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Health Disparities, Medicine X, Stanford News, Technology

Countdown to Medicine X: How to engage with the “no smartphone” patient

Countdown to Medicine X: How to engage with the "no smartphone" patient

When I saw the full agenda of the upcoming Stanford Medicine X conference, the name of one of the panels – “The ‘No Smartphone’ Patient” -  jumped out at me. The conference is focused on the ways new technology intersects with health care, and it’s heavily attended by researchers, health-care innovators, and patients who strike me as likely to never leave the house without their smartphone or tablet. The topic seemed a curious thing for the organizers to offer.

Once I read the full description of the Sept. 5 talk, though, it made complete sense. Part of Medicine X’s aim has always been to empower patients to be proactive in their care and to contribute to the discussion on how technology can be used to improve human health. So if a significant chunk of the population is low-income and/or has limited access to health-enhancing technologies, it would be prudent for stakeholders to determine how to improve that access and how, exactly, to give those so-called “no smartphone” patients a voice.

Intrigued by the topic and wanting a preview of the discussion, I reached out to panelist Veenu Aulakh, executive director of the Center for Care Innovation (CCI), which develops patient-engagement innovations and provides support to the state’s safety-net providers (community health centers, public hospitals, and public health clinics). After noting that almost one-third of California’s population is considered underserved and vulnerable, Aulakh talked with me about what’s been done for underserved populations in recent years, how she believes the digital divide among various populations is shrinking, and what those attending “The ‘No Smartphone’ Patient” panel can expect to learn.

At Medicine X, you’ll be discussing some of the cultural, social, and economic barriers that prevent certain patients from fully engaging with health-enhancing technologies. Can you provide a hint of what those things might be?

There are a number of barriers for patients to fully engage with health-enhancing technologies. The solutions that are created today are often not built for low-literacy, non-English speaking patients. Having solutions in Spanish and written at less than a 4th grade reading level are critical for getting solutions adopted. In addition, many of these technologies are often introduced to patients via their health-care providers, and the solutions are not created at a price point that either safety net health systems or patients can afford. Also, the solutions need to be more reflective of the realities of patients lives – folks are extremely busy and don’t have a lot of time to hand-enter data or engage with technologies that don’t provide immediate value. If we’re going to get patients (and their providers) to use effective technologies, we need to make sure that they can see immediate benefits if they are to use these technologies regularly. Lastly, the smartphone penetration rate in low-income populations still isn’t at a level where it would be useful for most safety net providers to broadly offer smartphone solutions to their patients. As this changes, the adoption rate of health apps and similar technologies may rise as well.

Do you foresee a time when patients who currently face such barriers can become part of the e-patient movement?

I think there are already many vulnerable and underserved people who would consider themselves part of the e-patient movement. Health centers are now beginning to e-mail with patients, inviting them to participate in texting programs and starting to roll out other e-offerings. However, for more patients to join the e-patient movement, we need to reduce the barriers. As more patients move to smartphones, I believe we’ll see a shrinking of the digital divide. According to Pew Research Center, as of January 2014, 47 percent of low-income people had smartphones. As this number continues to increase, this will help low-income patients be active e-patients (assuming language, literacy and cost issues are addressed).

CCI works to bring various health-enhancing technologies to California’s low-income patients. What are some of the patient-engagement techniques you’ve seen delivered in recent years?

We’ve seen everything from building strong patient and family advisory groups who give input to clinics on how to better design care systems that are truly patient-centered, to launching efforts to hear from the patients about their needs through surveys, focus groups and ethnographic research. Many clinics are also starting to implement texting programs to follow up with patients between visits with appointment reminders, or send education reminders for patients with chronic diseases. They’re also starting to use remote monitoring devices like home blood pressure and blood glucose monitoring. The funding environment (and the limited resources of both clinics and patients) have hampered wide-spread adoption of these types of solutions, but clinics definitely see the value in engaging patients – with both high- and low-tech solutions.

How have your group and other safety-net providers involved patients in developing these techniques?

Many health centers have developed patient and family advisory groups to provide feedback to design these programs. Other clinics are beginning to use the principles of design thinking to better understand the needs of their patients and going beyond the traditional patient experience surveys to hear the real voice of their patients. However, much more work needs to be done to make this the standard of care.

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Health Disparities, Men's Health, Public Health, Research, Stanford News, Women's Health

Why it’s critical to study the impact of gender differences on diseases and treatments

man_womanWhen it comes to diagnosing disease and choosing a course of treatment, gender is a significant factor. In a Stanford BeWell Q&A, Marcia Stefanick, PhD, a professor of medicine at the Stanford Prevention Research Center and co-director of the Stanford Women & Sex Differences in Medicine Center, discusses why gender medicine research benefits both sexes and why physicians need to do a better job of taking sex difference into consideration when make medical decisions.

Below Stefanick explains why a lack of understanding about the different clinical manifestations of prevalent diseases in women and men can lead to health disparities:

…Because we may have primarily studied a particular disease in only one of the sexes, usually males (and most basic research is done in male rodents), the resulting treatments are most often based on that one sex’s physiology. Such treatments in the other sex might not be appropriate. One example is sleep medication. Ambien is the prescription medicine recently featured on the TV show, 60 Minutes. Reporters found out that women were getting twice the dose they should because they had been given the men’s doses; consequently, the women were falling asleep at the wheel and having accidents. Physicians had not taken into account that women are smaller and their livers’ metabolize drugs differently than do men’s. Some women have responded by reducing their own medication dosages, and yet that practice of self-adjusting is not the safest way to proceed, either.

Previously: A call to advance research on women’s health issues, Exploring sex differences in the brain and Women underrepresented in heart studies
Photo by Mary Anne Enriquez

Health Disparities, Health Policy

A quiz on the social determinants of health

Given the topic of today’s SMS-Unplugged entry, during which Moises Humberto Gallegos discusses how things like housing insecurity and financial hardship can contribute to poor health, I was interested to come across this Covering Health quiz on the social determinants of health. Writer Joe Rojas-Burke asks 10 true-or-false questions, and I think some of the answers may surprise you. For example:

Expanding health insurance coverage and access to medical care (the focus of the federal Affordable Care Act) is unlikely to reverse the health disparities caused by the social determinants of health.

TRUE: In countries that established universal health coverage decades ago, lower social status still correlates with worse health and shorter lives. The research on social determinants suggests that progress is likely to require broader social changes, such as improving access to education, boosting economic opportunity and making disadvantaged neighborhoods safer and and more vital.

And:

Food deserts – neighborhoods with few or no grocery stores selling fresh, affordable produce – are a well-defined root cause of obesity and other health problems in disadvantaged communities.

FALSE: There is evidence showing that low-income and minority Americans are more likely to live in food deserts. But it’s not at all clear to what extent the lack of supermarkets and grocery stores contributes to obesity or other health outcomes.

Previously: In medicine, showing empathy isn’t enough, Should the lack of access to good food be blamed for America’s poor eating habits? and Hopkins researchers find place, rather than race, may be greater determinant of health

Health Disparities, Medical Education, Patient Care, SMS Unplugged

In medicine, showing empathy isn’t enough

In medicine, showing empathy isn't enough

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.

SMS_image_072214As a medical student, it’s difficult to face a situation where everything possible is done for a patient, yet due to circumstances (seemingly) beyond our control, the risk of future harm remains uncomfortably certain. The majority of our medical school learning focuses on how to cure illness; unfortunately we’re not always taught how to deal with the real-world issues that face our patients and that threaten the medicine we practice.

This month I’ve been on my neurology rotation at Santa Clara Valley Medical Center, a county hospital with patient demographics quite different from those seen at Stanford Hospital. As I serve a more diverse and disadvantaged socio-economic population, it’s often the case that the information in the patient’s “Social History” section, which I usually quickly pass over, becomes a defining piece in deciding next steps. The 20-something-year-old with daily seizures because he’s so high on methamphetamine that he forgets to take his pills, the 40-year-old with left-sided paralysis who keeps checking in to the emergency department because she feels unsafe living alone in a trailer park, the 60-year-old who didn’t present to the hospital until days after suffering a stroke because he couldn’t physically get to the door to call for help: These patients demonstrate how social situations can make efforts to provide medical care at times seem futile.

In medical school, we’re taught the pathophysiology of disease and systematic approaches to medical management, but not how to deal with social contributors to health. (The latter is a not-so-glamorous aspect of medicine relegated to the hidden curriculum of clerkships.) During pre-clinical years we spend a lot of time discussing how to make empathy a part of our clinical skill-set, but a pitfall to practicing medicine in a way that is sensitive to a patient’s social context is the belief that showing empathy is enough. To express concern for a patient is different from really understanding a patient’s challenges. Things like the fear that drives a patient to repeatedly present to the emergency room for “inappropriate” reasons and the thought process behind not getting an MRI done since it would mean missing work may not fit traditional logic, but they represent an important piece in delivering care.

What can’t be taught in school is an inherent understanding of the difficulties that some patients face, which is why the push for future physicians to be individuals representative of the various backgrounds that patients come from is so important. (It can be surmised that students who have endured these difficulties, themselves or through family, socio-economic or health related, could better relate to patients they come in contact with.) While socio-economic demographics are easily seen on paper, though, what is harder to select for and recruit is the student who has lived the real-world environment characterized by social issues like multiplicity of chronic illness, housing insecurity, and financial hardship. And, of course, many students in this very position never make it to the point of training for a health profession as a result of the very hardships that make them more attune to the social issues that may contribute to poor health.

Medical school recruitment has changed in ways that will hopefully improve diversity of recruited students and contribute to a greater understanding of the background of all sorts of patients among health-care providers. However, more still needs to be done to support students from less-traditional and under-represented backgrounds so they reach the point of applying in the first place. Instead of being discouraged by their less-than-ideal journeys to medical school, students who have endured educational, financial, and social hurdles should be encouraged to use their learned experiences as a frame of reference to positively impact the delivery of health care.

Moises Gallegos is a medical student in between his third and fourth year. He’ll be going into emergency medicine, and he’s interested in public-health topics such as health education, health promotion and global health.

Drawing by Moises Gallegos

Health Disparities, LGBT, Mental Health, Patient Care, Stanford News

Stanford med student discusses his documentary on LGBT vets’ health

Stanford med student discusses his documentary on LGBT vets' health

doublelifeWhen Stanford anesthesiologist Audrey Shafer, MD, welcomed attendees to a screening of “The Camouflage Closet“ on campus recently, she noted the artistic accomplishments and service work of the film’s director, Michael Nedelman. (And also mentioned he was “a Stanford medical student in his spare time.”) Nedelman, who will be entering his third year here, conducted a project with nine LGBT veterans, all patients at the Veterans Affairs Palo Alto Health Care System, exploring their experiences of trauma and recovery.

Nedelman and his collaborators engaged in a community-based participatory method of film-making, allowing participants to tell their stories through art as a path toward empowerment. The participants were provided with cameras to document their stories; they also had a say in the editing process. And while the project was neither officially sanctioned research nor therapy, many of the participants found the process therapeutic. Christine Stout-Holmes said this in the film about sharing her story:

It’s healing. It makes me feel like, “Hey, I don’t have to be agoraphobic.” “Hey, I don’t have to isolate.”

Of course, I feel fists beating me on my back, but I know that that’s not now. And I know that what I’m doing now is going to benefit clinicians, and vets, and hopefully artists, and young girls to know that every story is important.

Since the film’s premiere last June, it has screened at the National Queer Arts Festival, the 31st annual Gay and Lesbian Medical Association conference, and at universities, film festivals and VA hospitals across the U.S. and in Mexico.

Below, Nedelman answers questions about his work.

You have a BA in film studies from Yale. How did you decide to attend med school, and have your interests in art and medicine always intersected?

It took me a while to understand exactly how my interests in art and medicine intersected, but it turned out they had a common ancestor in my love of story.

A few years out of college, I was working at Mount Sinai in New York City on both clinical research and documentary film studies. Whether or not there was a camera in the room, I loved hearing people’s stories, and turning those stories into something meaningful. But in a medical context, I also saw the opportunity to get involved in these stories – to reach past the lens and make a tangible difference.

Combining the two wasn’t really a new concept, though. My first major work in college was a photography project addressing preventable blindness in South India. As with “The Camouflage Closet,” I loaned out cameras to rural vision clinic patients who were able to document their restored sight through images that were important to them. But I had no idea that hyphenating doctor-filmmaker was even an option until I discovered, and later met with, filmmakers like Maren Grainger-Monsen, MD, and Gretchen Berland, MD. Something clicked when I figured out that patient care and digital media could go hand-in-hand.

What are some of the issues faced by this population that you’re most interested in exploring through storytelling?

Some of the issues I found most compelling are not just the unique challenges faced by some individuals (e.g. witch hunts of the pre-DADT – “Don’t Ask, Don’t Tell” – era, increased rates of military sexual trauma, barriers to accessing care), but also the creativity and strength that come from their recovery narratives. Alongside some of the heavier moments in the film, there’s some humor, too. I think I personally learned a lot from the veterans’ resilience, and how their pride – for being LGBT, and for being veterans – factors into their personal growth.

What do you hope viewers will take away from your film?

I hope viewers will come out of the film with a desire to learn more about the unique challenges, types of trauma, and sources of resilience among a previously silenced community. I think there’s a lot to identify with in the film, whether or not you identify as LGBT or a veteran, and there’s a lot to be said for turning empathy into action. This is partly why we also created an accompanying educational resource that summarizes previous research, evidence-based suggestions for culturally relevant care, and resources for clinicians and veterans.

The veterans were excited that clinicians and providers would see and learn from their work. But at the end of the day, I wonder if some of them might have answered this question a little differently. Something we often heard among the vets was, “Even if just one other veteran out there sees this and knows they aren’t alone, we’ve accomplished what we came here to do.”

Previously: Documentary on LGBT veterans’ PTSD, trauma and recovery premieres tomorrow and Photography and storytelling may help poor women with HIV cope with their illness
Film still from “The Camoflauge Closet” courtesy of Michael Nedelman

Global Health, Health Disparities, Pregnancy, Research, Women's Health

In poorest countries, increase in midwives could save lives of mothers and their babies

In poorest countries, increase in midwives could save lives of mothers and their babies

midwifeThe World Health Organization reports that most maternal deaths are preventable; yet, preterm birth complications rank among the top 10 causes of death in low- and lower-middle-income countries. Two recent studies from the Johns Hopkins Bloomberg School of Public Health have explored the role skilled midwives may play in saving the lives of women and their babies in poor counties.

In one study, published in The Lancet, researchers found that deploying a small number of midwives – 10 percent more every five years through 2025 – in the world’s 26 poorest countries could stave off a quarter of the maternal, fetal and infant deaths there.

From a release:

The estimates were done using the Lives Saved Tool (LiST), a computer-based tool developed by Johns Hopkins Bloomberg School of Public Health researchers that allows users to set up and run multiple scenarios to look at the estimated impact of different maternal, child and neonatal interventions for countries, states or districts. For this analysis, the tool compared the effectiveness of several different alternatives including increasing the number of midwives by varying degrees, increasing the number of obstetricians, and a combination of the two.

In the other study, published in PLOS One, researchers used the LiST tool in the world’s 58 poorest countries, where they found that 7 million maternal, fetal and newborn deaths will occur between 2012 and 2015. The release continues:

If a country’s midwife access were to increase to cover 60 percent of the population by 2015, 34 percent of deaths could be prevented, saving the lives of nearly 2.3 million mothers and babies.

The researchers say boosting coverage of midwives who provide family planning as well as pregnancy care to 60 percent of women would cost roughly $2,200 per death averted as compared to $4,400 for a similar increase in obstetricians. Midwives are cheaper to train and can handle interventions needed during uncomplicated deliveries, while obstetricians are needed when surgical interventions such as cesarean sections are necessary, [lead author Linda Bartlett, MD] says. Midwives can administer antibiotics for infections and medications to stimulate or strengthen labor, remove the placenta from a patient having a hemorrhage as well as handle many other complications that may occur in the mother or her baby.

Previously: Indonesia’s cash transfer programs are valuable, Stanford health fellow findsStudy cautions babies born at home may be at increased risk for health problemsSimple program shown to reduce infant mortality in African country and Should midwives take on risky deliveries?
Photo by Vinoth Chandar

Health and Fitness, Health Disparities, Public Health, Technology

Creating safer neighborhoods for healthier lifestyles

hoodWalking sounds like a simple path to maintaining a healthy weight if you can’t afford a gym membership. But what if your neighborhood isn’t a safe space to walk or jog, or for your kids to play? Abby King, PhD, and scientists from Stanford Prevention Research Center‘s Healthy Aging Research and Technology Solutions lab have been working with residents of North Fair Oaks, Calif., to understand which environmental factors contribute to or detract from a healthy-living environment.

Participants used a GPS-powered Stanford Healthy Neighborhood Discovery Tool to survey the streets where they lived and provide information about which areas most need improvement in order to facilitate physical activity. During 36-minute walks, the middle-school-aged and older-adult participants collectively provided 224 audio and video recordings of their environment.

The low-income community of North Fair Oaks comprises 73 percent Latino residents. An article in Salud America! Growing Healthy Change reports:

“There are a lot of issues and challenges in the area,” [Priscilla Padilla-Romero, MPH, a public health educator at the Fair Oaks Center and a study author] said. “New immigrants face substantial challenges on a daily basis such as high unemployment rates, and significant social stressors.” Additionally, [Lisa Goldman Rosas, PhD, MPH] mentioned that, “Many immigrants point out that their lifestyles were naturally more active in their countries of origin and when they move to the US they have to think about how to get more physical activity for the first time.”

Among the findings, the piece notes:

The features that were reported as being facilitators of physical activity by the greatest number of participants were:

  • Having amenities and destinations to walk to
  • The presence of good quality sidewalks
  • The presence of parks, playgrounds and crosswalks
  • The aesthetic feel of the neighborhood (for example, attractive plants and well maintained homes)

The features that were reported as being barriers to physical activity by the greatest number of participants were:

  • Poor quality sidewalks
  • Trash and illegal dumping
  • Personal safety

At a June meeting with county officials the study participants, termed “citizen scientists,” discussed which factors of their environment were the greatest barriers to physical activity, hoping to influence local policy and strengthen their community.

Previously: Moderate exercise program for older adults reduces mobility disability, study showsHelp from a virtual friend goes a long way in boosting older adults’ physical activity and What type of smartphone apps are effective for promoting healthy habits among older adults?
Photo by Jukie Bot

Clinical Trials, Health Disparities, Medicine and Society, Research

High rates of incarceration among black men could be skewing study results

High rates of incarceration among black men could be skewing study results

prison bars

Few headlines have grabbed my attention like this one did today: “Doctors can’t research the health of black men, because they keep getting sent to prison.” The Vox article focused on a new Yale study that, in the words of writer Dara Lund, “suggests that some of the biggest medical studies of the last few decades may have seriously distorted data on African-American men.”

For the study, researcher Emily Wang, MD, MAS, and colleagues examined fourteen long-term trials that began enrolling participants between 1972-2000. They concluded that the high rates of incarceration among black men at this time (as of 2001, one in six black men had been incarcerated) “may have accounted for up to 65 percent of the loss to follow-up among black men in these studies.” Why is this important? As the researchers describe in the paper, which appears in Health Affairs:

The implications of having a disproportionate number of black men drop out of prospective cohort studies because of incarceration are significant, even though the differences between loss to follow-up are not always large or significantly different between black men, white men, black women, and white women. Conditions such as cardiovascular disease and sickle cell disease are more common in black men than in white men and have complex factors that influence morbidity and mortality. This makes it important for analysts to have access to a large number of cases so that they can adjust for possible confounders.

And:

The likely high association between imprisonment and being lost to follow-up in these studies may yield underpowered and biased estimates for black men. Furthermore, participants who are incarcerated are more likely to be sick than are participants who have never been incarcerated. This difference increases the likelihood that disease rates and progression of disease in blacks and black-white disparities will be underestimated.

One possible solution, Wang and her co-authors note, is for incarcerated people to be allowed to continue their participation in a study. But Lind reports that “for now, there doesn’t appear to be much momentum behind [this].”

Previously: NPR explores the need for improving diversity in clinical trials, Study shows deaths from acute leukemia higher in minority patients, A conversation with Augustus White, a pioneer for underrepresented minorities and Surgeon’s memoir calls for an end to health disparities
Photo by Martin Fisch

Health Disparities, In the News, Patient Care, Pediatrics

Adolescent Health Van wins community award for aiming to “help kids turn their lives around”

Adolescent Health Van wins community award for aiming to "help kids turn their lives around"

ammerman-and-teen-van-2Paying for a basic doctor’s visit is often impossible for low-income teens and young adults. That’s why Seth Ammerman, MD, has been bringing free health care to young people in the communities around Lucile Packard Children’s Hospital Stanford for nearly two decades. Ammerman, an adolescent medicine specialist at the hospital, is the founder and medical director of the hospital’s Adolescent Health Van, a mobile clinic that makes regular visits to high schools, community centers and other stops between San Francisco and San Jose.

Now, Ammerman’s work has been recognized with a Bay Area Jefferson Award for Public Service from our local CBS affiliate, KPIX-5. In the news segment CBS aired about Ammerman’s work, they mention that his efforts began years ago with free immunizations for local teens. But he soon realized that the kids he saw needed much more than just immunizations. “Dr. A,” as his patients affectionately call him, now addresses a wide range of adolescent health concerns in the teen van – including alcohol and drug use, anxiety and depression, high-risk sexual behaviors, poor nutrition, and, yes, lack of immunizations. His team in the van includes a nurse-practitioner, a social worker and a dietitian.

“The kids that we work with, a lot of people have given up on them,” Ammerman says in the CBS news segment. “But we haven’t. We know that we can help these kids turn their lives around.”

Congratulations, Dr. Ammerman! And a hat-tip to Steve Westly of the Westly Foundation, who nominated Dr. Ammerman for the award.

Previously: Packard Children’s Adolescent Health Van celebrates 15 years
Photo courtesy of Lucile Packard Children’s Hospital Stanford

Emergency Medicine, Health Costs, Health Disparities, Pediatrics, Research, Stanford News

ER visits for U.S. newborns show racial disparities

ER visits for U.S. newborns show racial disparities

Haiti Earthquake“Baby’s first trip to the ER” is probably one photo that no one ever wants to put in a baby book. But a surprising number of newborns – 320,000 each year – visit an emergency department within their first month of life. For reasons that are likely a complex mix of socioeconomic and biological factors, black newborns across the U.S. are more than twice as likely to make the trip.

Henry Lee, MD, an assistant professor of pediatrics at Stanford, broke down the stats of how often newborns end up in the emergency department and looked at race, age and insurance status. In collaboration with researchers at the University of California-San Francisco, Lee analyzed data from nationwide emergency room visits collected by the National Center for Health Statistics. The study appears in the May issue of the journal Pediatric Emergency Care.

The researchers found that 14.4 percent of black babies visited the emergency department, compared to 7.7 percent of Hispanic babies and 6.7 percent of white newborns. Some trips to the ER are unavoidable, such as when a baby has an infection or isn’t gaining weight. But it’s likely that some of these visits could have been prevented.

All babies must get a checkup within several days of being born. But if the delivering doctor failed to counsel the new parents about checkups – or if the doctor missed a common problem, such as jaundice – then the new family might end up in the ER instead of at a clinic. In addition to representing a lack of continuity of care for the newborns, these visits drive up health-care costs.

Additional studies may tease apart the factors that cause black newborns to end up in the emergency room more often than other groups, and to find ways to reduce spending on health care while providing better services.

“Improving the quality of care for this higher-risk group could also help to improve disparities and outcomes as well,” Lee said.

Patricia Waldron is a science writing intern in the medical school’s Office of Communication & Public Affairs.

Previously: Decreasing demand on emergency department resources with “ankle hotline” and Speed it up: Two programs help reduce length of stay for emergency-room visitors
Photo by Olav Saltbones / Norwegian Red Cross

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