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Behavioral Science, Chronic Disease, Neuroscience, Pain, Research, Stanford News

Obscure brain chemical indicted in chronic-pain-induced “Why bother?” syndrome

Obscure brain chemical indicted in chronic-pain-induced "Why bother?" syndrome

why botherChronic pain, meaning pain that persists for months and months or even longer (sometimes continuing well past the time when the pain-causing injury has healed), is among the most abundant of all medical afflictions in the developed world. Estimates of the number of people with this condition in the United States alone range from 70 million to 116 million adults – in other words, as much as half the country’s adult population!

No picnic in and of itself, chronic pain piles insult on injury. It differs from a short-term episode of pain not only in its duration, but also in triggering in sufferers a kind of psychic exhaustion best described by the rhetorical question, “Why bother?”

In a new study in Science, a team led by Stanford neuroscientist Rob Malenka, MD, PhD, has identified a particular nerve-cell circuit in the brain that may explain this loss of motivation that chronic pain all too often induces. Using lab mice as test subjects, they showed that mice enduring unremitting pain lost their willingness to perform work in pursuit of normally desirable goals, just as people in chronic pain frequently do.

It wasn’t that these animals weren’t perfectly capable of carrying out the tasks they’d been trained to do, the researchers showed. Nor was it that they lost their taste for the food pellets which with they were rewarded for successful performance – if you just gave them the food, they ate every bit as much as normal mice did. But they just weren’t willing to work very hard to get it. Their murine morale was shot.

Chalk it up to the action of a mysterious substance used in the brain for god-knows-what. In our release describing the study, I explained:

Galanin is a short signaling-protein snippet secreted by certain cells in various places in the brain. While its presence in the brain has been known for a good 60 years or so, galanin’s role is not well-defined and probably differs widely in different brain structures. There have been hints, though, that galanin activity might play a role in pain. For example, it’s been previously shown in animal models that galanin levels in the brain increase with the persistence of pain.

In a surprising and promising development, the team also found that when they blocked galanin’s action in a particular brain circuit, the mice, while still in as much pain as before, were once again willing to work hard for their supper.

Surprising, because galanin is a mighty obscure brain chemical, and because its role in destroying motivation turns out to be so intimate and specific. Promising, because the discovery suggests that a drug that can inhibit galanin’s activity in just the implicated brain circuit, without messing up whatever this mystery molecule’s more upbeat functions in the brain might be, could someday succeed in bringing back that drive to accomplish things that people in chronic pain all too often lose.

Previously: “Love hormone” may mediate wider range of relationships than previously thought, Revealed: the brain’s molecular mechanism behind why we get the blues, Better than the real thing: How drugs hot-wire our brain’s reward circuitry and Stanford researchers address the complexity of chronic pain
Photo by Doug Waldron

Aging, Chronic Disease, Public Health, Research

How multiple chronic conditions are affecting older Americans’ life expectancy

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

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

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

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

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

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

Chronic Disease, Research, Science, Stanford News, Technology

Stanford team develops nanotech-based microchip to diagnose Type 1 diabetes

Stanford team develops nanotech-based microchip to diagnose Type 1 diabetes

Dr. Brian Feldman?s M.D. hold a computer chip that he develop that will benefit diabetic patients at the Stanford School of Medicine,  on Thursday, July 4, 2014.  ( Norbert von der Groeben/ Stanford School of Medicine )

Years ago, when patients showed up at the doctor with excessive thirst, frequent urination and unexplained weight loss – in other words, the classic symptoms of diabetes mellitus – diagnosing them was usually just a matter of checking for high blood sugar. Yes, they needed to be treated for the correct form of the disease, but the two main types were found in different populations. So, in most cases, no lab test was needed to figure out whether someone had Type 1 or Type 2 diabetes; demographic factors were enough to make the distinction.

Of late, there’s been much more cross-over between the two groups. To treat patients correctly, it’s important to diagnose the right form of diabetes, but there’s a problem: The only test that does so is expensive, cumbersome and available only in hospitals.

So it’s great news that Stanford scientists are developing a new Type 1 diabetes test, described in a paper published online this week in Nature Medicine. The new nanotechnology-based microchip, which researcher Brian Feldman, MD, PhD, holds in the photo above, tests patients’ blood for the auto-antibodies that cause Type 1 diabetes. The new test is cheap, portable, and uses much less blood than the older diagnostic test. Unlike the old test, it requires no radioactive reagents and is simple enough to use in low-tech settings.

The test uses a nanotech enhancement (specifically, nano-sized islands of gold; hence the golden glow of the chip that Feldman is holding) to help detect auto-antibodies. In addition to diagnosing new patients, this technology will also enable better research into how Type 1 diabetes develops, as our press release explains:

…[P]eople who are at risk of developing Type 1 diabetes, such patients’ close relatives, also may benefit from the test because it will allow doctors to quickly and cheaply track their auto-antibody levels before they show symptoms. Because it is so inexpensive, the test may also allow the first broad screening for diabetes auto-antibodies in the population at large.

“The auto-antibodies truly are a crystal ball,” Feldman said. “Even if you don’t have [Type 1] diabetes yet, if you have one auto-antibody linked to diabetes in your blood, you are at significant risk; with multiple auto-antibodies, it’s more than 90 percent risk.”

Feldman’s team has started a biotech company to further develop the test and is seeking FDA approval for the new method. In addition, Stanford University and the researchers have filed a patent for the new technique.

Previously: A simple blood test may unearth the earliest signs of heart transplant rejection, Stanford microbiologist’s secret sauce for disease detection and One family’s story on caring for their children with type 1 diabetes
Photo by Norbert von der Groeben

Chronic Disease, NIH, Patient Care, Research

NIH network designed to diagnose, develop possible treatments for rare, unidentified diseases

doctors' tools - smallVertigo, nausea, headache, fatigue, confusion. For years someone close to me has experienced severe and periodic bouts of these symptoms. It’s clear something is wrong and yet, despite countless tests and visits with specialists in cardiology, neurology, ophthalmology, pulmonology, otolaryngology, and immunology, no one has been able to figure out what that something is. At one of his last appointments – to the great disappointment of this patient and (perhaps even more so) his worried and frustrated wife – my loved one was gently told that he may have to face the very real possibility that he’ll never get a definitive diagnosis.

Unfortunately, this patient is far from alone: Plenty of people are living with mysterious symptoms that affect their quality of life (or worse), and it’s not uncommon for patients with rare diseases to have waited years for their diagnosis. With this in mind, the National Institutes of Health launched in 2008 its Undiagnosed Diseases Program, a pilot program designed to “provide answers to patients with mysterious conditions that have long eluded diagnosis” and “advance medical knowledge about rare and common diseases.” (Since that time, 600 children and adults have been evaluated, and approximately 100 patients were given a diagnosis.)

Now, the program is being expanded into the Undiagnosed Diseases Network, with the NIH announcing last week that six medical centers – including Stanford – will be joining and contributing local medical expertise. The NIH will work with experts from these centers (including Euan Ashley, MD, PhD, Stanford’s principal investigator) to, as described in a release, “select from the most difficult-to-solve medical cases and together develop effective approaches to diagnose them.” The physicians will “collect and share high-quality clinical and laboratory data, including genomic information, clinical observations and documentation of environmental exposures,” and they’ll “benefit from common protocols designed to improve the level of diagnosis and care for patients with undiagnosed diseases.”

In our online story on the network and the $7.2 million grant that Stanford received, Matthew Wheeler, MD, medical director for the grant, notes that “Stanford was chosen for our informatics expertise, our experience with clinical interpretation of whole-exome and whole-genome data, and our scientific potential to follow up any lead.” As my colleague Erin Digitale further explained:

The team will use cutting-edge genomics and medical phenotyping techniques to diagnose patients, and will also aim to understand the underlying biology of patients’ conditions so they can generate targets for new therapies, Wheeler said. “We aim to make a deep dive into each patient’s biology,” he added.

By the summer of 2017, each new clinical site is expected to see 50 or more patients per year. Referring clinicians can submit applications on behalf of undiagnosed patients on the program website.

Previously: Using crowdsourcing to diagnose medical mysteries, New search engine designed to help physicians and the public in diagnosing rare diseases and The road to diagnosis: How to be insistent, persistent and consistent
Photo by Adrian Clark

Chronic Disease, Stanford News, Videos

Gracefully saying goodbye: Isabel Stenzel Byrnes shares lessons to help cope with losing loved ones

Gracefully saying goodbye: Isabel Stenzel Byrnes shares lessons to help cope with losing loved ones

Isabel Stenzel Byrnes and her identical twin sister Anabel were diagnosed with cystic fibrosis when they were only three days old. At the time, physicians told their parents it would be unlikely that they would survive to see their 10th birthday. Working together, the sisters completed rigorous daily respiratory and digestive treatment to maintain their health, and in their 20s, they received double lung transplants at Stanford Hospital & Clinics. The dynamic duo become forceful organ donor advocates and authored a memoir, titled The Power of Two, that inspired an award-winning documentary.

In this powerful and moving TEDxStanford talk, Byrnes shares her lifelong experience of practicing the art of saying goodbye. Over the past 30 years, she has said goodbye to 123 friends, including her sister, who died of cancer last October. To help others cope with loss, she discusses the lessons about bereavement that she’s learned along the way and outlines the choices we have in saying goodbye.

Previously: A spotlight on TEDxStanford’s “awe-inspiring” and “deeply moving” talks, Film about twin sisters’ double lung transplants and battle against cystic fibrosis available online, Meet the filmmakers behind “The Power of Two” and Living- and thriving- with cystic fibrosis

Ask Stanford Med, Chronic Disease, Grand Roundup, Stanford News

Stanford physician Sanjay Basu on using data to prevent chronic disease in the developing world

Stanford physician Sanjay Basu on using data to prevent chronic disease in the developing world

Basu and RosenkranzThere’s a new health policy challenge in developing countries. Though many see chronic conditions like type-2 diabetes and heart disease as problems plaguing the wealthiest nations, “Nearly 80 percent of the deaths worldwide from these two diseases are coming from the developing world,” says Sanjay Basu, MD, PhD, an assistant professor of medicine at the Stanford Prevention Research Center.

But Basu is working to change this statistic, and his efforts just won him the $100,000 George Rosenkranz Prize for Health Care Research in Developing Countries. Administered by Stanford’s Center for Health Policy/Center for Primary Care and Outcomes Research at the Freeman Spogli Institute for International Studies, the award will help fund Basu’s large-scale data collection project in India. With a data set from over 65,000 people, Basu hopes to improve type-2 diabetes screening in the country, leading to better treatment and detection of the disease.

A researcher focused primarily on global development and human health, Basu is also an internal medicine physician with a master’s in medical anthropology and a doctorate in epidemiology. In the following Q&A, he discusses his current research interests and plans for the future.

How did you first become interested in global health policy and the developing world?

As a child, our family went back and forth between the United States and India, and the contrasts in daily life were striking and overwhelming. There is a sense in many parts of India that life is a privilege, and a constant struggle to maintain.

Your research in India will involve data collection and mathematical modeling, which sounds rather abstract. How does this work translate into real-world improvements in people’s health?

Our research serves as a bridge between the clinical science of how to prevent and treat disease, and the detailed operations of how to actually deliver better prevention and treatment in the real world. What we specifically do is combine biological and clinical data with data on program reach, budgets, and operations. In other words, we might learn how to build a car in a textbook, but our models look at how to make the car factory operate optimally so that the product, in the end, is drivable. We’ve worked closely with both government agencies and non-governmental groups to deliver programs in real-world populations, and to continuously improve those programs over time. For example, our work on how to introduce better tobacco control programs in India has actually resulted in recent legislation that has lowered tobacco use in some critical parts of the population.

What’s different about approaching chronic disease prevention in India versus in the United States?

The sheer size and diversity of the population is one big difference. India is four times the size of the United States, and far more diverse. There is simultaneously malnutrition and obesity, starvation and type-2 diabetes, vitamin deficiency and heart attacks – often in the same city. That means designing programs for a country – or a province, or even a city – requires a lot of attention to complicated perverse outcomes that may happen. For example, we’ve looked into reducing sodium intake as a strategy to lower hypertension and cardiovascular disease. But we also have to make sure that we don’t generate iodine deficiency since salt is the major delivery strategy for iodine and, unlike the United States, iodine deficiency is a serious concern in India.

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Chronic Disease, Public Health, Stanford News

Stanford alums aim to bring back a community approach to treating chronic disease

Inspired by shared medical appointments and Blue Zones, areas in the world where people live measurably longer lives, fourth-year medical student Sohan Japa, MBA, and Stanford alumna Bansi Shah are striving to bring back a community approach to treating chronic disease and enable better care that is efficient and evidence-based.

Japa and Shah partnered with Stanford physician Bryant Lin, MD, earlier this year on a small study to test the effectiveness of using a private social network for diabetic patients and their care teams. Based on this pilot they developed HealthCrew, a secure online platform to help clinicians more effectively manage patient populations. In the following Q&A, Japa discusses the results from the pilot, the technology behind the platform and the next phase of the study.

What about the group health visit setting did you find particularly inspiring?

The way patients leaned on each other for support and guidance was very powerful. A doctor or nurse may remind you over and over about your diet, but when it comes from a peer, it is just much more convincing and impactful. And, every group had an unofficial leader who would do an amazing job in inspiring the group and mentoring others who may not be as empowered about the condition.

What did the preliminary results of the pilot show?

In this initial pilot, we were curious how patients would respond and whether they would see the value in it. And the overwhelming response was yes. Patient engagement and satisfaction rates were higher than we expected. We are doing a second pilot to test the results with a larger group and also start tracking the software’s impact on actual health outcomes. The participants in the initial pilot also gave us great feedback on how to make the platform even better.

Can you briefly explain how the platform works?

The platform is designed to deliver tailored education, which is something doctors don’t have time to provide in a typical 15-minute visit.

There are three key components to our platform. The first is a medical intake tool, which is able to assess a patient’s health literacy and social/emotional capacity. The second component is a content engine that takes the results of the medical intake to tailor education and materials. For example, a patient who scored low on our empowerment scale will get materials to help raise their confidence and skill set to tackle their condition. The last component of our platform is a peer-to-peer mentoring tool, which allows patients to confer securely with similar patients both online and offline.

The Affordable Care Act, in addition to healthcare reform at the state level, has put new attention on patient outcomes. Increasingly hospitals and clinics are on the hook for the health outcomes of their patients. So a platform like this is timely. Because it helps patients in between those semi annual visits they have with their doctors.

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Autoimmune Disease, Chronic Disease

Empowered is as empowered does: Making a choice about living with lupus

We’ve partnered with Inspire, a company that builds and manages online support communities for patients and caregivers, to launch a patient-focused series here on Scope. Once a month, patients affected by serious and often rare diseases share their unique stories; this month’s bonus column comes from Pattie Brynn Hultquist, C.H

“How do you do it?”

I get it. A mother of five, a wife, a childcare provider, president of the condo board. Chartered herbalist, scrapbook design team member, wool and fiber spinner, avid camper. Yoga enthusiast, a weight-training type-2 diabetic – the list continues.

How, exactly, does one manage living with an autoimmune disease like lupus: the disease of a thousand faces, the epitome of “You don’t look sick”?

When I first received my diagnosis of systemic lupus erythematosus I was devastated not only for myself but for my family, friends and extended personal communities. It wasn’t just me receiving a diagnosis on that brilliantly colored fall day in 2010; it was my entire social network.

Lupus can affect people very differently. Some people have skin issues. Some have joint pains. Some, like myself, also have had a heart attack, pericarditis and kidney issues that makes taking medications a game of pharmaceutical roulette: sometimes, medications makes me feel worse.

That isn’t living. That’s existing.

I joined forum after forum, community after community, group after group, all over the Internet. I had to know how to live with an autoimmune disease. What I found were either the “Whine-1-1” or the “Positive 24/7!” I left them all.

I felt a little like Neo when offered a choice between the red pill and the blue pill.

My choice?

Taking neither and forging my own way through this made-for-TV-movie kind of life living with a chronic disease.

I started a blog. I started sharing how I, a mother of five in the chaos of my reality, was living with lupus. I wrote about the good, the bad, the ugly, and the deliriously exhausted life I live. It struck a chord with many who know chronic illness for its complexity. There were so many people experiencing the very same thing!

I went from blogger to globally recognized health advocate. And one day I told my primary care physician about my writing. I told her about how many people are suffering in silence because they feel “invisible” not just with their health-care teams, but with friends and even family. I even told her about how I felt that way, myself. She told me, in all honesty, that she had never really considered the magnitude of social effects that someone’s diagnosis can engender.

I was stunned. Sure, she had mentioned my husband and children at our appointments, yet she conceded that she had simply not considered event invitations no longer extended (I simply can’t commit to one way or another because lupus can flare up at any given time with pain, exhaustion or sickness), or, of having often to redefine my abilities and seek out new friendships in order to keep proactively engaged in life.

That was the day I illustrated the research, networking and usage benefits of social media as my outlet, and she became empowered to begin treating the socio-emotional impact of health care: how interpersonal communities and social media can be a powerful tool in the health-care toolbox for individual patients.

The result? I was validated by the health-care professional who is most intimately aware of the clinical and physical demands of this disease on my body and how it affects my entire social network. Validation heightens my confidence to be a proactive patient. Proactive behavior advances whole-body health care and awareness.

Choice is a beautiful thing.

Pattie Brynn Hultquist, C.H., is a globally recognized lupus and chronic illness health advocate at her weblog, Lupus Interrupted. A team captain for the Walk for Lupus, held annually, she participates in fundraising efforts at Gold Award levels for Lupus Ontario. She can be found on multiple social media platforms sharing information, resources and the realities of living with chronic conditions, her supportive family always within reach.

Chronic Disease, Public Health, Research, Technology

More evidence that text message programs can help in managing diabetes

mobile_phone_6.16.14Previous research has shown that automated daily text messages can increase medication adherence among diabetic patients and reduce their repeated visits to the emergency room. Now new research offers more evidence that text-message-based programs are an effective tool in helping in those with type 2 diabetes improve their glycemic control.

For the study, researchers from the Scripps Whittier Diabetes Institute partnered with a San Diego-based community clinic providing care to a large percentage of Latino patients with type 2 diabetes. A group of 126 patients were randomly assigned to receive either standard care alone or standard care combined with frequent text messages. According to a release:

Standard care consisted of regular visits with a primary care physician and a brief computerized presentation conducted in English or Spanish that included; diabetes nutrition standards; desired targets for blood sugar, cholesterol and blood pressure; and medications recommended to achieve control.

For the text messaging group, the same standard care was provided but in addition messages were sent to their mobile devices at random times throughout the week. The messages focused on healthy nutrition tips, the benefits of physical activity and medication adherence, and requests to check blood sugar and send back results. Two to three messages were sent each day at the beginning of study enrollment, and the frequency tapered off over a six-month period.

“At the six-month mark, we found that the Dulce Digital [study] participants had a significantly larger decrease in hemoglobin A1c test levels than the control group,” said [Athena Philis-Tsimikas, MD, corporate vice president for the Scripps Whittier Diabetes Institute.]

Noting the promise of mobile phones to aide low-income populations in managing chronic diseases, Philis-Tsimikas said in the release, “We found that by using text messages we were able to circumvent many of the barriers these patients face, such as lack of transportation or childcare, while still being able to expand the reach of diabetes care and education.”

The findings were presented on Friday at the 74th Scientific Sessions of the American Diabetes Association in San Francisco.

Previously: Text message program helps smokers “stay focused on quitting”, Text message reminders shown effective in boosting flu shot rates among pregnant women and Texts may help people with diabetes manage care
Via HealthCanal
Photo by Wolfman-K

Chronic Disease, Patient Care, SMS Unplugged

High yield: Lessons from a 4-year-old

High yield: Lessons from a 4-year-old

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

AlanIn two days, we take our last exam as first-year medical students. Sitting in the same library that I used to as a pre-medical student, I think about what it is, exactly, that has changed this year. For me, the point of transition from pre-med to med student really happened over Thanksgiving break a few months ago.

I had come home from my first term of medical school more ready for my mom’s hugs and homemade banana bread than ever. People say that the first few terms of medical school are like trying to drink out of a fire hose, because there’s so much information we are expected to learn and retain. On an average week, for example, we have 40 hours of class, not to mention the time we need to study.

Luckily, one of the hardest classes this term had its final the day before Thanksgiving break, so we could go home with some amount of stress alleviated. Biochemistry had been the hardest, least intuitive class for me, and I was relieved it was done – and I was happy to be with my family.

* * *

“So what have you learned in medical school?” my beloved step-dad, Dan, asks excitedly. We’re having our traditional family brunch, with my grandparents, parents and sister, and all the cousins that are around. I look down at my plate, thinking. I’ve learned that the vitamin B12 bottle I can see on our kitchen counter next to the leftover pie contains a unique vitamin because it’s only helpful to two enzymes. I’ve learned how the fatty food that we’re eating kills us, and what that food looks like in dead bodies.

“Diabetes,” I answer, smiling at Dan. “I’ve learned how the two types of diabetes happen.”

“Ah, sí?” my grandmother asks in Spanish. “Debemos invitarle a Bea para que nos enseñes.”

My little 7-year-old cousin, Aida, was diagnosed with type 1 diabetes two years ago. It’s caused quite a stir in my Hispanic family that we can’t feed her quesillo, bread or even fruit without worrying. Her mom, my Aunt Bea, has been plagued with guilt that she did something wrong ever since the diagnosis.

In every family there is that one cute little kid – usually the youngest – whose misbehavior makes all the other kids look like angels. Punishment doesn’t work because they don’t mind being yelled at, discipline doesn’t work because they’re stubborn, and praise doesn’t work because they’re so cute they get attention all the time anyway. If my siblings read this, they’ll nod their heads remembering me as a child. When I hear this description, though, I think of my 4-year-old cousin, Aida’s little brother. He is the most beautiful little child, with big brown eyes, tan skin and dark rusty red hair.

Alan was born when I was already away in college, so I don’t get to see him or his adorable older sisters very much. But here I am now, with Alan and the rest of my family, who gather on the couch after brunch and wait for me to explain to them what’s going on with Aida. I talk with Aida and Bibi, the two little girls, about clean-up cells that got the wrong message in Aida’s body.

I’m asking Aida and Bibi to explain to me what they understood from what I had said when I look over at my aunt to make sure she’s okay. It’s then that I realize that Alan is quiet. It’s the only time that I’ve ever seen him sit quietly, and I see his attention is on me, as well. There’s no way he understood what I was talking about with beta cells and the immune system, but he understands that this is important, and because everyone in his family is focused on it, so is he. In the dynamics of his family, diabetes trumps all other cards.

***

In that moment, my 4-year-old cousin taught me the two most important lessons that I’ve learned so far in medical school. First, that diseases – whether common and rather boring to learn about, or rare and still not understood – affect everyone in the patient’s family. Every family has someone with something, my own included. And, second, everyone whose life is influenced by such diseases looks to doctors more often for support, affirmation and solidarity than anything else. This moment on the couch with my precocious cousin listening to me, this was medicine. And I was becoming a doctor.

Natalia Birgisson is a first-year medical student at Stanford. She is half Icelandic, half Venezuelan and grew up moving internationally before coming to Stanford for college. She is interested in neurosurgery, global health, and ethics. Natalia loves running and baking; when she’s lucky the two activities even out.  

Photo of Alan Higuery by Beatriz Royo Higuerey

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