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Ethics, Global Health, Health Policy, In the News, Medicine and Society, Public Health

Thinking about “culture” as part of global well-being

Thinking about "culture" as part of global well-being

5294003888_300b57c958_zEffective and ethical global-health initiatives involve some acknowledgement of culture – that is, they take into account local practices, beliefs, and circumstances, and they recognize that medicine is not “one size fits all.” A recent post on the blog Anthropological Observations takes this one step further, asserting that “culture” should be seen as something that is always changing, rather than a static fact to be accounted for. As a medical and cultural anthropologist pursuing a PhD, I couldn’t agree more.

Culture is often seen as a barrier to health by global-health professionals, as in “it’s not part of the local culture to visit clinics” or “cultural beliefs about how medication works make patients non-adherent to drug regimens: they take pills when they experience symptoms instead of at regular intervals.” Such observations are useful and can help adapt health initiatives to specific locales. However, this attitude can also be paternalistic and limiting because it doesn’t give people credit for being able to adapt to new information or situations.

The post’s author, Ted Fischer, PhD, a professor of anthropology at Vanderbilt University who has been advising the WHO’s project on the cultural contexts of health, writes:

A human-centered approach to health and wellbeing should adopt contemporary understandings of culture as dynamicfuture oriented, and driven by agency. We in anthropology now see culture as much more of a fluid process, a process rather than a thing. Cultural actors are always improvising, actively creating meaning out of the resources at hand.

He concludes that it is more accurate is to see culture as an opportunity for health, instead of an obstacle to it.

Previously: Exploring the benefits of pursuing anthropology and medicine, What other cultures can teach us about managing postpartum sleep deprivation, Exhibit on health and medicine among indigenous cultures opens at US National Library of Medicine and It’s a small world after all: Global health field takes off in the US
Photo by Onasil Bill Badzo

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

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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.

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Clinical Trials, Ethics, Research, Stanford News

Should patients pay their way into clinical trials?

Should patients pay their way into clinical trials?

Photo of U.S. currency and a pharmaceutical capsuleIn a time of shrinking federal research budgets, here’s one idea for a solution: charge patients to participate in clinical trials.

Patients’ payment could fund studies that would not otherwise be conducted, said a group of medical ethicists led by Ezekiel J. Emanuel, MD, PhD, the former White House health-policy adviser who now chairs the Department of Medical Ethics and Health Policy at the University of Pennsylvania. Emanuel was asked by a group of academic investigators to review the legality and ethics of charging for enrollment in an early-phase clinical trial; he and his co-authors examine the pros and cons.

No laws or regulations prohibit pay-to-play, said the authors, and it has some upsides. By putting their money where their mouth is, patients could be demonstrating deep engagement with the research protocol, and affirming their informed consent. Their payment could be seen as a direct, Kickstarter-style version of a charitable contribution to medical research, or as an analogue to permissible payment for experimental treatments outside the confines of a clinical trial. Last but not least, there is a liberty argument, that “people should have the freedom to do whatever they want with their own money as long as they are not harming others or diminishing their rights and opportunities,” said the authors, whose perspective essay (subscription required) appears today in Science Translational Medicine.

But before going full libertarian, the authors put on the brakes. Let’s be honest, they said, this is less about a collaborative partnership than a potentially desperate need to save one’s own life; less about a charitable impulse than purchasing a service. It will skew research toward the health needs of the wealthy and could interfere with research integrity: A paying participant may be less willing to accept randomization to a control group or more reluctant to disclose symptoms and side effects. For their part, investigators might feel pressure to bend inclusion or removal criteria, or not to terminate a study. Ultimately, the authors conclude that pay-to-play is generally unethical, and warrants legislative and regulatory attention.

Co-author Govind Persad, JD, a Stanford graduate student in philosophy, told me he’s particularly concerned about participants feeling pressure to pay: “There is this real psychological pressure, if you or your kid are sick or in this desperate position, to do something that not only you wouldn’t have done, but that you see as having this direct, imminent benefit to yourself out of proportion to the benefit it’s likely to have.”

Persad hopes the essay will ignite an “educated debate” among researchers, policy makers, potential donors to medical research and people who stand to benefit from interventions to be studied in clinical trials. “An issue for people to think about going forward is: If we need more research into Condition X but pay-to-play is not the way, what would be some other good ways to try to expand the universe of trials?”

Related: A look at crowdfunding clinical trials, Can crowdfunding boost public support and financing for scientific research, Stanford forum on the future of health care in America posted online and When it comes to health-care spending, U.S. is “on a different planet”
Photo by David Goehring

Ethics, In the News, Medicine and Society, Science, Science Policy, Sports, Stanford News

Stanford expert celebrates decision stopping testosterone testing in women’s sports

Stanford expert celebrates decision stopping testosterone testing in women's sports

Female track and field athletes no longer need to have their natural testosterone levels below a certain threshold to compete in international events, the so-called “Supreme Court of sports”, the Court of Arbitration for Sport, ruled Monday.

Katrina Karkazis, PhD, a Stanford senior research scholar who was closely involved with the case, got the news on Friday, while she was in a San Francisco dog park. “What a day!” she said. “I was madly refreshing my email — I thought we were going to lose… I just started screaming and crying.”

Karkazis, who is an expert on ethics in sports and also gender, said she spent a year of her life working on the case.

She served as an advisor to 19-year-old sprinter Dutee Chand, who challenged the regulation that female athletes must have certain testosterone levels or undergo medical interventions to lower their testosterone to be allowed to compete against women in events governed by the International Association of Athletics Federations (IAAF), the international regulatory body of track and field.

The ruling suspends the IAAF’s testing regimen for two years, but Karkazis expects the decision will lead to permanent changes in women’s sports, including a reevalution by the International Olympic Committee.

“I’m thrilled,” Karkazis said. She said she was also surprised. “I didn’t think it was our time. I thought there were still too many entrenched ideas about testosterone being a ‘male hormone’ and it not belonging in women.”

Karkazis gained international attention after penning an op-ed in The New York Times in 2012 when the IAAF and the International Olympic Committee crafted a new policy banning women with naturally high levels of testosterone from competing.

“You can’t test for sex,” Karkazis said. “It’s impossible. There’s no one trait you can look at to classify people. There are many traits and there are always exceptions.”

She said that now women who have lived and competed their entire lives as women will be eligible to compete, a default policy she believes is sufficient to ensure a level playing field.

Previously: “Drastic, unnecessary and irreversible medical interventions” imposed upon some female athletes, Arguing against sex testing in athletes and Is the International Olympic Committee’s policy governing sex verification fair?
Photo by William Warby

Emergency Medicine, Ethics, Global Health, Medicine and Society, Patient Care

After Haiyan: Stanford med student makes film about post-typhoon Philippines

After Haiyan: Stanford med student makes film about post-typhoon Philippines

Multi-talented Stanford Medicine student Michael Nedelman has been featured on Scope before for his filmmaking and storytelling abilities. His new film, “After Haiyan: Health narratives in the aftermath of the typhoon,” is a series of vignettes about the November 2013 disaster in the Philippines. The film, which will be released soon, connects socioeconomic and structural issues of access to health in times of crisis.

It was filmed primarily in Tacloban, Leyte, in July and August of 2014, and Nedelman made a follow-up visit in November and December to premiere and promote the project. Despite his busy end-of-school-year schedule, Nedelman answered some questions for me about his work in a recent email exchange.

What was it like filming in the wake of a tragedy? 

Phil Delrosario said it best. He’s the cinematographer and editor I met here at Stanford. Knowing when to turn on the camera was a “huge balancing act” between our drive to document the truth, and our obligation to be compassionate storytellers. We couldn’t ignore the emotional weight of Typhoon Haiyan, and we couldn’t ignore the fact that we weren’t part of the communities we were documenting. So we sought out people who not only wanted to share their stories with us, but who could also provide some insight as to how they wanted those stories to be seen… For one of the videos, Deaf advocates like Noemi Pamintuan-Jara reached out to us first, not the other way around… That was really special for us, to be able to work alongside a community that has been promoting Deaf accessibility and culture long before we ever arrived on the scene. And we had these new partners who could give meaningful feedback on our filmmaking decisions.

Filming in the wake of a tragedy doesn’t mean everything is tragic. The shadow of Haiyan is still there, but there’s also a sense of living in the moment and moving forward. All over the city, you’ll see posters and graffiti that say, “Tindog Tacloban!” (“Rise Tacloban!”) That’s something that really resonated with our team and the ethos of our project. You can’t tell the full story of Tacloban without optimism and resilience.

How does this film link storytelling and health, and what is special about that for you?

When I was first discussing the project with one of the producers, Roxanne Paredes, we asked ourselves a similar question: How would our project add to or nuance the coverage of the typhoon? Right after the storm, Haiyan was all over the news. Tacloban was in survival mode. But months later, after many of those cameras had left, there was a different set of long-term challenges and a focus on recovery. Those were the issues we wanted to explore, which tend to be less covered by the media but still have profound implications for community health and future disaster preparedness. In short, just because the cameras stopped rolling doesn’t mean there weren’t more stories to tell. That really broadened the way in which I think of health stories.

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Ethics, Imaging, Medicine and Society, Neuroscience, Research, Stanford News, Technology

Hidden memories: A bit of coaching allows subjects to cloak memories from fMRI detector

Hidden memories: A bit of coaching allows subjects to cloak memories from fMRI detector

11501949224_dac2b41c91_zImagine the usefulness of knowing if someone is drawing on a memory or experiencing something for the first time. “No, officer, I’ve never seen that person before.” 

That’s possible, using an algorithm that interprets brain scans developed by a team of Stanford researchers led by psychology professor Anthony Wagner, PhD. But according to a Stanford Report articleit’s also possible to fool that same program when subjects are coached to hide their memory.

The program, or decoder, capitalizes on the complexity of memory, which taps many different regions of the brain. They use functional magnetic resonance imaging (fMRI) to view which parts of the brain are active.

Hoping to illustrate the limits of their own creation, the researchers asked 24 study participants to study a series of faces. The next day, they exposed them to some of the same faces mixed with entirely new faces:

“We gave them two very specific strategies: If you remember seeing the face before, conceal your memory of that face by specifically focusing on features of the photo that you hadn’t noticed before, such as the lighting or the contours of the face, anything that’s novel to distract you from attending to the memory,” said Melina Uncapher, PhD, a research scientist in Wagner’s lab. “Likewise, if you see a brand-new face, think of a memory or a person that this face reminds you of and try to generate as much rich detail about that face as you can, which will make your brain look like it’s in a state of remembering.”

With just two minutes of coaching and training, the subjects became proficient at fooling the algorithm: The accuracy of the decoder fell to 50 percent, or no better than a coin-flip decision.

The new study shows that imaging technology alone will not be able to “pull about the truth about memory in all contexts,” Wagner said. And, as pointed out in the article, he “sees [the results] as potentially troubling for the goals of one day using fMRI to judge ‘ground truth’ in law cases.”

Previously: Memory of everyday events may be compromised by sleep apnea, The rechargeable brain: Blood plasma from young mice improves old mice’s memory and learningResearchers explore the minds of man’s best friend using fMRI technology, Using fMRI for lie detection and Brain scan used in court in potential fMRI first
Photo by David Schiersner

Ethics, Health and Fitness, Medicine and Society, Orthopedics, Patient Care, Sports

Thinking through return-to-play decisions in sports medicine

Thinking through return-to-play decisions in sports medicine

2913800550_7fc291c915_zIn an opinion piece appearing in the AMA Journal of Ethics today, two Stanford physicians – Michael Fredericson, MD, and Adam Tenforde, MD – explore the ethics of how doctors should advise patients recovering from an injury.

Consider this scenario, the case which opens the piece:

Jordan is a 17-year-old senior in high school who has been his football team’s star quarterback, led his team to two state championships, and has a real possibility of receiving a full scholarship to a top college sports program next year. In his last session of summer training camp, Jordan took a fierce hit… [an MRI] showed that Jordan had a torn labrum in his right shoulder that would require surgery and months-long recovery, meaning that he would miss the rest of his final season.

[His physiatrist] had known instances in which this particular type of injury ended a quarterback’s athletic career. She had also read about a few cases in which athletes recovered fully from the injury. Since so much of recovery depends on the injured person’s following the rehabilitation and physical therapy plans, [she] wanted Jordan to approach his injury with the optimism that adherence to the plan would enable him to return to athletics. At the same time, she did not want to hold out false hope that might keep Jordan focused exclusively on football when, in the long term, that might not be the best use of his senior year.

The most important part of what we’re trying to convey when treating athletes is that as team physicians our goal is the health and well being of the athlete

When college scholarships and admissions decisions are on the line, a doctor’s recommendations affect more than her patient’s physical health. How to weigh the different interests at stake? Fredericson and Tenforde make clear that medical decisions must prioritize the long-term health of the athlete. When I interviewed him, Fredericson, a professor of orthopedic surgery, director of PM&R Sports Medicine, and team physician for Stanford Athletics, told me:

The most important part of what we’re trying to convey when treating athletes is that as team physicians our goal is the health and well being of the athlete. Ultimately, we are the ones who are trying to protect their health. Sports physicians have gotten a bad rap; people think we’re trying to help coaches, or help athletes at the expense of their overall or long term well being. We might push the process to help try to get them better more quickly, but ultimately we have their long-term best interests in mind.

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Behavioral Science, Ethics, Events, Medicine and Society, Mental Health

Anger: The most evil emotion or a natural impulse?

Anger: The most evil emotion or a natural impulse?

5846841745_f2f620c5d3Anger isn’t good for your health. It spikes your heart rate, exacerbating heart conditions and anxiety. It leaves an ugly residue, a sensation of unease and aggression and it can lead to violence against others or oneself.

But in the west, we have an uneasy relationship with this powerful emotion, said Owen Flanagan, PhD, co-director of the Center of Comparative Philosophy at Duke University and speaker at the annual Meng-Wu lecture hosted by the Stanford Center for Compassion and Altruism Research and Education last week.

In the United States and Europe, some anger is considered justified, even necessary for healing after one is wronged, Flanagan said. It’s natural, just a part of our constitution. An appropriate amount of anger is expected, a sign that you care. Flipping out because your barrista took too long making your latte? Probably not okay. But yelling at a driver who rear-ended you while texting? Certainly.

Not in Asia, Flanagan said. There, in accordance with Buddhist traditions, anger is right up there with hatred as the worst emotion, something that should be eliminated as soon as it arises.

Flanagan said he and other academic colleagues posed a question to the Dalai Llama several years ago: If you find yourself in a public place with a very bad person, like Hitler, before the atrocities have started, what should you do? Westerners would say anger was AOK, as was perhaps even murder. After conferring with his colleagues, the Dalai Llama said yes, murdering Hitler would be justified to prevent a very bad karmic causal chain. But anger? Absolutely not.

One could argue that even Hitler’s behavior was a byproduct of his genes, his upbringing, the surrounding society, Flanagan told the audience.

Flanagan said he still hasn’t figured out his own views toward anger. “Anger is a destructive emotion, but it might be a necessary emotion. I’m still not sure about that.”

But in the U.S., we don’t always live in accordance with our own traditions, Flanagan said. “We give ourselves sloppy permissions all over the place to be very angry people. That’s something that’s just not good.”

To counter anger, Flanagan offers several tips, drawn from both western and eastern traditions. First, embrace an emotion that is incompatible with anger, such as gratitude. Or reflect on your own insignificance and the transitory nature of the harm: This too will pass. “Astronomy is a good antidote to taking yourself too seriously,” Flanagan said.

In a longer term, Seneca suggests that it helps to “live among people who teach the children that anger is always bad.”

But is it even possible to completely eliminate anger? Some argue no, even babies express a form of frustration or discontent that could be a sign of inner anger. Or, we could all be conditioned by society, learning to be angry as soon as we’re born.

Previously: Bright lights breed stronger emotions, study finds, Is it possible to control one’s emotions? and Study suggests emotions may trump mind in matters of self-control while meditating
Photo by katmary

Ethics, In the News, Patient Care, Pediatrics

Study of outcomes for early preemies highlights complex choices for families and doctors

Study of outcomes for early preemies highlights complex choices for families and doctors

3363144800_8c4c7ee6a5_zA tiny fraction of babies born at 22 weeks of gestation survive to childhood without major impairments or disabilities, according to a study recently published in the New England Journal of Medicine. But, although some of these babies can do well, there is variation between hospitals in the rate at which they are resuscitated after birth.

As was widely reported late last week, the results add to the existing debate about providing the earliest-born preemies with intensive medical care. I talked with Henry Lee, MD, a neonatologist at Lucile Packard Children’s Hospital Stanford, to get his take on the new findings. Doctors who work with tiny preemies and their families aren’t surprised by the study’s results, Lee told me, since the generally poor outcomes for 22-week babies are consistent with other studies. But they are carefully considering what to do next.

“We already knew, to a large extent, that there is variation in how different practitioners and hospitals manage patients in this peri-viable range,” Lee said. “Some hospitals tend to be more aggressive at resuscitating and actively treating these babies, others less so.”

The study’s findings highlight that doctors may have difficulty letting parents make the choice about how to handle the birth of a very early preemie, Lee noted. “We’re supposed to be communicating with parents, and they’re supposed to be making an informed decision,” he said. The variation between hospitals suggests that’s not what is actually happening; if parents were deciding what to do, the rate of resuscitation would be more consistent across hospitals. “This data is telling us that we as medical professionals are making the decision for parents, especially at really young gestational ages,” Lee said. “It’s an area that we need to continue to learn to deal with better.” Hospitals also vary in their capacity to care for such babies, he added.

Physicians from several Bay Area hospitals have already begun meeting to discuss their approaches to the earliest-born preemies, he told me. “We might not practice exactly the same, but we want to understand the rationale for what everyone is doing,” Lee said. “If one group is doing something that makes sense, we could learn from them.”

And the study also brings into focus the difficulty of balancing statistics against an individual family’s situation, Lee added. “These larger population studies help us to counsel families, but one thing I always have to say to them is that there’s uncertainty,” he said. “I tell parents that we don’t know what is going to happen to their baby – ultimately their baby is an individual and we don’t know yet. There is that very huge uncertainty.”

Previously: Counseling parents of the earliest-born preemies: A mom and two physicians talk about the challenges, Stanford-led study suggests changes to brain scanning guidelines for preemies and Talk to her (or him): Study shows adult talk to preemies aids development
Photo by Sarah Hopkins

Anesthesiology, Ethics, Medicine and Literature

“Write what you know”: Anesthesiologist-author Rick Novak discusses his debut novel

419jAUWZsYLThe Doctor and Mr. Dylan is a murder mystery, a medical puzzler and a tale about love and parenting. And, it stars Bob Dylan, who may, or may not be, the real Bob Dylan. It’s also the debut novel by Rick Novak, MD, an adjunct clinical associate professor of anesthesiology, perioperative and pain medicine at Stanford.

Novak took the time recently to answer a few questions about the book, writing and his work as a doctor.

How did you become interested in writing?

I’ve enjoyed creative writing since my high-school English classes. My college essay for a successful Harvard application was a short story in which God revealed himself to the patrons of a Minnesota tavern. For the past three years I’ve authored a website called, which receives 250,000 hits per year from both anesthesia professionals and laypeople interested in the nuances of my specialty.

Why did you choose to write about an anesthesiologist – and do you have much in common with Nico, the primary character, who is also an anesthesiologist?

Wise advice to authors is, “Write what you know.” I’ve been an anesthesiologist for three decades, so I know a great deal about the practice and malpractice of anesthesia. The science and art of anesthesia are fascinating. We enter patients’ lives abruptly, at short notice, and have immense power to save lives and to do harm. The unequal nature of this relationship is fertile ground for storytelling.

The Doctor and Mr. Dylan is fiction, but yes, I do have a lot in common with Nico. I grew up in Hibbing, Minnesota, graduated from Hibbing High School, migrated to Stanford, and became a clinical faculty member here. I grew up 5 blocks from Bob Dylan’s home, am a huge fan of his music, and knew several members of his family. I’m the single father to three boys, and I’ve dealt with the highs and lows of the father-son relationship such as Nico has with Johnny, and the stressors of a failed marriage just as Nico does.

What motivated the plot of your story?

Anesthesiologists have control of dozens of powerful medications, and if misused, they can be lethal. One day I heard someone describe his significant other by saying, “I don’t want to pray that a bus runs her over, but my life would be a lot simpler if one did.” Combining these two ideas led to a plot where a physician seemingly makes use of an anesthetic as a tool to eliminate his troublesome wife. I have an active medical-legal practice of expert witness work, and this experience led me to set the second half of the novel in the courtroom, where tension runs high and mysteries can be posed and solved.

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