Published by
Stanford Medicine

Author

Ethics, Events, Medical Education, Medicine and Literature, Stanford News

During their first days at Stanford, medical students ponder the ethical challenges ahead

During their first days at Stanford, medical students ponder the ethical challenges ahead

students reading oath2 - 560

In an effort to help prepare this year’s crop of new medical students for the future challenges of keeping true to the spirit of the Hippocratic Oath – to first do no harm ‑ Stanford’s School of Medicine held a new discussion session during orientation.

In between learning about housing and schedules and all the necessary details of starting medical school, the 90 new students who started class on Monday joined with two deans of the school last week to discuss one of the most controversial topics in the world of medicine: euthanasia.

Included among the students’ summer reading assignment was the book Five Days at Memorial, a blow-by-blow account of the days medical staff and patients spent trapped in a New Orleans hospital after Hurricane Katrina struck. Left without electricity or sanitation, staff slept little and worked endlessly to care for the sick and dying patients not knowing if any of the patients – or anyone else trapped at the hospital — would survive. An online story explains why the book was assigned as summer reading:

Most [new students] had not yet faced the responsibilities they will encounter routinely as physicians. It was the ethical and emotional challenges ahead that [Lloyd Minor, MD, dean of the medical school, and Charles Prober, MD, senior associate dean of medical education] hoped to explore during the book discussion. “I think one of the key lessons from this book: If we’re going to make progress in medicine, we’re going to have to face realistically when we make errors,” Minor said. “Progress only occurs when we are able to frankly address those situations and acknowledge those errors.”

The book describes health-care workers treating patients in a way that could arguably violate tenets of the Stanford Affirmation. “You will be reciting this later today after you receive your white coats and stethoscopes,” Prober said. “Hopefully, the affirmation will have more meaning to you. It will help you to reflect more deeply on the words as you ponder it into the future.”

The book describes how medical staff and patients had to fend for themselves in the days following Hurricane Katrina. After the waters receded, and authorities entered the hospital, 41 bodies were found. Three health-care professionals, including one physician, were arrested for murder. A New Orleans grand jury ultimately refused to indict them on charges of involuntary euthanasia and murder, but exactly what happened during those five days, when temperatures soared, sleep was rare and proper sanitation was nonexistent, remains unclear.

Continue Reading »

Big data, Cardiovascular Medicine, Chronic Disease, In the News, Research, Stanford News

Using “big data” to improve patient care: Researchers explore a-fib treatments

Using "big data" to improve patient care: Researchers explore a-fib treatments

Turakhia photoA Stanford cardiac electrophysiologist and colleagues have used a unique research method to learn more about atrial fibrillation. Mintu Turakhia, MD, and collaborators at Medtronic and Massachusetts General Hospital, extracted data out of decades of continuously recorded medical information from implanted medical devices – pacemakers and defibrillators — in 10,000 heart patients. Then they linked it to medical records, and analyzed it.

The researchers’ goal was to explore whether patients who experienced sudden attacks of a-fib, an irregular and rapid heart rate caused by spasms of the heart’s upper chambers, should be treated with long-term anticoagulants like those who had permanent a-fib or whether perhaps temporary drug therapy could be considered an option. They wanted to know if a patient’s risk of stroke changes as a-fib comes and goes.

The results, which were published recently in Circulation: Arrhythmia and Electrophysiology, found that patients were at an increased risk of stroke the first seven days after their hearts went into a-fib.

A-fib, which afflicts more than 3 million Americans, is known to increase a patient’s risk of stroke – but exactly when this risk occurs is controversial. Currently, physicians recommend long-term anticoagulation for patients, whether the a-fib occurs in sudden attacks or is continuous. This study indicates that transient use of anticoagulants could be an option for some patients and deserves further investigation. Future treatment plans might explore the idea of some kind of wearable device that shows when a patient goes in and out of a-fib, then taking medications just when needed rather than for a lifetime, said Turakhia.

Turakhia told me the study also provides an important example of how using “big data” research methods can ultimately lead to improved clinical care. In an email, he explained:

This is truly a big data approach where we took raw data from implanted pacemakers and implanted defibrillators and linked it to clinical data. The medical device data comes from home remote monitoring systems that patients have and goes to the cloud. We pulled the raw data off the cloud and linked it to VA (Veterans Affairs) electronic health records, VA claims, Medicare claims, and death records. This is truly a novel approach where we are assembling highly disparate data sources and linking them to gain insight into disease.

Previously: A little help from pharmacists helps a-fib patients adhere to prescriptions, Study highlights increased risk of death among patients with atrial fibrillation who take digoxin and What is big data?
Photo of Turakhia by Norbert von der Groeben

Medical Education, Medical Schools, Stanford News

Passing the boards: Reassessing “Step 1 madness”

Passing the boards: Reassessing "Step 1 madness"

medical booksCharles Prober, MD, senior associate dean of medical education at Stanford, has long been concerned about the misuse of Step 1. The national standardized test, which must be passed in order to get a medical license, is also often used inappropriately, according to Prober, as a screening tool by residency programs.

But his concern about the test — dubbed “Step 1 madness” by some med students and the first of three required for medical licensure — extends even further to what he and others believe are the unnecessary and sometimes detrimental effects on both the education of medical students and their stress levels.

In a commentary published this week in the journal Academic Medicine, Prober and his co-authors — which includes the president of the National Board of Medical Examiners, the non-profit that develops and manages the test — issue a “plea to reassess” its role in residency selection. They write:

There is an increasingly pervasive practice of using the score, especially the Step
1 component, to screen applicants for residency. This is despite the fact that the test was not designed to be a primary determinant of the likelihood of success in residency… [I]t is disconcerting that the test preoccupies so much of our students attention with attendant substantial costs (in time and money) and mental and emotional anguish.

Prober and his colleagues go on to explain how students sequester themselves for four to nine weeks on average studying full-time for the day-long multiple-choice examination, which is usually taken sometime following their second year of medical school. The stress to pass the test, which is designed to test  “important concepts of the sciences basic to the practice of medicine,” is particularly high because students know a poor score may keep them from qualifying for the first step to get into a residency program — the interview:

Despite its intended purpose, many residency program directors continue to use applicants’ USMLE Step 1 scores as a sole or primary filter for selecting candidates to interview… In general, the more competitive the residency discipline (e.g. orthopedic surgery, radiation oncology, dermatology, ophthalmology, and otolaryngology,) the higher the Step 1 score needed to pass through the filter.

The authors express the opinion that it is “ill advised” to use the test for a purpose for which it was not developed, that the test is not a good predictor of who will do well in residency and that it is being misused for “convenience” as a easy to apply mechanism to reduce large applicant pools. Their solution isn’t to get rid of the test, which is still a valuable tool, but to create additional measurement tools of equally important skills for selection by residency programs.

“A more rational approach to selecting among residency applicants would give greater attention to other important qualities, such as clinical reasoning, patient care, professionalism, and ability to function as a member of a health
care team,” they conclude.

Previously: Using the flipped classroom model to bring medical education into the 21st-century and Student transitions in medicine: putting blinders on
Photo by jcalyst

Cardiovascular Medicine, Medical Apps, Public Health, Research, Stanford News

Stanford’s MyHeart Counts app reaches overseas to Hong Kong and the UK

Stanford's MyHeart Counts app reaches overseas to Hong Kong and the UK

MyHeart Counts on phoneIn an effort to continue signing up new participants for their heart research study at groundbreaking speeds, researchers at Stanford launched their iPhone app MyHeart Counts overseas in Hong Kong and the United Kingdom today. The goal is to reach out far and wide — quickly.

To date, about 41,000 users have signed up for the free app launched in March, which allows users to learn about their own heart health while also participating in a large-scale heart study. That’s an unprecedented number of people in such a short amount of time, researchers say, adding that it’s only the beginning. From our press release on today’s launch overseas:

“The idea is to move into one country at a time until we go global,” said Euan Ashley MD, a professor of cardiovascular medicine at Stanford and co-investigator for the MyHeart Counts study. “We hope to add more countries every few months.

“We are ready to take the study as far as it will go. We would like to build a new Framingham heart study for the ages,” Ashley said, referring to the long-term cardiovascular study that has followed three generations of participants in Framingham, Massachusetts. “We would like millions of participants.”

MyHeart Counts is the first of the initial handful of apps designed using ResearchKit, Apple’s open-source software platform for creating medical-research apps, to expand overseas. Along with its reach into Hong Kong and the U.K., the app is also being upgraded today, providing more information to users about their own heart health and breaking heart health news. The press release gives a brief overview of what the app does:

The free app offers users a simple way to participate in the study, complete tasks and answer surveys from their iPhones. Once every three months, participants are asked to monitor one week’s worth of physical activity, complete a 6-minute walk fitness test if they are able, and enter their risk-factor information. The app now also delivers a comprehensive summary of each user’s heart health and areas for improvement.

Previously: Lights, camera action: Stanford cardiologist discusses MyHeart Counts on ABC’s NightlineBuild it (an easy way to join research studies) and the volunteers will comeMyHeart Counts app debuts with a splash and Stanford launches iPhone app to study heart health

Cancer, Chronic Disease, Dermatology, Stanford News, Surgery, Transplants

Rebuilding Cassie’s smile: A lung transplant patient’s struggle with skin cancer

lung patientWhen I first met Cassie Stockton, she was seated in an exam chair in Stanford’s dermatology clinic, getting cosmetic skin treatments. Lovely and young, just 21 years old, it seemed a bit silly. How could she possibly need injectable lip fillers or laser skin treatments?

I knew Stockton had a lung transplant at 15 and that the immunosuppressant drugs she was required to take to keep her body from rejecting the donated lungs had made her susceptible to skin cancer. But it wasn’t until I researched her story in depth that I truly understood how she ended up needing regular cosmetic treatments here.

As I explain in my recently published Stanford Medicine article, her story began at birth:

Born premature, [Cassie] was intubated the first two weeks of life, then sent home with her mother and an oxygen tank. She remained on oxygen 24 hours a day for the first two years of her life. Eventually, she was diagnosed with bronchopulmonary dysplasia, a chronic lung disorder …

Sixteen years later, the donated gift of new lungs saved her life – but it left scars, both emotional and physical:

The day Stockton woke up out of the anesthesia six years ago after a 13-hour surgery at the Transplant Center at Lucile Packard Children’s Hospital Stanford, she breathed in oxygen with newly transplanted lungs, and breathed out sobs. Tears streamed down her face. “At first, I thought she was in pain,” says her mother, Jennifer Scott, who stood by her side. But that wasn’t it. Stockton was overwhelmingly sad because she now knew her new lungs were the gift of a child. It was Dec. 6, 2009, just before Christmas. The death of someone else’s child had given her a whole new life.

And now:

Every four months, she and her fiancé make the four-hour drive from their home in Bakersfield, California, past the oil rigs and cattle farms to Stanford’s Redwood City-based dermatology clinic for her skin cancer screening. It’s been two years of treatments: freezings, laserings, a total of eight outpatient skin surgeries — the most significant resulting in the removal of the left half of her lower lip. The dermatologic surgeon removes the skin cancers, and then gets to work to repair the damage. “It’s heart-breaking to have to remove the lip of a 21-year-old woman,” says Tyler Hollmig, MD, clinical assistant professor of dermatology and director of the Stanford Laser and Aesthetic Dermatology Clinic, who leads Stockton’s treatment and keeps her looking like the young woman she is, restoring her skin, rebuilding her lip, making sure she keeps her smile.

Stockton doesn’t complain about any of the struggles she’s had post transplant. She knows she got a second chance at life. And, she tells me, it’s her job to take care of the lungs given to her by that child who died.

Previously: This summer’s Stanford Medicine magazine shows some skin
Photo by Max Aguilera-Hellweg

Cardiovascular Medicine, Chronic Disease, In the News, Research, Stanford News, Transplants

Are donor hearts getting wasted?

Are donor hearts getting wasted?

heart choiceI wrote a press release recently on a study that showed a high percentage of donated hearts were not being used, raising concerns that some were getting wasted when they could be used to save lives. This made me curious about the process of just how a donor heart, which ideally has about a two-hour window before it gets transplanted to a patient with heart failure, gets matched.

The result is a Stanford Medicine magazine story titled “Heart Choices” that describes this process, the tough decisions that family members make when a loved one donates a heart, and the excruciating waiting that patients in need of a new heart go through.

Most importantly the article asks the question: Should more “high-risk” donor hearts be used? An estimated 20,000 people across the country are waiting for new hearts, and only a few thousand transplants happen on average per year. My story explains the dilemma:

The general assumption is that there simply are not enough donor hearts available to meet a growing demand. But new research is questioning that assumption. Some researchers and surgeons claim that thousands of donor hearts that could be used are turned away each year. The hearts are considered marginal because they come from older, sicker or riskier donors, but many argue they are safe for transplant, and could be saving lives.

“As patients wait longer, they often get sicker, and we often lose patients,” says Stanford cardiologist Kiran Khush, MD, whose research reports that 65 percent of available heart donations are discarded because of stringent acceptance criteria. Yet the criteria have not been critically evaluated, she says. “Increasing the supply of donor hearts is, of course, a great concern of mine.”

Continue Reading »

Cardiovascular Medicine, Chronic Disease, Imaging, Research, Stanford News, Technology

DNA damage seen after CT scanning, study shows

DNA damage seen after CT scanning, study shows

16288548276_e155ec8843_zUsing new laboratory techniques, Stanford scientists have been able to get a closer look at what happens inside the cells of patients undergoing medical imaging techniques. In a study published today, their research clearly shows that there is cellular damage in heart patients after CT scanning.

The researchers explained to me in interviews for a press release on the study that this doesn’t link CT scans to cancer. But as Patricia Nguyen, MD, lead author said in the release, it is further indication for caution:

“Whether or not this (cellular damage) causes cancer or any negative effect to the patient is still not clear, but these results should encourage physicians toward adhering to dose reduction strategies.”

Due to an explosion in the use CT scans for heart patients over the past decade, public health concerns have been raised over whether there might be a causal link with cancer. But until now, little has been known about exactly what happens at a cellular level when patients undergo CT scanning, a type of medical imaging which exposes them to low-dose radiation. This study took advantage of new laboratory techniques that made it possible to look inside cells of patients after they underwent CT scanning. As Nguyen explained in my release:

“Because we don’t know much about the effects of low-dose radiation — all we know is about high doses from atomic bomb blast survivors — we just assume it’s directly proportional to the dose. We wanted to see what really happens at the cellular level.”

Researchers examined the blood of 67 patients undergoing cardiac CT angiography using such techniques as whole-genome sequencing and flow cytometery to measure biomarkers of DNA damage. The results:

… showed an increase in DNA damage and cell death, as well as increased expression of genes involved in cell repair and death, the study said. Although most cells damaged by the scan were repaired, a small percentage of the cells died, the study said.

“These findings raise the possibility that radiation exposure from cardiac CT angiography may cause DNA damage that can lead to mutations if damaged cells are not repaired or eliminated properly,” the study said.

Photo by frankieleon

Public Health, Research, Stanford News

Study sheds light on physicians testifying in court that smoking didn’t cause cancer

addict-84430_1280 (1)A small group of board-certified physicians helped defend the tobacco industry in more than 50 cases by providing expert testimony that years of heavy smoking did not cause the head and neck cancers of the individual plaintiffs despite overwhelming scientific evidence to the contrary.

This is the finding of a study led by Robert Jackler, MD, professor and chair of otolaryngology-head and neck surgery at Stanford. From a press release I wrote on the research, which was published today in the journal Laryngoscope:

 “I was shocked by the degree to which these physicians were willing to testify, in my opinion in an unscientific way, to deny a dying plaintiff — suffering the aftermath of a lifetime of smoking — of a fair trial,” said Jackler, referring to the physicians cited in the study as a “pool of experts willing to say over and over again that smoking didn’t cause cancer.”

In previous research, Jackler has written about the tobacco industry’s influence on public health through advertising, marketing, manipulation, and promotion. But most of his research up to this point has focused on the past. In this study Jackler turned to the present day. He read through thousands of publicly available expert-witness depositions and trial testimony from Florida courtrooms from 2009 to 2014 and took a hard look at the accuracy of the testimony. In his study, he states that testimony was remarkably similar from case to case and was “faithful to the tactical narrative that there are many, many causes of head and neck cancer — and that factors other than smoking must have caused the plaintiff’s disease.” But as I wrote in our release:

An obvious fallacy of this argument lies in the fact that literally billions of nonsmoking people are exposed regularly to gasoline fumes, use cleaning solvents, eat salted fish or live in urban environments. Were these causative factors for head and neck cancer, with even a minute fraction of the potency of tobacco, the rate of head and neck cancer among nonsmokers would be much greater than what has been observed.

The study, which includes a review of the scientific literature, said this testimony is just inaccurate:

“The tobacco industry identifies the best experts that money can buy, trains them in their well-honed narrative to manufacture doubt in the minds of the jury and makes use of them over and over in case after case,” the study said. Given the ethical traditions of medicine, it seems likely that these physicians believe their well-compensated testimony on behalf of tobacco companies occurs in the shadows, out of view of their families, friends and professional colleagues, Jackler said.

Previously: What’s being done about the way tobacco companies market and manufacture productsHey doc, got a light? Research highlights Big Tobacco’s long history with the medical community and Throat doctors manipulated by Big Tobacco
Photo by PublicDomainPictures

Chronic Disease, In the News, Pain, Research, Science, Stanford News

Scientific discovery could lead to treatments for chronic pancreatitis

Scientific discovery could lead to treatments for chronic pancreatitis

Pancreatitis is one of the most common gastrointestinal hospital admissions-related illness. Patients with the acute form of the disease show up at hospitals doubled over with severe abdominal pain, a swollen belly that’s tender to the touch, nausea, and vomiting.

For some patients the disease flares up then disappears. For others, it develops into an ongoing, chronic form of the disease with no known cure. Not only is it extremely painful, it also causes malnutrition and carries with it a high risk of leading to pancreatic cancer. Treatment options are pretty much limited to prescription pain killers.

This has great implication in a disease that has no active therapy with no known agents that can alter its natural devastating course

It’s known that chronic pancreatitis is marked by the uncontrolled growth of scar tissue in the pancreas known as fibrosis, which slowly destroys the organ’s ability to function. Since the pancreas is in charge of excreting enzymes to digest food, patients begin to suffer malnutrition. It’s also known that excessive alcohol consumption is the leading cause of pancreatitis but just what is happening at a molecular level to cause the fibrosis is less clear.

Now, Stanford researcher and gastroenterologist Aida Habtezion, MD, and colleagues here and at Cedars-Sinai Medical Center have published research that sheds light on what exactly is happening and could lead to treatments for the severe disease. In a story I wrote on the study, Habtezion discusses their discovery of a new molecular pathway that when blocked by an experimental pharmacological drug can slow the progression of pancreatitis in animal models and in human cells.

As Habtezion told me, her lab’s research into just how the immune cells of the pancreas behave when inflamed with pancreatitis unveiled the new pathway:

“For the first time we can show that macrophages interact with pancreatic stellate cells via a particular immune pathway, and by targeting this pathway we show a decrease in chronic pancreatitis/fibrosis progression,” she said. “This has great implication in a disease that has no active therapy with no known agents that can alter its natural devastating course.”

The hope is that researchers will now be able to develop a form of the experimental pharmacological agent used in the study to block the molecular pathway that can be given to humans. Blocking the pathway will block the scar tissue growth, and hopefully either slow the progression of the disease or reverse it altogether.

Cardiovascular Medicine, Medical Apps, Precision health, Research, Stanford News, Technology

MyHeart Counts shows that smartphones are catching on as new research tool

MyHeart Counts shows that smartphones are catching on as new research tool

using iPhone - 560

In the three months since Stanford researcher and cardiologist Michael McConnell, MD, told ABC’s Nightline that the new MyHeart Counts iPhone app would give scientists “a whole new way to do research,” the number of users has continued to steadily climb.

“Traditionally reaching many people to participate in research studies is quite challenging,” McConnell told business correspondent Rebecca Jarvis in March. “The ability to reach people through their phone is one major advance.”

The number of iPhone owners who have downloaded the app and consented to participate in a large-scale study of the human heart has now reached 40,000. In an effort to keep updated on how the app is progressing as a new research method, I reached out to McConnell, the lead investigator of the study, with a few questions. The MyHeart Counts study continues to break ground as a new method for reaching large numbers of research participants in a short amount of time, McConnell told me. Comparing it to traditional research trials, he said:

There have been larger research studies, particularly national efforts to study their populations, but we believe enrolling this many participants in such a short time frame is unprecedented.

The app, which was launched in early March, collects data about users’ physical activity using the smartphone’s built-in motion sensors. Participants also answer surveys concerning their cardiac-risk factors. In return, they get coaching tips and feedback on their chances of developing heart disease.

McConnell says that the next phase of the project, which will use behavior-modification methods to encourage healthy behaviors, is about to be launched. App users will be given more personalized feedback about their individual behaviors and risk, based on the American Heart Association’s Life’s Simple 7 guidance. Future tips will include messages on everything from how to manage blood pressure, eat better, lose weight and control blood sugar. Part of the study is to determine whether these type of “pings” used through apps are actually successful at changing human behavior, McConnell told me:

Healthy behaviors are critical to preventing heart disease and stroke, so the MyHeart Counts app will study which motivational tools are most helpful. This will follow the second activity and fitness assessment… The initial approach will be empowering participants with more personalized feedback about their individual behaviors and risk.

To sign up for the MyHeart Counts study, visit the iTunes store.

Previously: Lights, camera, action — Stanford cardiologist discusses MyHeart counts on ABC’s Nightline, Build it (an easy way to join research studies) and the volunteers will comeMyHeart Counts app debuts with a splash and Stanford launches iPhone app to study heart health
Photo by Japanexperterna (CC BY-SA)

Stanford Medicine Resources: