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Medical Education, Medical Schools, Stanford News

Medical students start “transformational” journey

Medical students start "transformational" journey

With the help of Lars Osterberg MD, MPH, and Dr. Neil Gesundheit, MD. they give Brandon Turner  his official white coat at at the Stanford Medicine White Coat and Stethoscope Ceremony on Friday, August 22, 2014,at Stanford School of Medicine.  ( Norbert von der Groeben / Stanford School of Medicine )

The new school year has begun for students across the country, including Stanford’s 90 first-year medical students – who started class on Monday and spent last week at orientation activities anxious and excited for the  journey to finally begin.

To help the students prepare, faculty talked to them about the emotional and academic challenges of medical school and emphasized that it can be metamorphic and, not surprisingly, somewhat stressful. “They are seeing life and death,” said one faculty member at orientation, who added that medical school “is a transformational time the likes of which I don’t think you see in any other level of education.”

The week of preparation concluded with the traditional stethoscope ceremony, which I wrote about in an article published online today. The ceremony symbolizes the importance of the personal connection between doctor and patient, and during the event each student walks across the stage to accept their stethoscopes. As Laurie Weisberg, MD, president of the medical center alumni association, told the students:

The great thing about the stethoscope is you have to be close to your patient to use it. This is your chance to truly interact with the patient. You are listening to what the patient has to tell you.

In his address to the students, Dean Lloyd Minor, MD, told them the four-year, or longer, journey would change the way they see the world and that they “will learn some of life’s most valuable lessons from your patients.” He also highlighted some of the demographics of the new class:

Fifty-one percent of you are women; 15 percent of you are from communities underrepresented in medicine; 21 of you were born outside of the U.S., coming from China, Columbia, India, Vietnam, just to name a few. You come from a diverse and wide range of universities — 10 of you from Stanford, 13 from the Stanford of the East [Harvard]. Eighteen of you already have a master’s or a doctorate, and many of you have already published research, participated in varsity athletics, shined in the arts and contributed to your community.

Previously: Abraham Verghese urges Stanford grads to always remember the heritage and rituals of medicine, Top 10 reasons I’m glad to be in medical school and “Something old and something new” for Stanford medical students
Photo, of Brandon Turner receiving his official white coat at a ceremony last Friday, by Norbert von der Groeben

Medicine and Literature, Stanford News, Surgery

A surgeon battles her own unexpected complications

A surgeon battles her own unexpected complications

I first interviewed Stanford surgeon Sherry Wren, MD, a year and a half ago for an article about a course she taught to other surgeons on global health care. Based on her personal experience from medical missions to Chad, Congo and Ivory Coast, it was obvious the course was a labor of love. Here was a surgeon who was passionate about her work, and whose goal it was to overcome any and all obstacles to save patients – from using papaya paste for wound dressing to hand drills for relieving brain bleeds. She made use of a combination of her surgical skills, her physical strength and her love for her work to accomplish her goals. “You have no idea how physically hard it is to crank a six-millimeter pin into someone’s femur with a hand drill,” she told me then. “And I’m strong.”

When Wren mentioned off-hand that she was still recovering from post-surgical paralysis after her own neck surgery, I knew there was another story waiting to be told. Almost two years later, that story about Wren’s struggle to return to surgery following the partial paralysis of one of her most important tools, her left hand, has been published in Stanford Medicine magazine. My colleague Paul Costello referenced it here earlier this month.

This is a story about a surgeon experiencing what it’s like to be on the other side of the scalpel when something goes horribly wrong. In the piece, she describes what she felt upon waking up following neck surgery:

My left hand was like a claw. I couldn’t lift my left knee. Then my surgeon came to see me, and I recognized that ‘Oh shit!’ look on his face, because I’ve had that ‘Oh shit!’ look many times.”

Wren, who injured her spine following a deep-sea diving shipwreck, also talks of her struggle to return to the demanding, 10-14 hours surgeries that she excels at despite lingering damage to her left hand and the accompanying depression that blindsided her. I wrote:

It was the correct diagnosis. The correct treatment. There was no surgical error. And yet somehow, the veteran surgeon who makes a living with her hands woke up partially paralyzed. The unexpected complications included paralysis of her left hand and her left leg, and a weakened right hand. Already she thinks, Will I still be able to operate? Already she thinks, What am I if I’m not a surgeon?

This is Wren’s very personal story, one that she tells open and honestly. The experience of being the patient has made her a better physician, she said. And it’s a story that she hopes by telling, others can learn from.

“I thought a lot about whether I wanted to share this story,” Wren said. I, for one, am appreciative that she did.

Previously: Sherry Wren, MD – a surgeon’s road home, Surgery: Up close and personal, Stanford Medicine magazine opens up the world of surgery Surgery: Up close and personal and Stanford general surgeon discusses the importance of surgery in global health care

From August 11-25, Scope will be on a limited publishing schedule. During that time, you may also notice a delay in comment moderation. We’ll return to our regular schedule on August 25.

Aging, Health Policy, In the News, Public Health, Research, Stanford News

Study: Doctors would choose less aggressive end-of-life care for themselves

Study: Doctors would choose less aggressive end-of-life care for themselves

DNR bindersWhy do physicians continue to provide high-intensity care for terminally ill patients but choose to forgo such care for themselves at the end of life? That’s the question raised by a new Stanford study published in PLOS ONE today.

An overwhelming percentage of doctors surveyed for the study in 2013 – 88.3 percent to be exact – said they would choose “no-code” or do-not-resuscitate orders for themselves. And though other studies have shown that most other Americans would choose to die gently and naturally at home, that’s not what’s happening. As I describe in a release:

“A big disparity exists between what Americans say they want at the end of life and the care they actually received,” the study says. “More than 80 percent of patients say that they wish to avoid hospitalizations and high-intensity care at the end of life, but their wishes are often overridden.”

In fact, the type of treatments they receive depends not on the patients’ care preferences or on their advance directives, but rather on the local health-care system variables, such as institutional capacity and individual doctors’ practice style, according to the study.

The study involved two sets of subjects – 1081 physicians in 2013 and 790 physicians in 1989 – which both completed the same 14-question survey on their attitudes concerning advanced directives. Stanford researchers hypothesized that attitudes would have changed in the 24-years since the passage of the Self-Determination Act in 1990, a law designed to give patients more control over end-of-life care decisions and requires health care organizations to inform patients that they have the option to fill out such directives.

Surprisingly, despite the law, physicians attitudes have not changed, said VJ Periyakoil, MD, an expert in palliative care and lead author of the study. More from the release:

As a geriatrics and palliative care physician who sits at the bedside of sick patients herself, Periyakoil said she understands the disconnect between the type of care doctors want for themselves at the end of life and what they actually do for their patients. It’s not because doctors are trying to make more money or because they are intentionally insensitive to their patients’ desires. At the core of the problem is a biomedical system that rewards doctors for taking action, not for talking with their patients.

“Our current default is ‘doing,’ but in any serious illness there comes a tipping point where the high-intensity treatment becomes more of a burden than the disease itself,” said Periyakoil, who trains physicians in palliative medicine. “It’s tricky, but physicians don’t have to figure it out by themselves. They can talk to the patients and their families and to the other interdisciplinary team members, and it becomes much easier.

“But we don’t train doctors to talk or reward them for talking. We train them to do and reward them for doing. The system needs to be changed.”

A touching first-person essay on this topic by Ken Murray, MD, a retired family practitioner has been popping up recently on various blogs and other internet sites. It describes how doctors don’t want to experience the kind of suffering that they see their patients go through. In the piece, titled “How doctors die: It’s not like the rest of us, but it should be,” the author mentions that he has even seen one medical professional with a “Do not Resuscitate” tattoo.

Previously: Communicating with terminally ill patients: a physician’s perspective, Asking the hardest questions: Talking with doctors while terminally ill, On a mission to transform end-of-life care, The importance of patient/doctor end-of-life discussions and A Stanford nurse shares her experience in talking to her aging mother about end-of-life decisions
Photo by Frank DiBona

Medical Education, Medical Schools, Stanford News

Medical students take time to thank their patients

Medical students take time to thank their patients

thank you tree - smallWith their heavy academic workloads and the constant demand to keep up with the ever-growing body of medical literature, one might question whether medical students have time to learn and absorb the importance of developing the human connection vital to the doctor-patient relationship. Here’s something that provides strong evidence that they do: A group of fourth-year medical students here started a project to thank patients for being their most important teachers.

In today’s Inside Stanford Medicine, I write about the project, which featured 35 anonymous thank-you cards from medical students arranged into a display for the recent Medicine and the Muse Symposium. Some cards touch on life and death issues, some focus on the importance of hands-on medical training, and others express simple appreciation of the human bond. Reading over these heartfelt letters, it’s clear that the students recognize that the patient-doctor connection is key to their medical education. Here’s a sampling:

I will always remember that you asked me for an ice-cold Slurpee from 7-Eleven in broken words when you finally gained consciousness and spoke to me. I will never forget your gentle but firm nod expressing that you wouldn’t want artificial feedings prolonging your life… Taking care of patients like you and helping them in times of need makes medicine worthwhile… You taught me how to be a good physician and I will always remember you.”

Thank you to the patient with vasculitis and related short gut syndrome for sharing your physical pain as well as worried for the future with me. Thank you to the former physician with mental health concerns for teaching me humility. Thank you also to your families for teaching me about the impact of illness on your lives as well.

Thank you for reminding me why I chose to do medicine. For showing me that we can improve medical care further. For you and future patients.

Previously: Medical students and author Khaled Hosseini share their muse with Stanford community and Reality Check: When it stopped feeling like just another day in medical school
Photo by Jia Luo

Research, Stanford News, Stem Cells

Studying the inner ear and advancing research in developmental biology

Studying the inner ear and advancing research in developmental biology

hellerResearcher Stefan Heller, PhD, came to Stanford in 2005 from Harvard. His laboratory focuses on inner ear development and works on approaches to regenerate sensory hair cells, scarce sensory receptor cells that are essential for our senses of hearing and balance.

As I explained in an article about his arrival, Heller’s goal was to come here and collaborate with others to devise “a variety of possible cures for deafness from drug therapy treatment – which could be as simple as an application of ear drops-to stem cell transplantation into the inner ear to remedy hearing loss.” Since then, his lab has continued to add to the body of research on the inner ear’s early development and to pave the way towards regenerative therapies for hearing loss. The researchers’ most recent milestone (subscription required) – during which they designed the most detailed 3-D model to date of the otocyst, the embryonic structure in vertebrates that develops into the inner ear in the adult – was published online this month in the journal Cell.

In a video on the journal website, Heller and the lead author of the study, Robert Durruthy-Durruthy, a PhD candidate, describe the mathematical method used that allows the 3-D reconstruction of the developing inner ear. Russ Altman, PhD and Assaf Gottlieb, PhD, from Stanford bioengineering were collaborators of the study.

Heller recently described to me how microfluidics technology developed in the lab of Stanford bioengineering professor Stephen Quake, PhD, was essential to analyze single cells in order to develop the blue prints for their 3-D model. The approach is new in biology, Heller said. Much like dismantling the engine of a car into its smallest parts, taking apart a simple organ into single cells results in the challenge of putting the pieces back together.  “Our new method provides a good strategy for such reconstructions,” Heller said.

Heller also explained how this advancement will help as he continues researching early ear development and working on growing inner ear sensory hair cells, the linchpin for hearing. (Hair cells exist in limited numbers in human ears and once they are gone, hearing loss occurs.) He said:

This [paper] gives us deep insight into how this organ forms in early development. It identifies the different cell types and defines them in much more detail than previously known. It provides details about the inner ear progenitor cells that we are trying to generate from stem cells. Having this blue print will help us to generate sensory hair cells more efficiently and hopefully to regenerate hair cells at some time in the future.

The technology, Heller said, can also benefit others: “It can be used to reconstruct all kinds of things, other simple organs, perhaps even simple multicellular organisms, or structures like tumors.”

Previously: Regenerating sensory hair cells to restore hearing to noise-damaged ears, Stanford chair of otolaryngology discusses future regenerative therapies for hearing loss, Stefan Heller discusses stem cell research on Science Friday and Growing new inner ear cells a step toward a cure for deafness
Photo by Steve Fisch

Chronic Disease, Health Costs, Health Policy, Research, Stanford News

Keeping kidney failure patients out of the hospital

Keeping kidney failure patients out of the hospital

Keeping kidney patients healthy enough to stay out of the hospital certainly sounds like a good thing – both for the patients and the economy. Now there’s scientific evidence to show how this can be done.

Reducing hospital readmissions was a focus of the the Affordable Care Act, and Kevin Erickson, MD, an instructor in nephrology at Stanford, decided to study a group of patients who are often hospitalized. He and his colleagues examined whether an additional doctor’s visit in the month after hospital discharge would help keep kidney-failure patients on dialysis from being readmitted. He and his colleagues analyzed data collected between 2004-2009 by the United States Renal Data System, a national registry of nearly all end-stage renal disease patients in the country.

It’s nice to find something that may generate both cost savings and better health outcomes

Results showed that there was a significant reduction in hospital readmissions with that extra doctor’s visit in the month after hospital discharge. And while the percentage doesn’t sound all that significant – 3.5 percent -  in real numbers that translates to 31,370 fewer hospitalizations and $240 million per year saved, according to the study published this month in the Journal of the American Society of Nephrology.

“It’s nice to find something that may generate both cost savings and better health outcomes,” Erickson told me. “Patients with end-stage renal disease suffer from poor quality of life. Some of that I suspect is related to multiple trips in and out of the hospital.”

Patients with kidney failure are at a particularly high risk of hospital readmission: In 2009 patients getting dialysis were admitted to the hospital nearly two times per year, 36 percent of whom were rehospitalized within 30 days, according to the study.

Previously: Study shows higher Medicaid coverage leads to lower kidney failure rates; Study shows higher rates of untreated kidney failure among older adults; Study shows daily dialysis may boost patients’ heart function, physical health.

Ethics, Research, Sexual Health, Sports, Stanford News, Women's Health

“Drastic, unnecessary and irreversible medical interventions” imposed upon some female athletes

"Drastic, unnecessary and irreversible medical interventions" imposed upon some female athletes

Four female athletes were required to undergo “partial clitorectomies” and gonadectomies (removal of gonads) as a result of the current gender-policing polices of major sports governing bodies, according to an article published this week in the British Medical Journal.

The article, co-written by Stanford bioethicist Katrina Karkazis, PhD, raises concerns that new policies that use testosterone testing to determine eligibility for elite female athletes accused of having “male-like attributes” have resulted in unnecessary interventions that are both “invasive and irreversible.” The paper was timed to coincide with an editorial that she and Barnard College’s Rebecca Jordan-Young, PhD, wrote for the New York Times, which was previously discussed here.

Karkazis told me that both the journal article and the editorial were written in response to a case study published last year in the Journal of Clinical Endocrinology and Metabolism by physicians who conducted the medical procedures on the four female athletes. The athletes, ages 18-21 and all from developing countries, had tested high for naturally occurring testosterone levels. Their identities remain confidential, but the physicians who performed the surgeries and wrote the report acknowledged that there was no medical need for the procedures, which have been used as treatments for intersex conditions. Karkazis and colleagues argue that not only is there no medical benefit to such procedures, they also make no difference to athletic ability. From the journal article:

Clitoridectomy is not medically indicated, does not relate to real or perceived athletic “advantage,” and is beyond the policies’ mandate. Moreover, this technique is long eschewed because it has poor cosmetic outcomes and damages sexual sensation and function. Clitoral surgery should have no role in interventions undertaken for athletes’ eligibility or health.

Karkazis and her colleagues go on to refute the logic of using testosterone level testing in women as grounds for exclusion from competition as having no scientific grounds, and quote sports officials as saying that female athletes with unusually high naturally occurring testosterone levels have no more competitive advantage that other elite athletes. Karkazis and Jordan-Young wrote in the Times:

Sports officials (the report does not identify their governing-body affiliation) sent the young women to a medical center in France, where they were put through examinations that included blood tests, genital inspections, magnetic resonance imaging, X-rays and psychosexual history… Since the athletes were all born as girls but also had internal testes that produce unusually high levels of testosterone for a woman, doctors proposed removing the women’s gonads and partially removing their clitorises. All four agreed to undergo both procedures; a year later, they were allowed to return to competition.

Quite simply, these young female athletes were required to have drastic, unnecessary and irreversible medical interventions if they wished to continue in their sports.

Previously: Arguing against sex testing in athletes, Is the International Olympic Committee’s policy governing sex verification fair? and Researchers challenge proposed testosterone testing in select female Olympic athletes

Chronic Disease, Health Disparities, Health Policy, Patient Care, Research, Stanford News

Study shows higher Medicaid coverage leads to lower kidney failure rates

Study shows higher Medicaid coverage leads to lower kidney failure rates

Years ago, nephrologist Manjula Tamara, MD, treated a 23-year-old uninsured patient whose kidneys were failing. The patient’s medical options, at that point, were life-long dialysis or a hoped-for kidney transplant – bleak options for such a young person, and ones that adequate preventive care could have been avoided.

That memory, along with the federal government’s recent expansion of Medicaid spurred Tamura as a scientific researcher to pose the question: Does expanded Medicaid coverage translate into better care for low-income patients with chronic diseases, such as kidney disease?

According to the Stanford study published today in the Journal of the American Society of Nephrology, the answer is yes. Using data from national registries, Tamura, who is lead author of the research, and colleagues collected data on the more than 400,000 American adults who developed end-stage renal disease (or ESRD) between 2001 and 2008. As I explained in a release:

Medicaid coverage during those years among low-income, nonelderly adults ranged from 12.2 to 66 percent, depending on the state, with California averaging between 30 and 35 percent. For each additional 10 percent of the low-income, nonelderly population covered by Medicaid, the study found there was a 1.8 percent decrease in ESRD incidence.

The study is particularly timely because states are in the process of deciding whether to adopt the recent changes to Medicaid, which came with the passage of the Affordable Care Act. So far, only about half of the states have. The study discusses these recent changes and what the expansion in Medicaid coverage could mean to low-income Americans with kidney disease, along with patients with other chronic diseases:

Before the Affordable Care Act, only low-income Americans who were pregnant, had a disability or were parents of minors could receive Medicaid coverage if they met their state’s income eligibility levels. States now have the option to increase Medicaid coverage to all adults under the age of 65 with incomes below 133 percent of the poverty level regardless of whether they are pregnant, disabled or parents of minors.

“The care of patients approaching kidney failure or end-stage renal disease is a useful model to study the potential effects of Medicaid expansion on chronic disease care because ESRD care is costly and the quality of pre-ESRD care is tracked nationally,” Tamura said.

What the study did not look at was whether this expansion could ultimately result in financial savings. In the United States, 75 percent of health care dollars goes into the treatment of chronic diseases and these conditions – which include heart disease, diabetes, hypertension, and kidney disease – are all on the rise. In an interview, Tamura suggested that future research on this topic is needed.

Previously: Study shows higher rates of untreated kidney failure among older adults and Geography may determine kidney failure treatment level

Medicine and Literature, Stanford News

Stanford’s Abraham Verghese honored as both author and healer

Stanford's Abraham Verghese honored as both author and healer

Verghese signing booksSeveral times I’ve heard Stanford physician Abraham Verghese, MD, champion of hands-on medicine and bestselling author, answer the question: Which does he considers himself first – a doctor or an author?

Always, I’ve heard him give the same answer. He is a physician first. For him, medicine is “a ministry with a calling.” The meaning to his life is in his ministry to the patient; how best to fulfill that ministry is his life’s journey. This he tells the entering first-year medical students during orientation, reminding them to always hold onto to the desire that drew them to medicine in the first place. The desire to help people.

But obviously, it’s not that simple. For Verghese, the author of nonfiction and fiction books and numerous articles in both the general and academic press, the two passions are intertwined and feed into each other. For him, writing is a path of discovery to become a better physician.

Now, Verghese’s work of combining the two fields has again been honored, this time with Verghese being named today the recipient of the $250,000 Heinz Award for Arts and Humanities. In a news story I quote Teresa Heinz, chairperson of the Heinz Family Foundation, which administers the annual Heinz Awards in five categories, on the choice:

Dr. Verghese’s widely acclaimed writings touch the heart and inform the soul, giving people of all walks of life a true understanding of what it is to heal the whole person – not just physically, but emotionally.

Verghese, who will be the commencement speaker for the Stanford medical school graduation in June, said he was excited about the award, which he considers “a lovely validation of work that is in that realm of being on the edge of science yet very much about the art.”

He also received another recent honor. His only novel (he’s currently working on his second), Cutting for Stone, has made the list of Amazon.com’s “100 Books to Read in a Lifetime.” It’s an accomplishment, he told me in an e-mail, that he’s indeed proud of. What writer wouldn’t be honored to have their book listed alongside the likes of Hemingway’s The Sun Also Rises and W. Somerset Maugham’s Of Human Bondage?

Hearing of these two honors – along with recently having reread Verghese’s second memoir The Tennis Partner - reminded me of how close the author’s love for both art and medicine are wedded. And it reminded me yet again that for Verghese both art and science – which includes the entire medical establishment – ultimately exist as tools to help heal patients.

Previously: Abraham Verghese’s Cutting for Stone: Two years as a New York Times best seller, How Abraham Verghese writes, How a battle with Napoleon helped Abraham Verghese write his novel, Abraham Verghese at Work: A New York Times profile and Physicians turn to books to better understand patients, selves
Photo by Singer, 2012

Cardiovascular Medicine, Chronic Disease, Genetics, Research, Stanford News

Damage to dead cell disposal system may increase heart disease

Damage to dead cell disposal system may increase heart disease

garbage cansThink of it like taking out the garbage.

That’s the way Stanford researcher Nicholas Leeper, MD, explained to me the findings of his recently published study.

Actually, it’s more helpful to think of the study’s discoveries on the genetics of heart disease as something of a garbage strike – at the molecular level.

Due to a genetic defect, the body’s ability to dispose of its daily tonnage of dead cells gets damaged, and as a result the body’s garbage - in the form of old cells and debris - starts to build up in the walls of its blood vessels. Normally, the body is extremely efficient at taking out the garbage. Two hundred billion cells die every day in our bodies and most get cleared out within a matter of seconds. But when this process breaks down and garbage in the form of necrotic cells starts building up in the walls of blood vessels, it’s not a good thing.

Leeper, a physician and assistant professor of vascular surgery, and colleagues Yoko Kojima, MD, Tom Quertermous, MD, and others set out to discover why genetic variation at the chromosome 9p21 location has been repeatedly identified as the most important commonly inherited DNA sequence for a wide range of cardiovascular diseases including stroke, heart attacks and aneurysms.

Conducting studies in mice with atherosclerosis, the researchers showed that loss of a candidate gene at this locus leads to impaired “efferocytosis” - from the Latin for “take to the grave” – the process by which dead or necrotic cells are removed. Literally, the burying of dead cells. Mice with this genetic variation showed an increase in buildup of these dead cells, further advancing their atherosclerosis as opposed to those that did not have the genetic variation.

In other words, a commonly inherited genetic variant, which is found in 20 percent of the population, contributes to the development of coronary artery disease (also known as coronary atherosclerosis) by stimulating the accumulation of necrotic debris within the evolving plaque. Coronary atherosclerosis is the process by which plaque builds up in the wall of heart vessels, eventually leading to chest pain and potentially lethal heart attacks. Leeper explained it to me further:

If you were born with genetic variation at the 9p21 locus, your risk of heart disease is elevated, though we haven’t understood why. This research gets at that hidden risk. You can be a non-smoker, be thin, have low blood pressure, and still be at risk for a heart attack if you were born with this variant. This work may help explain that inherited risk factor, and more importantly help develop a new therapy to prevent the heritable component of cardiovascular disease.

Photo by shooting brooklyn

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