a woman as the central character because the illness disproportionately affects women.

The BeWell@Stanford blog recently featured a Q&A with Stanford neurologist and Alzheimer’s researcher Michael Greicius, MD, MPH about Alzheimer’s and women. The piece covers the effects of the disease, but I was intrigued to read about the challenges for caregivers of people with the disease (who are also disproportionately women):

Most of the caregivers of people with Alzheimer’s Disease are women. Do you have any advice for them in terms of how they can take care of themselves while taking care of a loved one with the disease?

This gets to the damned-if-you-do, damned-if-you-don’t aspect of AD and women. On the one hand, women are more likely to develop AD; on the other hand, they are also more likely to find themselves as the primary caregiver for someone with AD. It is now well known that caring for someone with AD has a powerful, negative impact on physical and emotional well-being. Particularly as the disease progresses and patients require more care, there is a large physical toll taken when, for example, having to lift patients out of a chair or off the toilet or out of bed. Sleep becomes fractured for the patient. which means it becomes fractured for the caregiver.

Some of the questions also dealt with the fact that despite the recent advances in Alzheimer’s research, we still don’t completely understand how the disease works or how it can be prevented:

What can we do to reduce our risk for developing the disease?

We do not know of anything that definitely reduces a person’s risk of developing Alzheimer’s, although there is strong data to suggest that regular aerobic exercise and a heart-smart diet will reduce risk. Head trauma is an important risk factor for AD and another type of dementia, so minimizing exposure to head trauma can also reduce risk of AD. Numerous companies make explicit or implicit claims about their “nutraceutical” or vitamin or “brain-training” software being able to stave off AD. None of these claims are true and most, if not all, of these purveyors are modern-day snake-oil salesmen and saleswomen.

But Greicius is optimistic and pointed out that Stanford recently became an NIH-sponsored Alzheimer’s Disease Research Center, which means we can build upon Stanford’s past “ground-breaking Alzheimer’s research.”

Previously: Are iron, and the scavenger cells that eat it, critical links to Alzheimer’s?Alzheimer’s forum with Rep. Jackie Speier spurs conversation, activismScience Friday explores women’s heightened risk for Alzheimer’s and The toll of Alzheimer’s on caretakers
Photo by Maria Morri

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