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Medical Schools, Patient Care, Stanford Medicine Unplugged

What happens when you can’t communicate with your patient?

What happens when you can’t communicate with your patient?

Stanford Medicine Unplugged (formerly SMS Unplugged) is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the Stanford Medicine Unplugged category.

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Over the past eight months, I’ve rotated at the Palo Alto VA, Santa Clara Kaiser, Stanford outpatient family medicine and pediatrics clinics, and most recently, at Santa Clara Valley. At the VA and Kaiser, all my patients spoke English. Occasionally, at Stanford’s outpatient sites, our patients spoke a language other than English; however, this never felt like a barrier to care because Stanford had phone interpreters available, as well as iPads on wheels that you could use to videoconference in an interpreter. These resources made it feel as though the interpreter was right there in the room with us. And indeed, they could not only hear the patient’s words but also see their expressions, adding an extra dimension to the interpreting services they generously provided.

Valley, however, felt like a different world. As a county hospital, Valley doesn’t often have the luxury of flashy resources. I spent this past month there, on my general surgery/trauma rotation. On morning rounds each day, we would check on each one of our patients, asking whether their pain was under control, if they were able to eat post-surgery, if they had walked around the ward to get back to their baseline activity level, and more. These rounds would take place as early as 6:15 a.m., and they were efficient, since operating room cases would begin at 7:30 a.m.

At various point in the month, our Valley team had patients who spoke only Spanish, only Korean, only Cantonese, and only Vietnamese. Sometimes, we got lucky, and a member of the nursing staff spoke one of these languages. But at other times, we worked through hand gestures and simple words to try and ascertain patient pain, symptoms, etc. Phone interpreters were an option, but the early timing and rapid pace of rounds made it cumbersome to call an interpreter. We usually circled back in the afternoon with a phone interpreter – and if we happened to have multiple traumas that came into the hospital that day, it would be later rather than earlier that we returned to the patient’s bedside. Putting myself in patients’ shoes, I imagine how frustrating it must have been for them, to feel both dependent on the medical team for care as well as helpless to communicate how they felt and what they wanted.

I began to think about how this problem could be fixed, and my thoughts took me back to my middle and high-school years. In middle school, I was required to take at least one foreign language. I chose Spanish and continued taking Spanish throughout high school (then promptly forgot everything when I went to college, making me rather useless on surgery rounds). Wouldn’t it be useful to have a similar language requirement in medical school? I don’t mean a comprehensive foreign language course. Instead, I think it would be meaningful to know key words and phrases – Do you have pain? Are you able to eat? Where does it hurt? – in, let’s say, the ten most common languages spoken in the particular geographic region a medical school is located in.

I know, I know, medical school curricula are already teeming with courses and requirements, and adding a language requirement feels like just one extra thing. But, if it makes a valuable difference in patient care, isn’t it a worthwhile addition? It’s certainly something to ponder. As for me, I just downloaded Duolingo on my iPad, so if you catch me awkwardly practicing my Spanish out loud in any one of my favorite Palo Alto cafés, you’ll know why!

Hamsika Chandrasekar is a third-year student at Stanford’s medical school. She has an interest in medical education and pediatrics. 

Photo courtesy of Bill Pugin, The Sign Language Company

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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History, Medical Schools, Stanford News

The “terribly exciting” days of Stanford’s young Department of Medicine

The "terribly exciting" days of Stanford's young Department of Medicine

Stan Schrier

In the summer of 1959, not long after Stan Schrier, MD, joined Stanford’s Department of Medicine as an assistant professor, he attended his first meeting with just 12 other faculty members.

Where many would see a sparsely filled room, Schrier saw possibility. “It was pretty clear that we had a very small department and the place was going to build,” he recalled in a recently published article.

Those early days were “terribly exciting,” reminisced Schrier. “As young assistant professors with not many of the older faculty around we had enormous leverage. We proposed programs that, in fact, took place, and that have led to what we see now — an enormously powerful department with strengths in basic science and translational medicine.”

He has collected many stories like this over the span of his 56-year career. “We’re an extraordinarily different place today. Instead of 12 or 15, there are 400 in the Department of Medicine. We have people at ValleyCare Medical Center, and we have people at the Palo Alto VA, to say nothing of the enormous expansion of Stanford Hospital.”

Schrier, who is now 86, continues to see patients in the hematology clinic and still has plenty of teaching opportunities.

As if that’s not enough for a man who was alive during the Depression, he also studies the impact of anemia on older patients with congestive heart failure.

“The best time of my life is now,” he said. “And though I’m supposed to be retired, I’m actually an ‘active emeritus.’”

Previously: Exploring the history and study of sleep with William Dement, The history of U.S. health care in about 1,000 words and A trip down memory lane: Stories from the early days of the School of Medicine
Photo by Norbert von der Groeben

Education, Medical Schools, Stanford Medicine Unplugged

Considering premed? Some things to think about…

Considering premed? Some things to think about...

Stanford Medicine Unplugged (formerly SMS Unplugged) is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the Stanford Medicine Unplugged category.

MatchDay14-Ever since I was little, people asked me if I would become a doctor like my dad. I wasn’t sure until I shadowed a doctor my freshman year of college. As soon as that happened, I started looking for guidance on how to choose between my many interests so that I could both be true to myself and become the best candidate for medical school that I could be.

I was lucky to have many great mentors who took the time to thoughtfully answer my questions, and now I’d like to pay it forward. For anyone in the early stages of premed that wants advice, here are my thoughts on certain areas.

Academics

  • Medical schools will likely want to see evidence that you’ll be able to keep up with the academic rigor of their program. This sounds obvious, but the way that you can demonstrate this is to do well in your classes as an undergraduate.
  • Don’t take more classes than you can master. There are many interesting courses available in college but you need to be strategic about giving yourself the time to excel in your classes and giving yourself time to just be.

Extracurriculars

  • Give yourself time to see what extracurriculars you gravitate towards naturally. When you find them, pick one or two and invest time and energy in them. Take them in interesting, unique directions:
    • If research is your thing, then ask interesting questions. Schedule time every few months to actually speak with the faculty overseeing your research.
    • If volunteering is your thing, then be a leader in your field. Identify a need that has not been filled or an organization that inspires you and work hard on that.
    • If you’re an athlete, then be a leader on the field and off. Be a mentor to younger teammates.
  • At the end of the day, medical schools want to see your leadership and legacy as an undergrad.

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Education, Medical Schools, Medicine and Society, Stanford Medicine Unplugged

Does medical school unfairly glamorize the medical profession?

Does medical school unfairly glamorize the medical profession?

Stanford Medicine Unplugged (formerly SMS Unplugged) is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the Stanford Medicine Unplugged category.

discovery walkAny Stanford student knows all too well that the immense campus, with its seemingly eternal sunshine and endless rows of palm trees, can make it difficult to want to get outside and experience the real world. When it comes to medical education, this creates a very real concern: Is it possible to experience the full diversity of our health-care system when you are living in the so-called “Stanford bubble” – an idyllic college campus in one of the wealthiest counties in the United States?

I’ve certainly felt the effects of the Stanford bubble, but interestingly, working with a diverse population of patients has not been my primary challenge. Stanford has a wide net of connections with the Peninsula region and larger Bay Area – from clinics serving the urban underserved in East Palo Alto to flu vaccination programs reaching a rural population in the Central Valley farmlands. Those experiences are widely accessible to anybody who seeks them out.

No, my problem with the Stanford bubble is not about the patients – but rather the doctors. Doctors are known for being overworked and stressed, right? It certainly doesn’t seem that way in our bubble, where speaking with our outstanding pre-clinical faculty about their careers brings inspiring stories of cutting-edge research achievements, clinics filled with fulfilling cases and grateful patients and many years of training bright up-and-coming doctors. On the contrary, my faculty mentors speak highly of the balance they’ve found in their professional lives – clinic one day, research the next and teaching in between.

But is this really representative of the real world? When you step outside the realm of “academic medicine,” the picture seems to change considerably. It’s not a secret that, among physicians nationwide, burnout is widespread and pervasive – afflicting 46 percent of doctors in a recent study. Burnout was defined as “emotional exhaustion, depersonalization and low personal accomplishment.” To be honest, I can’t say that I’ve ever observed anything like that in my pre-clinical years, let alone in 46 percent of our faculty. As pre-clinical medical students, burnout is something that we hear about constantly, but witness never, allowing us to convince ourselves that it’s just some abstract idea that doesn’t apply to us.

I’m constantly inspired by my teachers and mentors here at Stanford. I will consider myself incredibly fortunate if I manage to step into their shoes at some point in my career. But part of me that wonders if we’re really seeing the full picture as pre-clinical students. We’re being shielded from the “front lines” – the thousands and thousands of primary care doctors who work tirelessly under the strains that our health-care system imposes on private practice physicians. Are we being set up for an unpleasant surprise later on? How can we possibly avoid being part of the 46 percent if we don’t have a good awareness that it exists? Perhaps it’s time to start bringing these questions into the medical school bubble.

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

Photo by Norbert von der Groeben

Education, Medical Schools, Medicine and Literature, Stanford News

Tiger mother, tiger cub: A Stanford doctor reflects on his upbringing

Tiger mother, tiger cub: A Stanford doctor reflects on his upbringing

Tiger Child Pic JAMA PedsWhen Amy Chua’s book, “Battle Hymn of the Tiger Mother” was published in 2011, Jason Nagata, MD, was in medical school at the University of California, San Francisco. He caught on to the humor (which escaped some of the book’s reviewers), and the anecdotes resonated with him – reminding him of his own strict and intense upbringing. “It was very funny and very controversial,” he said. “A lot of that book stuck with me from the child’s perspective.” He started to share some of those memories with people around him and found that his fellow med school students had similar stories, too. He wrote about his experiences as a “tiger child” in a funny and touching essay (subscription required) published online today in JAMA Pediatrics.

When I connected with Nagata, we spoke over Skype because he was working in Ecuador as part of his global health residency. He noted that despite the negative press Chua’s book received, he believes that strict childhood training helped prepare him for medical school. “The tiger mentality is prevalent throughout medicine,” he said. “It was intense as a child, but it prepared me well for medical training – the hours and the intensity.”

But Nagata had to learn the hard way to make room in his schedule for rest. After a particularly intense time during medical school, he developed an ulcer that landed him in the hospital. His recovery took more than a month. He explored writing as a way to reflect and think through his experiences as a student and later as a doctor. When he came to Stanford, he attended the Medicine and the Muse writing workshops to hone his writing chops. His current essay is just the latest in a series.

Although he makes time for rest, he still has plenty of drive and intensity. He mentioned that he was planning a trip to the Galápagos Islands and to hike Mount Chimborazo, the highest mountain in Ecuador, the weekend after we spoke. After he completes his residency at Stanford, he’ll start a three year fellowship in adolescent and young adult health in July 2016.

Nagata describes his own mother’s unusual path from NICU nurse to graduate student in chaplaincy. “She exemplified the tiger mom and probably works even harder than I do,” he said. “I got a lot of my habits from her.” She doesn’t demand as much from Nagata these days, but her Tiger mom spark isn’t completely gone. When he told his mother about the upcoming essay, she quipped that she was planning to write a rebuttal to JAMA Pediatrics “in her own tiger mother vein,” he said.

Previously: For group of Stanford doctors, writing helps them “make sense” of their experiences
Photo of Jason Nagata as child, courtesy of Jason Nagata

Education, Media, Medical Schools, Medicine X, Technology

Integrating digital literacy into medical education

Integrating digital literacy into medical education

21474271319_dc2d63f449_zBertalan Mesko, MD, PhD, has cracked the code on convincing medical students that digital literacy skills are equally as important as clinical knowledge. Seats in his Social MEDia course fill up within 45 seconds of registration opening. Former students report a 100 percent satisfaction rate with the class, and 80 percent of those enrolling in the course heard about it from a classmate. How does Mesko do it? As it turns out: daily educational challenges promoted on Facebook, an arsenal of high-tech gadgets and lots of chocolate.

On Thursday at Stanford Medicine X|ED, Mesko shared his secrets with medical educators on how to develop a digital literacy curriculum that will engage millennial learners and keep pace with the ever-changing landscape.

A self-describe medical futurist, Mesko launched his class on social media in medicine in 2008 when Facebook and Twitter were still in their infancy. “I wanted to design the curriculum for students to prepare them for the future that is coming toward us,” he said. “My goal was to help them understand how to use these tools to be more productive and stay up to-date.”

Early on, the curriculum centered on his experience with social media tools, such as blogging, Twitter and Facebook. But as the field of digital media and medical devices has evolved, so has the class. These days, he’s constantly updating the coursework to the point where he never gives the same lecture twice. “Platforms come and go, but it’s the concepts and practices that really matter,” said Mesko, who teaches at Semmelweis University in Hungary. “Whenever I talk about these topics, I do everything live.”

Most students have been active on Facebook, Twitter, Instagram, Snapchat and other social media accounts, long before they enroll in Mesko’s class. However, he still believes it’s important to provide an introduction to social media; discuss search engines and the Google story; and provide instruction on medical blogging, crowdsourcing and mobile health.

“Students need some fundamental digital knowledge before diving into the topics of e-patients and how to empower patients,” said Mesko, author of the recently released book My Health: Upgraded . “Additionally, many students don’t fully understand the privacy polices of these services. I tell them to remember that there is no difference between offline or online conduct.”

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Education, Events, Medical Schools, Medicine X, Patient Care

Day One of Medicine X | Ed: Understanding and equipping today’s medical learner

Day One of Medicine X | Ed: Understanding and equipping today's medical learner

patient Dave on stageThe first day of Medicine X | Ed began with a suite of talks and technology demonstrations that focused on understanding and equipping today’s medical learner. The first grouping of talks, themed “meet the millennial learner,” explored how medical students learn and how technology and social media present new opportunities and challenges for these students.

Joseph Santini, PhD, kicked off the first set of presentations by discussing information barriers that disabled students, and patients, face. Santini gave his presentation in sign language, with subtitles and an interpreter so everyone could understand what he wanted to say. Unfortunately, he explained, these modes of communication aren’t always available for disabled students.

Many deaf medical students — and physicians — must pay for their own interpreters, he explained. This financial burden dissuades many deaf people from pursuing or remaining in the field of medicine. The recent shift from text-based communication to more audio and visual systems is also a challenge, Santini said. “Have you ever tried to watch videos on YouTube with automatic captioning?” he asked. We call it a crap shoot… The text is a jumble. Advances in these areas would be key.”

Speaker Dreuv Khullar, MD, a resident physician at Massachusetts General Hospital and Harvard Medical School, highlighted another challenge that medical learners face: A lack of time.

Khullar recounted a story from medical school. He was sitting with a critically ill patient when his pager buzzed. He wanted to stay with the patient, but he had eight more patients to see, and he was already late. He vowed to spend extra time with with patient the next day, but the patient died that night.

“It turns out that the most draining aspect of medical school is not the hours, it’s that you cannot be there for patients the way you thought you would be,” Khullar said. “I think of the countless opportunities for compassion that I squander for things that are less important… I think that next time [this happens] I will sit.”

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Education, Medical Schools, Sports, Surgery

Applying athletic and musical coaching techniques to surgical training

Applying athletic and musical coaching techniques to surgical training

5866567170_aa28901818_zPerforming in a harmonious group is a key characteristic in the success of athletes, musicians and surgeons. With this in mind, physicians at the University of Texas Medical Branch at Galveston worked with members of the Choral Arts Society of Washington D.C. and the U.S. National Rowing Team to develop a new coaching model for training surgeons that draws on strategies from the musical and sports world.

Findings (subscription required) from the study were recently published in a special edition of the journal Surgical Clinics of North America. A release offers more details about the training approach:

It has been shown that deliberate practice is crucial to expert performance. Deliberate practice, which entails setting a well-defined goal, being motivated to improve and having ample opportunities for practice and refinement of performance through structured feedback, is a hallmark of this model.

The model also employs a coaching team that is well rehearsed in the day’s training procedure and is in constant communication so that trainees receive immediate correction when needed.

“Coaching teams not only are more efficient at communicating but also have been shown to make fewer mistakes in high-risk and high-intensity work environments, compared with individuals,” said [Kimberly Brown, MD, associate professor of surgery at the University of Texas Medical Branch at Galveston.] “This fact is of greater relevance when performance requires multiple skills, judgments and experiences.”

Brown said that when all of the coaches and learners are actively engaged throughout the training session, the other team members also contribute more to their highest capacity. This leads to a multiplying effect on the team as a whole, resulting in a team’s best possible performance.

Previously: Spanish-speaking families prefer surgical care in their native language, study finds, Clementines help surgeons-in-training to practice and Surgical checklists and teamwork can save lives
Photo by Army Medicine

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

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