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Cancer, In the News, Palliative Care, Stanford News

Paul Kalanithi’s book will probably make you cry

Paul Kalanithi's book will probably make you cry

Just over a year ago, I received a first draft of an article for Stanford Medicine magazine that electrified me. It was gorgeous. It was heartbreaking. Its last words delivered a jolt of joy and made me cry. And this was just a first draft.

Now that essay, published in our spring 2015 issue as “Before I go,” is part of “When Breath Becomes Air,” the book Stanford neurosurgery resident Paul Kalanithi, MD, wrote in his last months of life about confronting an early death. The book is as compelling and beautiful as the essay. And just as likely to make you cry. Our next issue of Stanford Medicine will include an excerpt.

That I received the essay at all seemed at the time a small miracle. In September 2014, Kalanithi had agreed to write for the magazine, and two months later I had more than a magazine editor’s usual trepidation about whether the writer would meet the deadline.

I knew the cancer was wriggling through all medical defenses and that he was still fighting it with chemotherapy. I suspected the chemotherapy side effects were brutal. (I now know he wore silver-lined gloves to protect his fingertips, cracked from chemotherapy, while using his computer’s trackpad.) I hoped he was spending his last days doing what was most important to him, so I was loath to pressure him to finish his draft. Yet I selfishly hoped he had enough time to get the story done.

My deadline worries evaporated on Nov. 6 when, right on time, Kalanithi sent a first draft. It was magnificent. A month later the polished version came in, we published it and it proceeded to blow the minds of readers around the world.

Janet Maslin speaks for me in her New York Times review of the book:

Part of this book’s tremendous impact comes from the obvious fact that its author was such a brilliant polymath. And part comes from the way he conveys what happened to him — passionately working and striving, deferring gratification, waiting to live, learning to die — so well. None of it is maudlin. Nothing is exaggerated. As he wrote to a friend: “It’s just tragic enough and just imaginable enough.” And just important enough to be unmissable.

Kalanithi’s wife, Lucy Kalanithi, MD, a physician at Stanford, wrote the book’s epilogue and has penned an essay in the New York Times on their marriage before and after his death. It’s also unmissable.

Previously: Stanford neurosurgeon Paul Kalanithi, who touched countless lives with his writing, dies at 37 and For this doctor couple, the Super Bowl was about way more than football  and Stanford neurosurgeon/cancer patient Paul Kalanithi: “I can’t go on. I will go on.”
Photo courtesy of Lucy Kalanithi

Health Policy, In the News, Medicine and Society, Precision health

Aim higher: Dean Lloyd Minor calls for widespread embrace of precision health

Aim higher: Dean Lloyd Minor calls for widespread embrace of precision health

cycling-655565_1280Dean Lloyd Minor, MD, calls for President Barack Obama to use next week’s State of the Union to embrace precision health. He lays out his thoughts and Stanford’s vision in a commentary published today on Forbes:

If the amazing scientific advances of recent years can help us more effectively treat disease based on individual factors, shouldn’t we also put them to work by helping us keep people from getting sick in the first place?

…Instead of a frantic race to cure disease after the fact, we can increasingly focus on preventing disease before it strikes. By focusing on health and wellness, we can also have a meaningful impact in reducing healthcare costs. At Stanford, we call this idea Precision Health, where we focus on helping individuals thrive based on all the factors that are unique to their lives, from their genetics to their environment.

Precision health marries the advances of data science, biotechnology and genetic analysis with the old-school passion for patients as people, people who can now partner with their physicians to manage, and maximize, their well-being. It aims higher, he says.

“Because when it comes to health, we must think as big as we can – not just about treating disease, but about making and keeping people healthy,” Minor writes.

Previously: Lloyd Minor shares his vision for Stanford Medicine, talks about its “paradigm-shifting advances”, How Stanford Medicine will “develop, define and lead the field of precision health” and A conversation on the promises and challenges of precision health 
Photo by skeeze

Health and Fitness, In the News, Nutrition, Pediatrics

Teens need healthy brain food, says Stanford expert

Teens need healthy brain food, says Stanford expert

teens-healthy-foodToday, U.S. News and World Report released their 2016 ranking of the best diets. For their story on healthy eating for teenagers, Neville Golden, MD, division chief of adolescent medicine at Lucile Packard Children’s Hospital Stanford, explained how diet can affect teens’ brains and moods:

Teens are faced with myriad physical changes and academic demands, all while being bombarded by what their peers are doing – from what not to wear, to what to say and when to say it, to how to get the attention of you know who. And in the midst of all this, the body’s most critical organ – the brain –is still developing, says Dr. Neville Golden, a member of the American Academy of Pediatrics’ Committee on Nutrition…

“If [teens] don’t eat right, they can become irritable, depressed [and] develop problems such as obesity and eating disorders – and those have a whole host of psychological morbidities,” Golden says, adding that proper nutrition can help prevent and manage these conditions.

The rest of the story provides lots of specifics on how teens can improve their diets, including a sample menu for a day of healthy eating. If you know a teen who has made a nutritious New Year’s resolution, it’s definitely worth sharing.

Previously: Want teens to eat healthy? Make sure they get a good night’s sleep, Living near fast food restaurants influences California teens’ eating habits and British teens not getting enough fruits, veggies
Photo by Nestlé

Education, In the News, Medical Schools, Research, Stanford News

Medical schools get an “F” at grading graduates, study suggests

Medical schools get an "F" at grading graduates, study suggests

witteles word cloud imagePerformance evaluations, an important piece of the medical residency application packet, are often incomprehensible, sometimes useless and, at worse, misleading and unfair, according to a recent Stanford study published in Academic Medicine.

The study, which examined performance evaluations — commonly referred to as the “Dean’s letter” — from 131 medical schools across the nation, found that about half don’t follow recommended guidelines set by the Association of American Medical Colleges in 2002.

“This has real consequences as it leaves residency programs in the dark about how well an applicant performed,” says Ronald Witteles, MD, senior author of the study and director of the internal medical residency program at Stanford. “Some of the examples are actually rather humorous, such as one school having 33 percent of its students in the ‘top quartile’ and only 8 percent in the ‘bottom quartile.’ ”

AAMC guidelines recommend that medical schools include “easily interpretable comparative data on core clerkship performance and overall academic performance,” the study states.

To quantify whether the 117 medical schools in the study achieved this goal, researchers examined the grading and ranking systems used, if any. Among the results, they found that 14 of the schools didn’t use any ranking systems at all. Among the 83 medical schools that did assign key words to rank students, there was “tremendous variability” in the terms used — a total of 72 — making it extremely difficult to compare students across institutions.

Adding to the confusion, those 83 medical schools used 27 different words and phrases to describe the “top tier” students such as: exemplary, superior, distinguished, outstanding, exceptional, most outstanding, recommended highly, recommended with distinction, extraordinary and enthusiastically recommended. The meanings of the words varied from institution to institution, Witteles says, and were often difficult to interpret.

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Education, Health Costs, In the News, Patient Care, Research, Stanford News, Technology

Medical errors caused by doctors not examining their patients

Medical errors caused by doctors not examining their patients

800px-Child_examined_by_doctorStories of shocking medical errors that occur because doctors miss something during a physical exam — or forget to examine a patient at all — are common. Every physician knows them, says Stanford physician Abraham Verghese.

A missed breast mass in a patient that presents with chest pain. A missed gunshot wound in a patient wheeled into the emergency room. A missed pregnancy in a patient with a large belly.

But little has been done to quantify this type of medical error. In a first step toward creating data-based measurements of medical errors due to inadequacies in the physical exam, a study published recently in the American Journal of Medicine reports on a collection of 208 such occurrences, and their consequences.

I think of it as my worst nightmare, that a patient will slip through my grasp with a diagnosable or treatable condition.

Researchers collected the incidents from responses to surveys sent to 5,000 physicians asking for first-hand stories of such medical errors. The cause of the oversights in the 208 responses was most often a failure to perform the physical examination at all — in 63 percent of the cases, the study states. Other times, errors were caused by misinterpretating or overlooking physical signs.

“I think of it as my worst nightmare, that a patient will slip through my grasp with a diagnosable or treatable condition,” says Verghese, who is known as a champion of bedside medicine. “I call it the ‘low hanging fruit,'” he says, referring to the simple yet essential process of conducting the physical exam — and its low cost.

The consequences of these mostly preventable mistakes varied from missed or delayed diagnoses in 65 percent of the patients, to incorrect diagnosis in 27 percent or unnecessary treatment in 18 percent, the study says.

“We are talking about missing things that are very common, a mass, or a sore or a heart murmur or something in the lungs, that leads you down the wrong path,” says John Ioannidis, MD, senior author of the study. “This is something that happens everyday, and it’s something that could be corrected to a good extent.”

A well-known report conducted by the Institute of Medicine titled, “To Err is Human,” found that medical errors cause nearly 100,000 deaths per year, according to the study. The extent to which physical examination errors contribute to this figure remains uncertain and, as a result, little has been done to prevent them, it says.

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Cancer, FDA, In the News, Science Policy, Women's Health

Gynecologists call for revision of FDA ruling on device to remove uterine fibroids

Gynecologists call for revision of FDA ruling on device to remove uterine fibroids

6095122430_9cf3ac4ec8_zA group of gynecologists is calling for the Food and Drug Administration to reverse its 2014 ruling banning the use of a device called a power morcellator to remove uterine fibroids, or non-cancerous masses also known as leiomyomas.

The ruling stemmed from several high-profile cases and a concern that morcellators could chop up and spread tissue that might contain a rare but deadly cancer known as leiomyosarcoma. The FDA overstated the risk of morcellation and failed to consider the risks involved in more invasive surgeries needed to avoid using a morcellator, said Jonathan Berek, MD, the chair of obstetrics and gynecology.

Berek is the senior author of the paper published today in Obstetrics and Gynecology and one of 48 gynecologists, oncologists and women’s health advocates who sent an open letter to the FDA yesterday calling for a revision of the ruling.

With a morcellator, surgeons can remove fibroids with very small incisions, usually with a laparoscope, reducing the complication rate and speeding the recovery time needed for fibroid removal or hysterectomy using a large incision, Berek said. But the FDA estimated that 1 in 458 women undergoing the procedure could have an undiagnosed leiomyosarcoma that could be spread by the morcellator.

The gynecologists, with lead author William Parker, MD, from the University of California-Los Angeles, say the FDA is overstating the risk, because recent data analyses put the likely risk at no higher than 1 in 1,550-1,960 cases. In fact, a recent population-based study placed the risk as low as 1 in 4,360 women having surgery for fibroids. In addition, it isn’t even certain that morcellators actually spread the cancers, Berek said.

“A leiomyosarcoma is a highly malignant, rare tumor that tends to spread readily, most often prior to surgery of any type, regardless of whether morcellation is used in the operation,” he told me.

The ruling has had the unintended consequence that many women who might have benefited from a minimally invasive surgery, with lower risks, now undergo a more risky, invasive surgery, he said. The authors list 10 procedures affected by the FDA’s ruling.

In the paper, they suggest six steps that could improve the FDA’s ruling, including advising women of the risks involved with power morcellation and conducting more research into the biology of these rare malignancies.

Previously: Stanford expert weighs in on ovarian0-cancer screening recommendation, Stanford researchers protest NIH funding restrictions and “A historic moment for women”: FDA approves the first drug to treat hypoactive sexual desire disorder
Image by Lady Ro

Ethics, FDA, Genetics, In the News, Science Policy

CRISPR critters and CRISPR conundrums

CRISPR critters and CRISPR conundrums

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There’s much ado about the gene-editing technique CRISPR/Cas9 this week, with a multinational summit in Washington, D.C. on human gene editing, plus the clock ticking down on congressional appropriations bills, one of which would prohibit the Food and Drug Administration from spending money to evaluate research on or conduct clinical trials of gene editing in human embryos. The American Journal of Bioethics, edited by David Magnus, PhD, director of the Stanford Center for Biomedical Ethics, wades into the fray with a special issue on the ethics of CRISPR.

CRISPR is an unusually precise, fast and cheap way of snipping out and replacing genes. It has implications for preventing and treating genetic diseases, engineering new versions of the plants and animals we eat, and knocking out genes in insects so they can’t carry viruses that could kill us. The most controversial possibility is altering human sperm, eggs or embryos, because such germline changes would be heritable in future generations of offspring.

“The overriding question is when, if ever, we will want to use gene editing to change human inheritance,” said chair David Baltimore, PhD, of Caltech in kicking off this week’s summit. Ultimately, summit participants released a statement that left the door open for human germline editing, and advocated for ongoing international discussion.

Indeed, because of the low cost of CRISPR and the variability of research ethics across the globe, an international ban or moratorium would be difficult to enforce, said then-undergraduates Niklaus Evitt and Shamik Mascharak in a paper they wrote for a Stanford class co-taught by professor Russ Altman, MD, PhD. They and Altman turned it into an article for the special issue of the bioethics journal.

They propose a model regulatory framework for CRISPR human germline editing that includes vetting research for necessity and reversibility, establishing the safety and efficacy of the treatment in multigenerational animal models and conducting clinical trials over a 15-year period. “We seek concrete policies that responsibly phase in therapeutic uses of CRISPR-Cas genome editing at a pace amenable to ethical inquiry,” they write.

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In the News, Pain, Public Health

Pain: When the professional becomes personal

Pain: When the professional becomes personal

3199296759_e5130dc6c1_zFor 10 long months, Philip Pizzo, MD, suffered from incapacitating nerve pain. Even worse, top medical experts were stumped. He describes his ordeal in a recent essay in STAT News:

I tried everything — medication, physical therapy, deep-tissue massage, acupuncture — but nothing worked. Magnetic resonance imaging of my spine, hip, and pelvis didn’t show anything suspicious.

As a physician, a former dean of the School of Medicine, and chair of an Institute of Medicine panel on pain, Pizzo had known intellectually about the problem of chronic pain. Now he had experienced its unremitting intensity firsthand.

His pain was relieved by an unusual diagnosis and surgery, but Pizzo knows many others aren’t as fortunate.

“Nearly 100 million Americans suffer from chronic pain. We need to do more for them,” he writes.

Previously: Laughing through the pain: A comedy writer’s experience with chronic illness, “People are looking for better answers”: A conversation about chronic pain and  Study: Effects of chronic pain on relationships can lead to emotional distress
Photo by Kevin Dooley

 

Cancer, In the News, Palliative Care

Popular author writes about the “the circle of caring for a dying person”

Dying roseThanksgiving is a time of gratitude, obviously. But for many, it’s also a time to remember loved ones conspicuously missing from the dinner table. Death and dying are tough topics, but worth talking about even during a holiday weekend.

Last week, one of my favorite bloggers and authors, Catherine Newman, wrote a powerfully moving piece for the New York Times about caring for a lifelong friend as she was dying. I’ve been a fan of Catherine’s since before her second child, Birdy, was born – faithfully reading her thoughts about motherhood and the weird blend of elation, terror, sadness and longing that accompanying the experience of raising babies into children into teenagers. We’re the same age, and our children have grown up together, in a way. I’ve given her book, Waiting for Birdy, to many friends and colleagues, and I consider her a friend I’ve just never happened to meet yet. So when she mentioned on her blog that she’d written about her friend for the Times, I clicked through instantly. And then started to cry.

The article, “Mothering my Dying Friend“, is powerful and sad and unbelievably beautiful. As Catherine writes:

In a Venn diagram of tending helpless people at the extremes of life, the circle of caring for a dying person overlaps almost completely with the one for caring for a baby. Both are repetitive, intimate, often gross, sometimes funny, weirdly frantic even as they’re crushingly tedious, and a total act of devotion. […]  And for all of your endless patience there is nothing at the end. Just death, and your only job is a kind of mothering right up to the lip of the abyss.

I know it sounds grim, but I promise you won’t regret reading. Once again Catherine reminds me that we’re all in this together. I’m no longer of an age where my friends are getting married and having babies. Instead we’re caring for dying parents, getting divorced or watching, gobsmacked, as our formerly helpless infants waltz off with the car keys and a promise to not be late. I hope I can weather these and other changes with the same grace and beauty with which Catherine cared for her friend during her last days.

Previously: Author-physician Atul Gawande on dying and end-of-life care Desire for quality end-of-life care crosses ethnic groups  and Stanford doctor on a mission to empower patients to talk about end-of-life issues 
Photo by Ben Rea

Health and Fitness, In the News, Orthopedics

Walking tall: The challenge of correcting your gait

Walking tall: The challenge of correcting your gait

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Thanks to a bum knee, in elementary school I had to choose between two styles of special Oxford shoes to help correct my gait; I hated those ugly shoes. Luckily these days I have many cute options, along with custom orthotics.

Despite good shoes though, my plantar fasciitis recently sent me back to my physical therapist. Of course the first thing she had me do is walk back and forth across the room, a common sight at any physical therapy office.

 

Now, everyone from doctors and physical therapists to yoga instructors are teaching people how to walk properly.

A recent story in Vogue chronicles one woman’s efforts to correct her bad habits at two walking and gait clinics — with a physical therapist in Santa Monica and with a yoga teacher in Brooklyn. Author Marisa Meltzer also checked in with Jessica Rose, MD, a professor of orthopedic surgery at Stanford University and director of the Motion & Gait Analysis Laboratory at Lucile Packard Children’s Hospital.

Meltzer received immediate feedback from the physical therapist, displeased with the uneven wear of her shoes. As Melzter describes:

Finally, she instructs me to walk back and forth across the room. Her diagnosis: I’m constantly leaning back like a Looney Tunes character approaching oncoming traffic.

Similarly, Melzter visits a well-known yoga teacher, learning to straighten her upper body, rotate her pelvis, and swing her arms as she walks. She describes her new gait near the end of the article: “It feels unnatural, yet when I catch my reflection in the mirror I see I’m moving elegantly and with confidence.”

Jennifer Huber, PhD, is a science writer with extensive technical communications experience as an academic research scientist, freelance science journalist and writing instructor.

Previously: Walking-and-texting impairs posture – and walking, and texting, Walking and aging: A historical perspective and Global survey highlights the need for people to keep track of walking distance
Photo by sean_hickin

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