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Health Policy, Research, Stanford News

Exploring the link between patient-record fees and doctor switching

Exploring the link between patient-record fees and doctor switching

HCCH-medical_recordsWho owns your medical records – you or your doctor? If you answered that you do, you’re like most patients, according to a recent survey. But you would be wrong.

Legally, the doctors or hospitals who create medical records own them. Although federal law states they have to provide records to patients who request them at a reasonable cost, the definition of “reasonable” varies quite a bit. And that cost also has some surprising repercussions.

Three Stanford researchers – health economist Kate Bundorf, PhD, Laurence Baker, PhD, chief of health services research, and health and political economist Daniel Kessler, PhD, JD – examined the issue in a recent study in the American Journal of Health Economics. They compared rates of doctor-switching between states that have caps on medical-record copying fees and those that don’t.

The team found that patient record charges decreased the number of patients who switched doctors and that when there were caps on copying fees, more providers switched to electronic medical records. A Stanford GSB article described the findings in detail:

In states that imposed caps on fees for medical records, patients changed their primary doctors 11% more frequently and their specialty doctors 13% more frequently. In addition, the researchers found that health care providers were about 12% more likely to establish electronic medical records in states that imposed caps on copying fees.

The fact that more than 1 in 10 people would switch doctors if their records were easier to get means that copying fees matter. In addition, other research suggests that adoption of electronic medical records can significantly reduce mortality in complicated cases; to the extent this is correct, caps on copying fees not only enhance patient convenience but also save lives.

Kessler says the study suggests there is a good case for regulating the fees charged for medical records: “You can’t make it impossible for people to switch doctors. We know that can’t be the right direction.”

Baker agrees, telling me, “No one should have to feel like they’re stuck with a doctor when they’d like to switch. Policies that help people get reasonable access to their medical records look like they can help.”

Previously: Can sharing patient records among hospitals eliminate duplicate tests and cut costs?U.S. Olympic team switches to electronic health recordsA new view of patient data: Using electronic medical records to guide treatment and Do electronic health records improve health? It’s complicated
Image by Jackhsiao

Immunology, Nutrition, Stanford News, Videos

A Stanford dietician talks food sensitivities

A Stanford dietician talks food sensitivities

Ever wondered what the difference between a food allergy and a food sensitivity is? Neha Shah, MPH, RD, CNSC, a registered dietician at the Stanford Digestive Health Center, sheds some light in a new video.

In people with food allergies, she explains, the immune system responds to the presence of the food, which isn’t the case for food sensitivities. People with food allergies have to avoid the culprit foods entirely, whereas people with food sensitivities can sometimes have small amounts of the food – though they must figure out what their threshold is. (Too much and the offending food might set off other symptoms like gas, bloating or diarrhea.) Shah uses lactose intolerance as an example of a very common food sensitivity and describes how people can understand their threshold.

Previously: Peanut products and babies: Now okay?, Stanford dietitian explains how – not just what – you eat matters, Taking a bite out of food allergies: Stanford doctors exploring new way to help sufferers, Eating nuts during pregnancy may protect baby from nut allergies and Ask Stanford Med: Pediatric immunologist answers your questions about food allergy research

Behavioral Science, Neuroscience, Research, Stanford News

A not so fearful symmetry: Applying neuroscience findings to teaching math

A not so fearful symmetry: Applying neuroscience findings to teaching math

15415-symmetry_newsMany people grow up thinking of themselves as “not very good at math” after having struggled to learn abstract math concepts. Sometimes people hit their “math wall”— the point where math classes feel so complex that the subject becomes impossible to understand — in college, high school, or even earlier.

A team at the Stanford Graduate School of Education, led by Daniel Schwartz, PhD, might help young students avoid the math wall altogether. The researchers are using recent findings from neuroscience to explore how people learn core concepts in math and science. They recently published a study in the scientific journal Cognition and Instruction looking at how fourth-grade students learn about negative numbers and building on previous findings about our ability to process visual symmetry.

One of the new tools used in the study is described in a Stanford News article:

Students worked with a magnetic plastic strip that was numbered. To solve the problem 3 + -2, students attached three magnetized blocks to the right of zero and two blocks to the left of zero. The manipulative further included a hinge at zero, the point of integer symmetry. Students folded the two sides together, and the number of extra blocks on either side gave the answer, in this case +1. The hinge at zero helped students recruit their native abilities with symmetry, and the numbers on the little platform helped them coordinate the sense of symmetry with the symbolic digits.

The students taught with these new techniques were able to solve math problems involving negative numbers better than students taught using conventional teaching approaches; they built on the strategies they learned using the hands-on device. And:

As it turned out, students who learned to rely on symmetry didn’t simply do better than other students on the material they had just been taught. They also did better on topics that they hadn’t yet studied, such as making sense of negative fractions and solving pre-algebraic problems.

“The big difference was that the symmetry instruction enabled students to solve novel problems and to continue learning without explicit instruction,” said Schwartz.

Previously: Math and the brain: Memorization is overrated, says education expert, Building a bridge between education and neuroscience, Abstract gestures help children absorb math lessons, study finds, Peering into the brain to predict kids’ responses to math tutoring and New research tracks “math anxiety” in the brain
Photo courtesy of AAALab@Stanford

Addiction, Mental Health, Pain, Public Health, Technology

Student engineers unveil tamper-proof pill bottle

Student engineers unveil tamper-proof pill bottle

Pill-dispenserThe United States has been battling a prescription painkiller epidemic for years. The statistics from the Centers for Disease Control and Prevention are chilling: The number of painkillers prescribed has quadrupled since 1999; more than two million people abused painkillers in 2013; every day, 44 people die from a prescription opioid overdose.

In response, faculty at the Center for Injury Research and Policy at the Johns Hopkins Bloomberg School of Public Health issued a challenge to seniors in the university’s mechanical engineering program: build a pill bottle that would protect against theft and tampering.

One team of students came up with a design that worked so well that their team’s mentors Andrea Gielen, ScD, and Kavi Bhalla, PhD, submitted a proposal to the National Institutes of Health for further testing.

The device is about the size of a can of spray paint, much larger than the average pill bottle. It can only be opened with a special key, which pharmacists can use to refill with a month’s supply of OxyContin. A fingerprint sensor ensures only the prescribed patient can access the pills at prescribed intervals and doses. In a story on the Johns Hopkins website earlier this month, Megan Carney, one of the student engineers described how the pill dispenser works:

The device starts to work when the patient scans in his or her fingerprint. This rotates a disc, which picks up a pill from a loaded cartridge and empties it into the exit channel. The pill falls down the channel and lands on a platform where the patient can see that the pill has been dispensed. The patient then tilts the device and catches the pill in their hand.

A short video about the pill dispenser shows it in action, too. The dispenser still has to undergo additional testing, but the team hopes to bring it to market soon — and help prevent future opioid overdoses.

Previously: Unmet expectations: Testifying before Congress on the opioid abuse epidemic, The problem of prescription opioids: “An extraordinarily timely topic”, Assessing the opioid overdose epidemic, Why doctors prescribe opioids to patients they know are abusing them and Stanford addiction expert: It’s often a “subtle journey” from prescription-drug use to abuse
Photo courtesy of Johns Hopkins University

Neuroscience, Stanford News, Surgery, Technology

Stanford researchers provide insights into how human neurons control muscle movement

Stanford researchers provide insights into how human neurons control muscle movement

Brain-Controlled_Prosthetic_Arm_2A few years ago, a team led by Stanford researcher Krishna Shenoy, PhD, published a paper that proposed a new theory for how neurons in the brain controlled the movement of muscles: Rather than sending out signals with parceled bits of information about the direction and size of movement, Shenoy’s team found that groups of neurons fired in rhythmic patterns to get muscles to act.

That research, done in 2012, was in animals. Now, Shenoy and Stanford neurosurgeon Jamie Henderson, MD, have followed up on that work to demonstrate that human neurons function in the same way, in what the researchers call a dynamical system. The work is described in a paper published in the scientific journal eLife today. In our news release on the study, the lead author, postdoctoral scholar Chethan Pandarinath, PhD, said of the work:

The earlier research with animals showed that many of the firing patterns that seem so confusing when we look at individual neurons become clear when we look at large groups of neurons together as a dynamical system.

The researchers implanted electrode arrays into the brains of two patients with amyotrophic lateral sclerosis (ALS), a neurodegenerative condition also known as Lou Gehrig’s disease. The new study provides further support for the initial findings and also lays the groundwork for advanced prosthetics like robotic arms that can be controlled by a person’s thoughts. The team is planning on working on computer algorithms that translate neural signals into electrical impulses that control prosthetic limbs.

Previously: Researchers find neurons fire rhythmically to create movement, Krishna Shenoy discusses the future of neural prosthetics at TEDxStanford, How does the brain plan movement? Stanford grad students explain in a video and Stanford researchers uncover the neural process behind reaction time
Photo by FDA

Emergency Medicine, Medical Education

“We are a team”: Advice for new residents from chief residents, in their own words

"We are a team": Advice for new residents from chief residents, in their own words

1024px-Flickr_-_Official_U.S._Navy_Imagery_-_U.S._Naval_Academy_plebes_carry_a_log_as_part_of_teamwork_training_during_Sea_Trials.There are many things chief residents want new residents to know right out the gate, but much of that goes unsaid. So the blog Academic Life in Emergency Medicine recently put together a list titled “Dear Residents: 10 Things Your New Chiefs Want You to Know.” Each one was written by a different chief resident, as part of the blog’s Chief Resident Incubator project.

It’s a thoughtful collection of reflections that offers an interesting mix of poignant comments and practical advice. The full list is worth a read, but a few stand out:

 “WHEN YOU FEEL LIKE CRYING, CRY TO ME.”

…Know that every one of your attendings and senior residents continue to go through these same trials. When you find yourself on the ropes and feeling utterly alone, call us. We might not be able to make that Surgical ICU rotation any less painful, but we’ll at least buy you a beer and share some stories from our own days working the surgery salt mine.

(Rory Stuart, Chief Resident, Wright State University, Dayton, OH)

WE ARE A TEAM

…Our learning should not only take place during scheduled conference time; we can all learn from each other. Share your successes and failures. Teach us all what you know, and what you wish you would have known. When we get out on our own, we all represent this residency program. Together we can make each other and this program better.

(Valerie Cohen, Chief Resident, Christiana Care Health System, Newark, DE)

NEITHER RESIDENCY NOR LIFE ARE FAIR. USE IT AS AN OPPORTUNITY TO SHINE

…Your week long string of night shifts was not borne of malice or vendetta. We try to make decisions that are in the best interest of the program and we ALWAYS consider your requests.

Your faculty, chiefs, and colleagues are paying attention to how you react to these perceived slights. When you take that extra shift in stride, we’ll notice. When you take on a task that nobody else stepped up for, we’ll notice. When you swap into a weekend night shift so a co-resident can celebrate an anniversary or birthday, we’ll notice.

(Jimmy Lindsey, Chief Resident, University of Chicago, Chicago, IL)

Previously: Soon-to-be medicine resident reflects on what makes a good teacher, Keeping an even keel: Stanford surgery residents learn to balance work and life and A call to action to improve balance and reduce stress in the lives of resident physicians
Via Wing of Zock
Photo by U.S. Navy

Medical Education, Mental Health, Nutrition, Stanford News, Surgery

Keeping an even keel: Stanford surgery residents learn to balance work and life

Keeping an even keel: Stanford surgery residents learn to balance work and life

med students in sailboat

Residency is one of the most intense times in a surgeon’s training, and it can take a toll physically and mentally on newly minted medical school graduates as they learn to cope.

To help them counter that stress, Stanford’s Department of Surgery started the Balance in Life Program for its residents. The program, and one of its team-building exercises – a sailing lesson in one of the world’s best sailing spots, the San Francisco Bay – were highlighted in a recent Inside Stanford Medicine story.

As described in the piece, the program is dedicated to the memory of Greg Feldman, MD, a former chief surgical resident at Stanford who committed suicide in 2010. The program provides basics like easy-to-access healthy meals, group therapy sessions and social activities, and Ralph Greco, MD, the program’s director said of it:

A lot of people would argue with the notion that such a program is necessary… I know our day of sailing may raise some eyebrows, but our faculty decided that we should do whatever we could to give these young people the tools they need to help them deal with the vicissitudes of life and medicine through the rest of their careers.

The article also notes that the program attracts residents interested in work-life balance to Stanford:

“The fact that we have this Balance in Life Program is great for recruitment of like-minded individuals,” [resident Micaela Esquivel, MD,] said. “I can tell medical students considering us that they would be hard-pressed to find another program that cares enough about their well-being to offer what we do.”

Previously: A call to action to improve balance and reduce stress in the lives of resident physicians, Surgeon offers his perspective on balancing life and work, Program for residents reflects “massive change” in surgeon mentality and New surgeons take time out for mental health
Photo by Norbert von der Groeben

In the News, Neuroscience, Research, Stanford News

Stanford study shows how the brain responds to different types of reading instruction

Stanford study shows how the brain responds to different types of reading instruction

Girl ReaderFor years, early childhood teachers have seen that students taught to read using a phonics approach — sounding out the letters in each word — tended to become better readers than those taught to recognize whole words by sight. Now a new study, published in the scientific journal Brain and Language, has given researchers insight into why, providing some of the earliest neurological data about early readers’ learning processes.

During the study, which was co-authored by Bruce McCandliss, PhD, a Stanford education professor who is part of the Stanford Neurosciences Institute, researchers developed a new written language and compared how 16 adult study participants learned when they were taught using a phonics versus a whole-word approach. The researchers then used a brain mapping technique that employs an electroencephalograph, or EEG, to track participants’ responses to newly learned words. As described in a Stanford Report story:

[T]hese very rapid brain responses to the newly learned words were influenced by how they were learned.

Words learned through the letter-sound instruction elicited neural activity biased toward the left side of the brain, which encompasses visual and language regions. In contrast, words learned via whole-word association showed activity biased toward right hemisphere processing.

McCandliss noted that this strong left hemisphere engagement during early word recognition is a hallmark of skilled readers, and is characteristically lacking in children and adults who are struggling with reading.

The study also showed that as long as study participants used the letter-sound pattern, they were able to read words they had never seen before. As noted in the piece, the researchers believe this work “could eventually lead to better-designed interventions to help struggling readers.”

Previously: Building a bridge between education and neuroscience, Using texting to boost preschool reading skills, Examining the inter-workings of the brain when reading silently, Researchers identify the neural structures associated with poor reading skills and Stanford study furthers understanding of reading disorders
Photo by Philippe Put

Emergency Medicine, Global Health, Haiti, Stanford News

A tale of two earthquakes: Stanford doctor discusses responses to the Nepal and Haiti disasters

A tale of two earthquakes: Stanford doctor discusses responses to the Nepal and Haiti disasters

boy in Nepal - 560

Nepal’s 7.8 earthquake in late April killed 8,000 people and displaced thousands more. Paul Auerbach, MD, a professor of emergency medicine at Stanford, spent about a week caring for the people of Kathmandu and recently sat down for a Q&A session with Shana Lynch of Stanford’s Graduate School of Business, where Auerbach earned a master’s degree in 1989.

Auerbach was also part of the medical response team in Haiti after the 2010 earthquake there killed hundreds of thousands. While talking with Lynch, he compares the two earthquakes and the very different medical responses they needed:

When you come in, you need to find the victims. You need to treat them. You need medical supplies. You need adequate personnel in order to manage the life- and limb-threatening injuries in the first few days. From the moment of the earthquake and forward, there’s a need for water and food. In Haiti, the supplies initially weren’t there. Everything needed to be carried in. In Kathmandu, for the most part, the supplies were available. Of course, they needed supplementation, and that happened and will continue to happen. In Kathmandu, they never were in a situation where they had nothing, which was unfortunately the situation in Port-au-Prince.

He also discusses some of the challenges of coordinating an appropriate disaster response plan:

There comes a point when you have enough people and enough supplies. At that point, you need to start storing things and sending people home.

The responses are never perfect because you discover that you need more of something and less of something else. The same holds true for people. For example, the changing nature of medical conditions following an earthquake causes you to need emergency medicine specialists early on, but then orthopedic surgeons and reconstructive surgeons later during the response.

Lynch and Auerbach’s conversation also touches on why community leaders need to plan for disasters, regardless of where they are. It’s an interesting inside look into how medical teams think about and respond to natural disasters.

Previously: “Still many unknowns”: Stanford physician reflects on post-earthquake Nepal, Day 6: Heading for home after treating Nepal earthquake victims, Day 4: Reaching beyond Kathmandu in treating Nepal earthquake victims, Day 2: “We have heard tales of miraculous survival” following Nepal earthquake, Day 1: Arriving in Nepal to aid earthquake victims and Reports from Stanford medical team in Haiti
Photo courtesy of Paul Auerbach

Cardiovascular Medicine, Events, Patient Care, Stanford News

Honoring doctors, nurses of the early days of Stanford’s coronary care unit

Honoring doctors, nurses of the early days of Stanford’s coronary care unit

image.img.320.highWhen I was in the hospital recently to give birth to my daughter, I saw my doctors briefly during their rounds, but it was the nurses and nurse midwives who primarily cared for me. So when I read in a recent Inside Stanford Medicine feature story that 50 years ago, nurses weren’t even allowed to perform tasks like start IVs, I was shocked.

In the 1960s, Stanford was home to one of the earliest coronary care units, led by Alfred Spivack, MD. Spivack taught the nurses working on the unit to take on tasks that were, at the time, mainly done by physicians. Joan Fair, PhD, RN, who was one of the unit’s original nurses and is now a cardiovascular researcher, recalls:

“Some doctors were totally against nurses doing these kinds of things… It also took time for some doctors to accept our opinions about how their patients were doing, or if we saw a problem and called them and asked them to take a different line of treatment.”

Joan Mersch, MSN, the unit’s former nurse coordinator, described in the piece how beneficial this extra training was to patients. “When you know how to read electrocardiograms, recognize lethal cardiac rhythms, perform resuscitation and defibrillation — it saves patient lives,” she said. “You understand what needs to be done, and you can take action.”

A big proponent of using technology to improve care, Spivack depended on the nurses to learn how to use the devices and incorporate them in the daily care of patients. And he also encouraged the nurses to pursue their research interests; many, like Fair, went on to obtain graduate degrees.

Last month, almost two dozen former nurses from the unit came together for a dinner celebrating a major gift from Spivack, which will pay for the nurses’ station in the new heart acute care unit when the new adult hospital opens in 2018.

Photo by Steve Fisch

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