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Health Policy, Medical Education, Public Health, Public Safety

Why I never walked to school: the impact of the built environment on health

Why I never walked to school: the impact of the built environment on health

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.

kids walking to schoolMy California-acclimated body was a little shocked by the 15-degree weather I encountered while visiting my Kentucky hometown over winter break, but I was still determined to bundle up most days and to get outside for long walks with my mom and daughter. One day as we were struggling to catch an opening in traffic to cross the blindly curving road leading out of our subdivision, it occurred to me that the cold was the least of our barriers to getting a little exercise.

“I don’t think I could design a more dangerous place to walk if I tried,” I observed in frustration. Another car whizzed by within a couple feet of my daughter’s stroller. “This town was definitely built for cars, not people.”

For most of my childhood, my family lived right in the middle of town, within about a mile of many of the places a young family might visit on a daily basis. Grocery stores, school, church, the public library, restaurants, the park where I played softball, and my grandmother’s house were all close enough that they should have been an easy walk. But that one mile might as well have been twenty, and I can count on one hand the times I walked to those destinations. I tried a few times, but to get there on foot I’d have to navigate roads lined by steep hills or ditches with no sidewalks or crosswalks. There is one underpass that would require a pedestrian to climb onto a narrow strip of gravel and inch along the wall, close enough to the fast-moving traffic to be unbalanced by gusts from each passing car.

Because of these real physical barriers, the local cultural wisdom took it as self-evident that cars were the only reasonable way to get around. Walking and biking were recreational activities to be done in endless circles around the cul-de-sac, not viable modes of transportation. The risk of walking wasn’t just a theoretical one: Our roads were decorated with a couple of makeshift roadside altars made by the families of teenagers who had died while trying to cross the street. More recently, I was disappointed to read an article confirming my suspicions that cycling in the Southeastern U.S. is drastically more dangerous than in other regions.

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Aging, Health Policy, Patient Care, Stanford News

A call to “improve quality and honor individual preferences at the end of life”

A call to "improve quality and honor individual preferences at the end of life"

ICU IllustrationThis week’s New England Journal of Medicine featured a perspective piece co-authored by Philip Pizzo, MD, former dean of Stanford’s School of Medicine, and David M. Walker discussing recommendations for how U.S. physicians can approach the issue of end-of-life care. Pizzo and Walker co-chaired an Institute of Medicine (IOM) committee on the issue that culminated in a report that we wrote about last September.

In a recent survey, most physician respondents said they “would forgo high-intensity end-of-life treatment” for themselves. Yet many patients in their care are subjected to aggressive treatments that prolong the dying process unnecessarily. The editorial outlines the challenges that we face as a nation regarding end-of-life care and notes that the aging population of the country will soon make end-of-life care a critical issue. The authors recommend, among other things, adding end-of-life care to physician training, incorporating end-of-life conversations into patient care, even before they become terminally ill, and incorporating end-of-life decisions into health care delivery and payment programs.

In an email, Pizzo discussed why fixing our end-of-life care predicament is so important, telling me:

Unfortunately, all too frequently, individual preferences are not honored at the end of life – with many individuals experiencing more invasive interventions than they wished at the end of their life. It is important that we value the quality of life throughout the life journey, including at the end of life. As a nation, our current health-care system fails in end of life care – which has an enormous impact on individuals, their families and loved ones, and our community and nation.

The situation is complicated by politics. In 2009, end-of-life care became a hot-button issue when critics of the Affordable Care Act claimed that a provision to reimburse physicians for advising patients on living wills or advance directives would lead to “death panels.” Pizzo said of the debate:

Having conversations with our families and physicians about the end of life that allow us to express our personal preferences should not be seen as controversial… Sadly, what has made this issue controversial is egregious political rhetoric. The suggestion that health-care reform would result in “death panels” was wrong and highly destructive, frightening many Americans unnecessarily. When such hyperbole and soundbites become the story they have highly negative consequences. That is why the IOM committee underscored the importance of a more accurate and fact based public discussion about end of life care that made it clear that our intentions, as a society, must be to improve quality and honor individual preferences at the end of life.

Previously: No one wants to talk about dying, but we all need to, Study: Doctors would choose less aggressive end-of-life care for themselves, Former School of Medicine dean named to expert panel to reform end-of-life care in America, Communicating with terminally ill patients: A physician’s perspective and On a mission to transform end-of-life care
Image, “A portrait of death in modern America,” by Neils Olson

Health Policy, Patient Care, Podcasts

Steven Brill’s Bitter Pill

Steven Brill's Bitter Pill

Bitter PillA New York Times review called Steven Brill’s book, America’s Bitter Pill, “a thriller.” Brill’s tome on the building of the Affordable Care Act (ACA), aka Obamacare, “a thriller?” I thought. What recent treatise on the inner workings of public policy has garnered that sort of description? Didn’t the term “thriller” belong to writers like Paula Hawkins, Dean Koontz, Gillian Flynn and James Patterson? But Brill’s meticulous narrative of how Obamacare was constructed is a public-policy thriller, and the suspense he writes about is how the law was brought from broth to soup.

While Brill is hardly a public-policy advocate (he’s a long time investigative reporter), he does laud the president’s herculean effort to give millions of Americans access to affordable health care. He just doesn’t believe that any of the big “players” in health care – hospitals, device makers, insurance companies or pharmaceuticals –  felt a pinch of economic pain, and he sees America’s health care system still as an old “jalopy” financially out of control and enriching special interests.

The seed for the book was spawned in a 24,000-word article in TIME magazine in April 2013. A year later, while reporting on the rollout of the ACA, Brill was diagnosed with an aortic aneurysm – flipping the story and putting investigative reporter onto the operating table as a very real person needing cardiac surgery.

As he told NPR’s Terry Gross:

At that moment I wasn’t worried about costs; I wasn’t worried about a cost-benefit analysis of this drug or this medical device; I wasn’t worried about health-care policy. It drove home to me the reality that in addition to being a tough political issue because of all of the money involved, health care is a toxic political issue because of all of the fear and emotion involved.

At the end of my conversation I asked Brill if there was one question he’d been surprised that he’d not been asked during his media blitz, which began with a rollout by Lesley Stahl on CBS’ 6o Minutes.  “Yes,” he said, “you just touched on it.” How would his book had been different if he’d not had an aortic aneurism, a cardiac operation and become a patient? So how would Chapter One have begun?

I hope you’ll listen to my latest 1:2:1 podcast to hear what he has to say.

Addiction, Health Policy, Parenting, Pediatrics, Podcasts, Public Health

Discussing the American Academy of Pediatrics’ call to put the brakes on marijuana legalization

Discussing the American Academy of Pediatrics' call to put the brakes on marijuana legalization

A wave of changes in state laws on the use of marijuana for medicinal and recreational purposes has stirred the American Academy of Pediatrics. It’s taken 10 years for the AAP to update its policy on the legalization of marijuana, and they released its new one on Monday.

74381759_e5a563cf3d_zThe organization still opposes legalization but it has opened the door to reform in several ways. First, recognizing that minority kids bear the brunt of criminal penalties for pot use, they call for decriminalization. Second, they call for the U.S. Drug Enforcement Agency to reclassify marijuana from a Schedule 1 listing for controlled substances to a Schedule 2. This action would effectively allow more research to be conducted and in turn scientifically determine where marijuana is most effective as a treatment. A review by the federal government is currently underway.

I asked Stanford pediatrician Seth Ammerman, MD, the lead author of the statement, what the AAP was trying to achieve with its policy redo and why such a restrictive stance on legalization since the train for legalization – recreational and medicinal –  seems to have already left the “coffee house.”

In this 1:2:1 podcast, Ammerman cites major two concerns. First, if legalized and commercialized, marijuana will become a big business, and the same marketing efforts by tobacco companies that encouraged teens to take up cigarettes will lasso them to pot smoking. “Well, aren’t kids smoking pot already?” I asked. Ammerman fully realizes that any teen who wants pot can readily buy it – legalization, to the AAP, is an imprimatur. Secondly, Ammerman cited, as does the new policy statement, the compelling and growing scientific evidence that the brain in formation continues to gel through the teen years and into the 20s. Marijuana, just like alcohol and any other drug, is likely to play a lot of bad tricks as the prefrontal cortex solidifies.

As described in the policy paper:

New research has also demonstrated that the adolescent brain, particularly the prefrontal cortex areas controlling judgment and decision-making, is not fully developed until the mid-20s, raising questions about how any substance use may affect the developing brain. Research has shown that the younger an adolescent begins using drugs, including marijuana, the more likely it is that drug dependence or addiction will develop in adulthood.

Ammerman says that the AAP will follow closely what happens in states where marijuana has been legalized both for health and recreation, and it will look carefully at what future evidence suggests. Clearly, there’s still a lot of smoke around this issue.

Previously: To protect teens’ health, marijuana should not be legalized, says American Academy of Pediatrics
Photo by Paul-Henri S

Health Policy, Medical Education, Patient Care, SMS Unplugged

The downside of a free lunch: Incentives and the medical student

The downside of a free lunch: Incentives and the medical student

SMS (“Stanford Medical School”) Unplugged is 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.

money on hook  smallDoctors are people, too, and they respond to incentives. That was the message we got from a recent health-policy class session that discussed various ways of paying doctors for their work, and how this can play a role in patient care. In an ideal world, physicians would be motivated only by what is best for their patients; however, the reality is that doctors, like all people, can be influenced by external factors such as money, autonomy, and time.

This got me thinking about the incentives that currently shape my life as a medical student. While we would all like to say that the choices we make are determined only by our own internal desire to maximize our learning and become the best future physicians possible, even the most idealistic student among us would have to admit that incentives, big and small, influence our decisions every single day.

On a day-to-day basis, incentives determine how we budget our time and focus our efforts. For example, given the huge demands on our time and our budgets, the promise of a free lunch provides a strong incentive for us to attend lunchtime seminars and panel discussions – even if the subject matter is not of immediate interest or relevance to us.

In class, because of the Pass/Fail grading system during our pre-clinical years, our external incentives are not our class grades, but instead the standardized board exam that will play an important role in our residency applications. Our collective ears perk up every time our professors say “This always shows up on the boards,” even if we are told that the particular information is rarely (if ever) applied in real-world clinical practice.

In the bigger picture, as we begin to explore various specialties and avenues for practicing medicine, it is impossible to ignore the reality that average salary, lifestyle, and autonomy vary hugely from one specialty to the next, and from one type of practice to another. Not feeling very passionate about private-practice urology? Does that change when you find out that urologists make about twice the annual salary of a family medicine doctor?

The reality is that our intrinsic motivations to make the world a better place by becoming the best possible physicians do not always align with the incentives that medical school, and the larger health-care system, provide. We are incentivized to spend time and effort on things that will not help us be better doctors, and in the long run we might even be incentivized to make decisions that will reduce the amount of good we can bring to the world. Is it the job of policymakers and medical educators to better align incentives to create the desired outcomes for our health-care system? Or do we, as future physicians, need to shoulder more responsibility to do the right thing, passing up the literal and figurative “free lunch” in the process?

Maybe there is an ideal middle ground for each of us – a place where the incentives align at least reasonably well with our own internal goals. In that case, one of our tasks as medical students for the next several years will be to find it.

Nathaniel Fleming is a first-year medical student and a native Oregonian. His interests include health policy and clinical research.

Photo by Tax Credits

Global Health, Health Policy, In the News, Infectious Disease

President Obama and Indian Prime Minister praise partnership that led to rotavirus vaccine

President Obama and Indian Prime Minister praise partnership that led to rotavirus vaccine

Barack_Obama_talks_with_Narendra_ModiDuring his three-day visit to India, President Barack Obama issued a joint statement with Indian Prime Minister Narendra Modi praising the “highly successful collaboration” that led to the availability of a newly developed Indian rotavirus vaccine, which is expected to save 80,000 children in India alone each year.

The vaccine was developed with support from the Indo-U.S. Vaccine Action Program, co-chaired since 2009 by Harry Greenberg, MD, senior associate dean for research at the Stanford School of Medicine. Greenberg was the lead inventor of the first-generation vaccine for rotavirus, a severe diarrheal disease that kills between 300,000 and 400,000 children each in the developing world.

“This is the VAP’s biggest accomplishment to date,” Greenberg told me from Taiwan, where he is attending a conference. “The program really helped support the development of a new safe and effective rotavirus vaccine from the start to finish. And it’s the first time ever that a new vaccine was developed in a less developed country by and for that country and became licensed.”

The vaccine initiative, funded by the U.S. Public Health Service and the Indian government, was created in 1987 to help advance the development of new vaccines of importance to India. The NIH manages research grants in the United States for the vaccine program.

“The VAP has been the most successful, continuous program we have with India,” Roger Glass, MD, PhD, director of the NIH’s Fogarty International Center, wrote in an email from India to top NIH officials. “It’s amazing to me that this little research project on rotavirus with Harry Greenberg and George Curlin (former deputy director of NIH’s Division of Microbiology and Infectious Diseases) has turned into a real product that is being launched and will be used.”

A low-cost version of the vaccine, known as Rotavac, is being manufactured in India and was launched into the marketplace on Jan. 23, Greenberg said. It was the result of an unusual team effort involving diverse multinational groups of investigators from 13 institutions seeking to create a vaccine that was not only safe and effective, but also affordable enough for use in India and other low-income countries, Greenberg said. The Indian government is negotiating to purchase the vaccine for public distribution. The vaccine also will compete in the private market against at least two other commercially available vaccines.

In the joint statement, the two world leaders pledged continued support for the vaccine program, and Greenberg, who recently stepped down from his chairmanship, made an argument for now focusing the attention of the vaccine partnership on respiratory syncytial virus (RSV), a potentially serious lung disease that is prevalent in children in India and in other regions as well.

“RSV is an incredibly important pediatric pathogen all over the world, and there is now potential for great progress,” Greenberg said. “I suggested to VAP that it think about RSV as a new target for research. It has a huge public impact and it may well be that there are great advances to be made in the near future. I think that idea resonated with the people. We will see.”

Previously: Life-saving dollar-a-dose rotavirus vaccine attains clinical success in advanced India trial and Trials, and tribulations, of a rotavirus vaccine
Photo courtesy of The White House

Addiction, Health Policy, In the News, Pediatrics

To protect teens’ health, marijuana should not be legalized, says American Academy of Pediatrics

To protect teens' health, marijuana should not be legalized, says American Academy of Pediatrics

teen smoking Today, the country’s most prominent group of pediatricians issued a policy statement that opposes marijuana legalization and advocates for policies to help minimize the drug’s harmful effects on children and adolescents. The new statement, from the American Academy of Pediatrics, was written in response to recent research on adolescent brain development and the biology of addiction, as well as a changing national climate on marijuana laws.

I spoke with Stanford’s Seth Ammerman, MD, an adolescent medicine specialist and the lead author of the new statement and accompanying technical report. Ammerman studies substance-use issues in youth and also has extensive experience working with at-risk young people, in part through his role as medical director of the Adolescent Health Van run by Lucile Packard Children’s Hospital Stanford.

“The national trend is definitely toward more medical marijuana, and also toward legalization for adults,” he said. “This trend can definitely affect kids, so it was really important for the Academy to have a voice, to be working on a national conversation about this.”

During our conversation, Ammerman explained some of the latest research that has motivated the AAP’s stance against marijuana legalization:

In the past decade, we’ve learned that brain development doesn’t finish until one’s early to mid-20s, and substance use can alter the developing brain. There are a few ways we know this: One, there’s clear evidence that the younger you start using drugs regularly, the more likely you are to become addicted. This is true for alcohol, tobacco, and marijuana, among others. For those who put off substance use until their late teens or early 20s, addiction rates are significantly lower.

We also know that the developing brain is very vulnerable to substance use. One in 10 adolescents who use marijuana become addicted. That means that 90 percent won’t — which is the good news — but the problem is we can’t predict which 10 percent will develop addiction.

We also have a lot of research about the adverse effects of marijuana use. Heavy users fare worse in many ways: their cognitive levels fall, they are less likely to finish high school or attend college, and they tend to suffer more from depression. Most users are not heavy users, but again, we can’t predict who will fall into this category.

The AAP is also in favor of decriminalizing marijuana, replacing current criminal penalties with lesser criminal or civil penalties and drug treatment. This is an especially important step to reduce the long-term damage to educational and job opportunities that currently comes with marijuana arrests, Ammerman said, adding: “There is a significant problem of racial inequity associated with marijuana arrests: minorities are way over-arrested and their lives are messed up because of marijuana arrests. It’s a very important step to say we need to help kids, not punish them.”

Previously: Medical marijuana not safe for kids, Packard Children’s doc says, Pediatrics group calls for stricter limits on tobacco advertising and To reduce use, educate teens on the risks of marijuana and prescription drugs

Photo by mexico rosel

CDC, Chronic Disease, Health Policy, In the News, Infectious Disease, Public Health

To screen or not to screen for hepatitis C

Hep CIn the past few years, newer, more effective treatments have been introduced for hepatitis C – a disease that can lead to chronic liver problems and in the worst cases, liver cancer. In 2012, the Centers for Disease Control and Prevention recommended screening for the disease in anyone born between 1945-1965, since about three-quarters of cases occur in this age group, the Baby Boomers. Last year, the World Health Organization also called for more screening for the disease.

But in a recent analysis piece in The BMJ (formerly the British Medical Journal), several scientists, including Stanford epidemiologist John Ioannidis, MD, DSc, lay out the case that universal screening in this age group may not be warranted. A story in the San Francisco Chronicle today quotes Ioannidis:

“The question is whether these aggressive screening policies are justified and whether they would result in more benefit than harm,” said Dr. John Ioannidis...“We know very little about the potential harms of these drugs, especially in the long-term. And we don’t know how they will translate into long-term benefits.”

Ioannidis and his colleagues suggest that instead of rolling out widespread screening programs, researchers, as soon as possible, start a randomized trial to test the usefulness of screening and who may benefit from it.

On top of the medical uncertainties of the new treatments, they’re expensive, costing about $84,000 for the 12-week treatment. But they’ve been shown to cure patients of their hepatitis C infections at the end of that 12 week stint. Not all people who contract the disease will develop chronic infections, but a majority – two-thirds -will. Twenty percent of those cases will go on to develop severe liver disease.

Advocates of universal screening say that the new screening strategy could identify many people who don’t know they’re sick – symptoms from hepatitis C chronic infections can take years to manifest. But Ioannidis and his colleagues note that many people will get unnecessary treatment and that the long-term uncertainties of the treatment should be taken into consideration.

Previously: Despite steep price tag, use of hepatitis C drug among prisoners could save money overallA primer on hepatitis CFor patients with advanced hepatitis C, benefits of new drugs outweigh costsDrugs offer new hope for hepatitis C and Program examines hepatitis C, the “silent epidemic”
Photo of hepatitis C virus by AJ Cann

Aging, Chronic Disease, Ethics, Health Policy

Exploring the value of longevity with bioethicist Ezekiel Emanuel

baby hand in old hand - big

In a popular article in the Atlantic published this past fall, Ezekiel Emanuel, MD, bioethicist and prominent federal policy adviser, made a controversial case against longevity. Just before the recent holidays, the USC Annenberg School for Communication & Journalism sponsored a webinar during which Emanuel explained and elaborated on his message. It’s not that he “hopes to die at 75,” as the title chosen by the Atlantic suggested, but he wants a life at 75 focused on living, not on living longer.

Emanuel essentially argues for quality of life over quantity of years, and he claims that American society is becoming obsessed by the latter. I listened in on his December talk, which began with an ad from the AARP that glorifies “going on forever” – a value he says is reflected in both the medical system and our contemporary culture.

He directed his scientific criticism against the idea of the “compression of morbidity” – the belief that with enough medical advances, disabilities will go away and people will live in good health until, more or less suddenly, they die. He calls this the “rectangularization” of life: falling off a cliff instead of rolling down a gradual decline. The idea is immensely popular and money-making, but while some research claims to prove it, far more proves the opposite. There is, in fact, an expansion of morbidity as people live longer, an elongated and more gradual decline with more disabilities and less and less creativity.

Given this, Emanuel’s hope and recommendation is two-fold: that people will consider what makes their life meaningful and spend their energy cultivating that, and that medical resources will be redirected from prolonging life to improving its quality at the outset – by reducing the country’s exceptionally high rate of premature births, for example.

American life expectancy is at an all-time high at nearly 80 years, but are octogenarians living meaningfully? Last month in the New York Times, David Brooks argued against Emanuel’s earlier piece by saying that the “happiest people” are ages 82-85; in the webinar, Emanuel says this misses the point. It’s much easier to measure happiness than meaningfulness, yet the latter is the real aim of life (and, furthermore, Brooks didn’t account for the perspectives of those in nursing homes, assisted living, or suffering from dementia). Emanuel talked of patients who say cancer was “the best thing that happened to me” because it made them focus on what was meaningful in their life. The end of life is important to think about, as it helps us see what we want from life now.

“Contorting life around living as long as possible seems to me to be counter-productive,” he said. “What we should be focusing our life on is what’s meaningful, how we enrich other people and contribute to our families and society.”

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Ethics, Health Policy, In the News, Medicine and Society, Research

Watching your spouse die on a TV reality show: De-identification as a myth, in death and life

Watching your spouse die on a TV reality show: De-identification as a myth, in death and life

Much biomedical research relies on the idea of “de-identification.” The Common Rule, the federal regulation on human subjects research, applies, as a general matter, if the researchers make some kind of intervention with the research subject or if they use “identifiable private information” about the research subject. But the “Private information must be individually identifiable (i.e., the identity of the subject is or may readily be ascertained by the investigator or associated with the information) in order for obtaining the information to constitute research involving human subjects.”

De-identification doesn’t mean that no one will recognize the research subjects’ identity. Federal regulation says the researchers must not be able to ascertain it readily.

If the private information was not collected by the researcher (it comes from someone’s medical record or was collected as part of someone else’s research) and the research subject’s identity is not known to and cannot “readily be ascertained” by the researcher, it doesn’t count. No consent is required, no IRB review is required – it isn’t “human subjects research.”

And why should it be? If no one knows it is you, you cannot be hurt, or so the argument goes.

[Last Friday], the New York Times published an extraordinary article entitled “Dying in the E.R., and on TV Without His Family’s Consent” by Charles Ornstein, a reporter for ProPublica. It recounted how Anita Chanko, a 75-year-old widow, watching an ABC reality television show, NYMed, suddenly realized that she was watching her husband’s death in the emergency room. More than a year earlier, the 83-year-old man had been hit by a garbage truck while crossing the street and had died in the NewYork-Presbyterian hospital. The televised version blurred his face, but not the face of the surgeon, the description of the accident, or the sound of her late husband’s voice, asking “Does my wife know I’m here?”

At no time were any of the family told  that Mr. Chanko’s treatment was being filmed or asked their consent to its use on television.

The dead man’s widow and children were traumatized. One of their sons wrote in a complaint “I had to unnecessarily relive my father’s death at your hospital a second time, while knowing that the public at large was able to — and continues to be able to — watch my father’s passing, for the purposes of what can only be described as drive-by voyeuristic ‘entertainment.’ ”

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