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In the News, Medical Education, Mental Health, Stanford News

An Rx for physician burnout

An Rx for physician burnout

artsy stethoscope - 250Burnout, which is characterized by emotional exhaustion, a sense of depersonalization and a lack of a sense of personal accomplishment, is on the rise among physicians and medical residents and students in the United States. A lengthy article (subscription required) published Friday in Time examines the growing problem and the movement to save physicians’ mental health:

Experts warn that the mental health of doctors is reaching the point of crisis—and the consequences of their unhappiness go far beyond their personal lives. Studies have linked burnout to an increase in unprofessional behavior and lower patient satisfaction. When patients are under the care of physicians with reduced empathy—which often comes with burnout—they have worse outcomes and adhere less to their doctors’ orders. It even takes people longer to recover when their doctor is down.

Many factors contribute to physician burnout, including long-hours, a high-pressure work environment, the stigma against weakness and mistreatment from higher-ranking physicians. Efforts are underway to change the culture of medicine and alleviate these sources of stress, and much of the story focuses on what’s happening here at Stanford:

In 2011, [Ralph Greco, MD, professor of surgery a Stanford,] Chaplain [Bruce Feldstein, MD,] and a few other colleagues, including [Arghavan Salles, MD, former chief resident of general surgery at Stanford], got together to discuss how to change things. “When people go somewhere new, they lose everything that was around them that supported them, and it’s very natural to doubt them- selves,” says Salles. “I had this idea that we could have sessions where people talk to each other, and then it wouldn’t be so lonely.”

They put together a program at Stanford to promote psychological well-being, physical health and mentoring. Every week, one of the six groups of surgery residents has a mandatory psychotherapy session with a psychologist. Each senior resident mentors a junior resident, and residents are given time for team bonding. Young doctors rarely have time to go see a doctor of their own, so the wellness team issues lists of doctors and dentists it recommends. And there’s now a refrigerator in the surgery residents’ lounge, stocked with healthy foods. They call the program Balance in Life.

“We knew we couldn’t necessarily prevent suicide—too complicated for us to solve it,” Greco says. “But we needed to feel we did everything we could do to prevent it, if we could.”

Previously: Stanford’s “time banking” program helps emergency room physicians avoid burnoutKeeping an even keel: Stanford surgery residents learn to balance work and lifeA call to action to improve balance and reduce stress in the lives of resident physicians and Program for residents reflects “massive change” in surgeon mentality
Photo by Lidor

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

students reading oath2 - 560

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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Medical Education, Medical Schools

Using “spaced repetition” and other learning strategies to better retain medical school knowledge

Using "spaced repetition" and other learning strategies to better retain medical school knowledge

8747269303_eb647f98e2_zMany have described the medical school experience as “drinking from a firehose” of knowledge. Over on the Wing of Zock, radiology resident Peter Wei, MD, and MD/PhD student Alex Chamessian explain how they leveraged psychological research to develop new study techniques and better retain information as medical students.

To break the cycle of learning and quickly forgetting, they began using a technique known as “spaced repetition,” where material is regularly reviewed according to set schedule. They write:

At first, a newly learned fact is reviewed often; as time goes on, and the memory becomes deeply ingrained, it diminishes. In that way, you only have to study each fact exactly when the program predicts you’re likely to forget it – an enormous time savings. While cramming can buy you some short-term learning, if you want to retain information from medical school into clinical practice, spaced repetition is the way to go.

So, with this knowledge in hand, we and some of our classmates started using free, open-source flashcard apps, such as Anki and Mnemnosyne, which incorporate spaced repetition. Our understanding of the psychological literature also taught us the best practices for studying, and what sorts of resources to use for each course.

We talked with our classmates, who adopted parts of this methodology for themselves and offered useful suggestions to streamline it further. Pretty soon our class was teaching these techniques to the incoming first years, and a year later, that class started reaching out to the new incoming first years. And sure enough, many of us did very well on the USMLE step exams and found that had a firm grasp of clinical knowledge once we hit the wards; our studying yielded much better results than we could have expected otherwise.

In an effort to help other medical students learn more efficiently, Wei and Chamessian wrote the book “Learning Medicine, an Evidence-Based Guide” detailing the spaced repetition method and other learning strategies.

At Stanford, educators developed a new online learning initiative to re-imagine medical education using the “flipped classroom” model. The Stanford Medicine Interactive Learning Initiatives aims to make better use of the fixed amount of educational time available to train doctors and help students learn more efficiently.

Previously: Using the “flipped classroom” model to bring medical education into the 21st century, Flip it up: How the flipped classroom boosts faculty interest in teaching and A closer look at using the “flipped classroom” model at the School of Medicine
Photo by EdTech Stanford University School of Medicine

In the News, Media, Medical Education, Medicine and Society, Myths, Pregnancy, Research

Reality TV influences perspectives on pregnancy, study shows

Reality TV influences perspectives on pregnancy, study shows

272417047_806faa2243_zA new University of Cincinnati study on the influence that television programs have on pregnant women has found that most women are more affected by TV representations of childbirth than they think.

The study, funded by the NSF and conducted by Danielle Bessett, PhD, assistant professor of sociology, followed a diverse group of 64 women over the course of two years and investigated how they understood their television viewing practices related to pregnancy and birth. It found that class, as measured by education level, had the greatest influence on whether a woman acknowledged television as a significant source of pregnancy-related information. Highly educated women and those who worked outside the home were more likely to dismiss TV, while those with less education and who were unemployed or took care of children at home were more likely to report watching and learning from such shows as TLC’s “Baby Story” and “Maternity Ward” and Discovery Health’s “Birth Day.”

The particularly interesting finding is that TV portrayals affect women’s perceptions even when they don’t believe they have an influence. Bessett developed the term “cultural mythologies of pregnancy” to describe how TV, film, media, and word of mouth create expectations about “the way things are.” Most reality TV and fictionalized programming presents childbirth as more dramatic and full of medical interventions than the majority of births really are, and these images made a lasting impression on women.

As quoted in the press release, Bessett says, “Hearing women –– even women who said TV had no influence on them –– trace their expectations back to specific television episodes is one of the few ways that we can see the power of these mythologies.” Many women mentioned pregnancy representations they had seen long before they got pregnant.

Women who reported watching TV considered it part of a comprehensive childbirth education program and would often evaluate the programs’ reliability, while women who disavowed television saw it as entertainment or education for children, likely from a desire to be seen as valuing science and medical expertise.

“If we believe that television works most insidiously or effectively on people when they don’t realize that it has power, then we can actually argue that the more highly educated women who were the most likely to say that television really didn’t have any effect on them, may in the end actually be more subject to the power of television than were women who saw television as an opportunity to learn about birth and recognized TV’s influence,” hypothesizes Bessett.

“This research implies that many women underestimate or under-report the extent to which their expectations of pregnancy and birth are shaped by popular media,” concludes Bessett, suggesting that “scholars must not only focus on patients’ professed methods for seeking information, but also explore the unrecognized role that television plays in their lives.”

Previously: New reality shows shine harsh light on teen pregnancy and Study: TV dramas can influence birth control use
Photo by johnny_zebra

Medical Education, Stanford News

Stanford Medicine’s white coat and stethoscope ceremony, in pictures

Stanford Medicine’s white coat and stethoscope ceremony, in pictures

Friday was a big day for Stanford’s 90 new medical students, who – as my colleague Tracie White once eloquently put it – took their “symbolic first step on a journey to physicianhood.” The school’s white coat and stethoscope ceremony was held in the afternoon, and photographer Norbert von der Groeben was there to capture some special moments.

Previously: Stanford Medicine’s commencement, in picturesMedical students start “transformational” journey and “Something old and something new” for Stanford medical students

Medical Education, Microbiology, NIH, Public Health, Research, Videos

Investigating the human microbiome: “We’re only just beginning and there is so much more to explore”

Investigating the human microbiome: "We’re only just beginning and there is so much more to explore"

The more scientists learn about the body’s community of bacteria, the more they believe that the human microbiome plays an important role in our overall health. For example, research published earlier this week suggests that a specific pattern of high bacterial diversity in the vagina during pregnancy increases a woman’s risk of giving birth prematurely.

Despite these and other insightful findings, researchers have a long way to go to understand the composition of our internal microbial ecosystems. As Keisha Findley, a postdoctoral fellow at the National Human Genome Research Institute says in the above video, “We’re only just beginning and there is so much more to explore.”

Findley and colleagues are working to survey all of the fungi and bacteria living on healthy human skin and develop a baseline to determine how these microbial communities may influence skin conditions such as acne, athlete’s foot, skin ulcers and eczema. Watch the LabTV video above to learn more about her work.

Previously: Drugs for bugs: Industry seeks small molecules to target, tweak and tune up our gut microbes, A look at our disappearing microbes, Exploring the microbes that inhabit our bodies and Diverse microbes discovered in healthy lungs shed new light on cystic fibrosis
Via NIH Director’s Blog

Global Health, Medical Education, Medicine and Society, Patient Care, Public Health

Exploring the benefits of pursuing anthropology and medicine

Exploring the benefits of pursuing anthropology and medicine

3470650293_60b27d6539_zAs a PhD student in medical anthropology, and having come from a very “medical family,” pursuing an MD has been a kind of shadow-dream of mine. For a year or two in high school, I was convinced that neonatology was the path for me; now I’m a doula and research the culture of childbirth.

Some people do live the double dream, and I recently interviewed two of them: Jenny Miao Hua at the University of Chicago and Rosalind Franklin University’s Chicago Medical School, and Stanford’s Amrapali Maitra, both of whom are medical anthropologists pursuing PhD/MD degrees. (Amrapali has brought an anthropological perspective to Scope through our SMS Unplugged series.)

The two came to their joint degree from different sides: Hua was an anthropology student interested in Chinese medicine and the body, while Maitra was enrolled in medical school and became serious about understanding the social context of illness. Each intends to pursue internal medicine, and each, incidentally, has family connections in the site she chose to research. We talked shop for quite a while, and what I found most interesting was their thoughts on what anthropology brings to clinical practice:

Maitra: On the broadest level, anthropology gives you an immense empathy for your patients and allows you to see them as people. It sounds cliché, but with the focus on efficiency and evidence-based medicine that has taken over American biomedical practice, even the most kind and caring individual can lose [his or her] empathy. And the kind of empathy you get from anthropology is not just sympathizing with the person, but really understanding where they’re coming from, historically and because of their life position: why they live in a certain neighborhood or have a certain diet. It allows you to think creatively about what they’re able to do or not do in pursuing their own health.

Hua: With anthropological training, students understand the various ways pathologies are dependent on larger socioeconomic forces. As a practicing physician, the person who comes through the door is never a textbook patient, so within a very short amount of time you have to pick up on this deep history, and when you’re not careful you end up stereotyping and profiling. Anthropology brings a more nuanced way of thinking about patients: they’re not just uniform biological entities, but hybrids of biology, society, and culture.

Maitra: I’ve seen so many clinic visits where I can tell, as the anthropologist in the room, that the attending physician and patient just have completely different agendas. There are simple questions like those Arthur Kleinman has laid out, asking what about the pain bothers her, why she thinks she’s having it, what she hopes to get out of the encounter. I see some doctors use these, and their visits go so much better. They’re able to build an alliance with their patient that’s very therapeutic.

That’s anthropology on the individual level, but on another level it allows you to recognize that certain things are trends. It allows you to think systematically about different kinds of structural violence. For example, why is it that so many people whose occupation is picking strawberries come in with knee and back pain issues? Treating pain is not going to solve the problem. It’s about getting to the root of the occupational hazards of being a farm worker.

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Medical Education, Medical Schools, Stanford News

Passing the boards: Reassessing “Step 1 madness”

Passing the boards: Reassessing "Step 1 madness"

medical booksCharles Prober, MD, senior associate dean of medical education at Stanford, has long been concerned about the misuse of Step 1. The national standardized test, which must be passed in order to get a medical license, is also often used inappropriately, according to Prober, as a screening tool by residency programs.

But his concern about the test — dubbed “Step 1 madness” by some med students and the first of three required for medical licensure — extends even further to what he and others believe are the unnecessary and sometimes detrimental effects on both the education of medical students and their stress levels.

In a commentary published this week in the journal Academic Medicine, Prober and his co-authors — which includes the president of the National Board of Medical Examiners, the non-profit that develops and manages the test — issue a “plea to reassess” its role in residency selection. They write:

There is an increasingly pervasive practice of using the score, especially the Step
1 component, to screen applicants for residency. This is despite the fact that the test was not designed to be a primary determinant of the likelihood of success in residency… [I]t is disconcerting that the test preoccupies so much of our students attention with attendant substantial costs (in time and money) and mental and emotional anguish.

Prober and his colleagues go on to explain how students sequester themselves for four to nine weeks on average studying full-time for the day-long multiple-choice examination, which is usually taken sometime following their second year of medical school. The stress to pass the test, which is designed to test  “important concepts of the sciences basic to the practice of medicine,” is particularly high because students know a poor score may keep them from qualifying for the first step to get into a residency program — the interview:

Despite its intended purpose, many residency program directors continue to use applicants’ USMLE Step 1 scores as a sole or primary filter for selecting candidates to interview… In general, the more competitive the residency discipline (e.g. orthopedic surgery, radiation oncology, dermatology, ophthalmology, and otolaryngology,) the higher the Step 1 score needed to pass through the filter.

The authors express the opinion that it is “ill advised” to use the test for a purpose for which it was not developed, that the test is not a good predictor of who will do well in residency and that it is being misused for “convenience” as a easy to apply mechanism to reduce large applicant pools. Their solution isn’t to get rid of the test, which is still a valuable tool, but to create additional measurement tools of equally important skills for selection by residency programs.

“A more rational approach to selecting among residency applicants would give greater attention to other important qualities, such as clinical reasoning, patient care, professionalism, and ability to function as a member of a health
care team,” they conclude.

Previously: Using the flipped classroom model to bring medical education into the 21st-century and Student transitions in medicine: putting blinders on
Photo by jcalyst

Medical Education, Medical Schools, Palliative Care, Patient Care, SMS Unplugged

When Mr. Bailey passed away: A student’s story

When Mr. Bailey passed away: A student's story

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 categoryCertain details in this entry have been omitted or changed, and all names have been altered to protect the identity of those involved.

387521264_d1cd33d574_zBrief life update, since it’s been more than 3 months since I’ve last posted on SMS Unplugged:

  • I disappeared for most of April through the end of May to study for and take Step 1, which – for anyone who hasn’t heard of this test – is a pretty brutal, not to mention expensive (~$590!! One of many reasons why med students are poor), 8-hour exam that tests broad concepts of medicine (biochem, immunology, organ systems, etc.) and is widely heralded one of the most important tests for residency admission.
  • I started clerkships at the end of June, with my first clerkship being in internal medicine. The rest of this entry describes one of the most poignant experiences from my first month and a half on rotations.

It was just another call day, when all of a sudden, an overhead announcement rang through the ward: “Code Blue, respond to Room 281. Repeat – Code Blue, respond to Room 281.” Instantly, the atmosphere in our team room turned serious: We knew it was one of our patients, Mr. Bailey, there. As a group, we sprinted towards Room 281. Disorganized, panicked thoughts were running through my head – oh-my-god-what-happened-to-our-patient, thank-goodness-I’m-wearing-sneakers-and-scrubs-today-there’s-no-way-I-could-run-like-this-in-flats, oh-my-god-what-happened-to-our-patient, oh-my-god.

When we got to the room, there were at least 8 people there already, with more trickling in. Our patient was covered in wires, IV lines, a face mask for oxygen. My resident stepped up to the bed and began telling everyone else about our patient’s past medical history, what we were treating him for, how his clinical course had been. I stood in the back, with the single-minded goal of keeping out of everyone’s way. For the next several minutes, at least a dozen people worked to bring Mr. Bailey back to life – and when I left the room, they had succeeded.

I walked back to the team room in a bit of a haze, the relief beginning to course through me, mixed in with remaining vestiges of adrenaline. I had only met Mr. Bailey once before, as he was primarily being followed by another member of my team. From our daily morning rounds, however, I knew he was incredibly sick. We estimated that he only had a few months left. When I met him that one time, it was so clear to see that he was struggling, to breathe, to keep his state of mind. Still, I thought it would be months, not days before he passed away.

The morning after the code, I came into the hospital at the usual time, pre-rounded on my own patients, and headed back to the team room to prep my presentation and notes for rounds. As I walked back to the team room, I ran into another team member, who asked me, “Did you hear about Mr. Bailey?” “No,” I said. “He died last night.”

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Health Disparities, Medical Education, Medicine and Society, Public Health, Science

Stanford Medical Youth Science Program for underrepresented students expands and deepens

Stanford Medical Youth Science Program for underrepresented students expands and deepens

unnamedThe Stanford Medical Youth Science Program (SMYSP) is a 5-week summer residential program for rising high school juniors and seniors interested in science and medicine. The students, who come from underrepresented and low-income backgrounds, have an opportunity to experience the medical profession from the inside out. This year’s program concluded late last month with a graduation ceremony in which the students presented their scientific research projects on health disparities and advocacy to an audience of their parents and supporters.

A few weeks ago, I had the chance to speak with the program’s longtime director, Judith T. Ned, EdD, who told me SMYSP has come a long way since it was co-founded 28 years ago by Stanford epidemiologist Marilyn Winkleby, PhD, MPH. This is Ned’s 14th year running the show. She has made lot of beneficial changes and expansions, many of which happened since we last featured SMYSP in 2010, without losing sight of the program’s purpose: to expose these kids to the fields of science and medicine while increasing workforce diversity in the health professions.

Each year, 12 boys and 12 girls are selected for the program, all of whom come from 20 counties surrounding Stanford. “The goal is to really provide services and opportunities to students who are in our backyard, if you will,” Ned told me. The students have a well-rounded curriculum – not only do they attend lectures by leading academics and industry professionals, anatomy lectures and labs (with cadavers!), and twice-weekly clinical internships, but they have non-clinical days where they investigate departments like hospital food service, security, and art therapy. “We want to show them that it takes multiple people in multiple areas to really make the hospital function. Most of the time, many of my students serve as translators for their parents when they go into the hospital. This is the flip side: the provider’s perspective, not the patient’s. It’s been an interesting experience to see them switch mindsets.”

Programming includes SAT prep, “game shows” to improve knowledge retention, and evening workshops that include leadership development and performing arts. Ned wants the students to know that “you can take a well-rounded liberal arts education, get into medical school, and still practice your craft, embracing both sides of your identity.” Community service is also a key feature of the program, such as the beautification project they did at the East Palo Alto YMCA the Saturday before our interview.

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