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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

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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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Medicine and Literature, Stanford News

Charlotte Jacobs on finding “snippets during every day” to balance careers in medicine and literature

Charlotte Jacobs on finding "snippets during every day" to balance careers in medicine and literature

Stanford oncologist Charlotte Jacobs, MD, loved reading biographies as a child. But it wasn’t until years later, while on sabbatical at Stanford, that she decided to take a creative writing course and begin cultivating a second career as a biographer.

Her first biography, Henry Kaplan and the Story of Hodgkin’s Disease, was published in 2010 and chronicled the life and work of one of the foremost physician-scientists in the history of cancer medicine. Her latest book, Jonas Salk: A LIFE, tells the remarkable story of the man who conquered polio. The New York Times called Jacobs latest biography, “science writing at its best.”

In a recently published Q&A on the Department of Medicine website, Jacobs discusses how she balances her roles as mother, physician and author. “I could find snippets during every day to write. Even today I find that to be the case,” she says.

On the topic of being able to meld her doctor life with her writer life, Jacobs says:

I don’t meld the two at all. When I’m writing or doing research on one of my books, I’m totally focused on that. And when I’m with my patients, I’m totally focused on them. One thing I learned from Henry Kaplan, who had a whirlwind of activity surrounding him, was that when he was in the exam room, the patient was his only concern.

“I do think my background in science helped me be a better writer, though. I chose subjects who were in the field of science or medicine because that is what I know. One of the hardest tasks was interpreting my subjects’ work to the general public. I used to think if my next-door neighbor, who was a smart housewife, couldn’t understand and enjoy the books, I had failed.

“Knowing academic medicine also helped. Jonas Salk ran into major political hurdles, and he was not treated kindly—some of which was his own doing. Having spent my entire career in academic medicine, I could understand the world in which he worked.

Previously: Stanford doctor-author brings historic figure Jonas Salk to lifePrescribing a story? Medicine meets literature in “narrative medicine”, Literature and medicine at life’s end, Poetry’s connection to medicine and the body and More than medicine: Stanford medical students embrace their artistic passions through unique program

Humor, In the News, Medical Education, Medicine and Literature, Medicine and Society, Patient Care

Graphic medicine takes flight

Empathy-Ian-Williams-510x438A recent blog post on Somatosphere sparked my interest in the role that comics can play in the study and delivery of health care, an emerging field called “graphic medicine.” The term was coined by UK-based Ian Williams, MD, who is an artist and independent humanities scholar as well as a physician. He recently launched a website of the same name.

The post introduces a few new books that just came out on the subject: Graphic Medicine Manifesto, a collaborative work by six health-care professionals and humanities scholars, and Ian Williams’ The Bad Doctor. It also describes how comics can open us up to new ways of seeing in ways that text alone cannot:

Comics allow us to ask how we can “orient” ourselves… toward the potentiality of images and away from the systematizing effects of text alone… [Comics use] images and imagistic thinking as a way to see a different mode of existence.

Since it’s an anthropology blog, it suggests that a “graphic medical anthropology” would be a great way to accomplish the anthropologist’s goal of “seeing structure, complexity, nuance, emergence, and multiplicity simultaneously.” We anthropologists often try to achieve this goal with complicated metaphors and theories, but perhaps the old adage about a picture being worth a thousand words holds true in this case.

The post notes that drawings can provide an experience of self-reflection for the artist, and can inspire readers to readily and easily respond with their own experience, making the work more of a dialog. They can introduce “theoretical orientations” in ways that are more accessible, and can expose power relations in ordinary lived experience. Ordinary lived experience is particularly well conveyed by comics; they showcase the mundane and make it meaningful. They can take those “ordinary, chronic and cruddy moments” and convey what it’s like to be part of our society.

Previously: Cancer Ninja fights patient misinformation, one cartoon at a time, Using graphic art to understand the emotional aspects of disease, A comic look at 12 medical specialties, Economist to explain health reform through graphic novel, and Webcomic xkcd gets medical
Illustration by Ian Williams, “Autography as Auto-Therapy: Psychic Pain and the Graphic Memoir.” Journal of Medical Humanities 2011, reposted from Somatosphere

Events, Global Health, Haiti, Medicine and Literature, Patient Care, Stanford News

Physician writers share a “global perspective on healing”

Physician writers share a "global perspective on healing"

6319607736_156bcef31e_zWhen I saw that an event called “Medicine Around the World: Healing from a Global Perspective” was taking place on campus, I thought it would be right up my alley as a medical anthropologist.

The event, sponsored by Stanford’s Medicine and the Muse program and the Pegasus Physician Writers group, was a reading in which physicians shared some beautiful pieces they had written about their experiences providing medical services across the globe, including Haiti, Mexico, Austria, and Vietnam. The musings were less about culture than they were about poverty, conflict, disasters, and war, and what it’s like to seek health and healing in such overwhelming circumstances.

All five physicians’ writings brought to life a difficult scene. Julia Huemer, MD, a child and adolescent psychiatrist, wrote an aching piece about interviewing a young Somalian refugee in an Austrian winter just before Christmas. She conveys the utter incapacity of her survey to capture his experience, and an uneasy awareness that he is the one doing her a favor, indulging her intrusion. Here is a teenager too childlike to carry the weight of adulthood, yet who carries it with more grounded grace than many adults. Her holiday, once marked by stressful emptiness, is not transformed in any heartwarming sense, but at least becomes more heavy, more real.

Ali Tahvildari, MD, a radiologist, composed a “Ghazal for Global Health,” a poetic form used to convey love, loss, and longing, in this case pleading for the privileged to care about foreign suffering. Mali Mann, MD, a psychiatrist, chronicled her experience being one of “los medicos volodores” who fly to Mexico, where she works with orphaned children suffering severe emotional traumas. Henry Ward Trueblood, MD, a trauma surgeon, read an excerpt from his forthcoming book about being a surgeon in Vietnam during the war, where he worked in a tragically understaffed civilian hospital. The extreme environment pushed him to test the limits of his surgical competence, which both challenged him to grow and taught him to respect his own limits when he was way out of his league.

The piece that brought in the most “culture” in a classic anthropological sense was that of William Meffert, MD, a cardiovascular surgeon who read a fictional account of being trapped in a collapsed building in Haiti while on a medical mission after the earthquake. In it, he grappled with how religion – a Haitian mix of voodoo and Catholicism – played a vital role in the life of his assistant. As an atheist, the protagonist vacillated between being baffled, annoyed, and comforted in a way he couldn’t quite grasp; in a way that circled between dream and reality, the supernatural was a means toward healing.

Previously: Stanford doctor-author bring historic figure Jonas Salk to life, Stanford med student chronicles his experiences working in rural Kenya, Surgeon-author: “My intent is to let people know that the person next door could be intersex”, “Write what you know”: Anesthesiologist-author Rick Novak discusses his debut novel, For a group of Stanford doctors, writing helps them “make sense” of their experiences, and Exploring global health through historical literature
Photo by Hanna Sorensson

Events, Medicine and Literature, Medicine and Society, Patient Care, Sexual Health

Surgeon-author: “My intent is to let people know that the person next door could be intersex”

Surgeon-author: "My intent is to let people know that the person next door could be intersex"

None of the Above“How many of you know what intersex is?” surgeon and author Ilene Wong, MD, (who did her residency at Stanford and writes under the pen name I.W. Gregorio) asked an audience of medical students, doctors and community members at a recent panel discussion on the topic on Stanford’s campus.

Since we’d gathered at the event, which was sponsored by Stanford’s Medicine & the Muse Program and Pegasus Physician Writers, to listen to a book reading and discussion about intersex — a term that describes sex characteristics that are neither all female nor all male — you might think we were all well-informed about the topic. We were not, and our fidgety response to Gregorio’s opening question hinted at the problem we came to discuss: a widespread lack of knowledge in the medical, and general, community about intersex individuals.

As Gregorio and her fellow panelists, Jeanne Nollman, founder of the AIS-DSD Support Group, and Hillary Copp, MD, a pediatric urologist at the University of California, San Francisco, delved into the discussion topic – “Has the medical community failed the intersex community?” – we gained a better understanding of what it means to be intersex, why so little is known about it and what can be done to remedy this.

“I met my first intersex patient when I was pregnant with my first child,” Gregorio told us. “It made me think of what it means to be a woman and how your chromosomes determine so much.” At the time, medical students received little training on intersex, Gregorio said. “There’s still a huge gap in medical education on what intersex is. Too often intersex is distilled down to one line on the chalkboard or one question on an exam.”

Her experience inspired Gregorio to write None of the Above, a young adult book about an 18-year old girl who learns she is intersex. “Books help us think about and talk about difficult issues,” she explained. “My intent is to let people know that the person next door could be intersex.”

Intersex is more common than you may think, occurring in approximately one in every 2000 individuals. This means that a person is more likely to be intersex than they are to have cystic fibrosis – yet most people have heard of the latter condition.

So, why isn’t intersex more well known? Nollman and Copp offered some possible explanations. “Many people think [it’s] a dirty thing because it has the word ‘sex’ in it,” said Nollman. “They think it’s something shameful they can’t talk about.”

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Medical Education, Medicine and Literature

MeDesign Human Health Book: human anatomy diagrams with sleek new look

MeDesign Human Health Book: human anatomy diagrams with sleek new look


HumanHealth-FIN-16-May-2013-1_Page_01

For many people, the topic of human anatomy evokes feelings of both marvel and dismay. The workings of the body may be a wonder to behold, but their intricacies can be a pain to sort out, remember and explain.

To make human anatomy easier to learn and understand, Bruce Ian Meader, an associate professor at the Rochester Institute of Technology’s Vignelli Center for Design Studies, and his class of 13 first-year graduate students tackled the task of streamlining diagrams of human anatomy in 2014 as part of the School’s Medicine+Design initiative.

For this assignment, the class was given 10 weeks to design several short book chapters that explain systems of the human body for a general audience. To accomplish the task, the class split into small groups to research, write, and design simplified layouts of body systems, such as the brain, eyes, joints and nervous system. Once the book chapters were complete, the students worked together to assemble the chapters into a book they called the MeDesign Human Health Book.

The book is already earning praise and has sparked a second phase for the Medicine+Design initiative in 2015. You can view the entire book online for free at the school’s website.

Previously: University of Glasgow medical student makes learning anatomy a feast for the sensesImage of the Week: A playful take on the human respiratory systemImage of the Week: VeggieanatomyImage of the Week: Quilled anatomyKitchen anatomy: Brain carved from a watermelon
Via Street Anatomy
Artwork courtesy of Bruce Ian Meader and artist Cai Jai

Medical Education, Medicine and Literature, Patient Care, Pediatrics

Stanford Storytellers: Medical students write a children’s book to comfort and educate

Stanford Storytellers: Medical students write a children's book to comfort and educate

hospitalcolorThis spring, four Stanford medical students wrote a children’s book, Stanford Storytellers, which uses imagination to help children understand and feel comfortable in the hospital.

Authors Afaaf ShakirMichael Nedelman, Karen Hong, and Zahra Sayyid, along with illustrator Emma Steinkellner, a Stanford undergraduate, came together through a call for interested Stanford Medicine students to collaborate on a children’s book in honor of this year’s Medicine and the Muse symposium’s keynote speaker, Perri Klass, MD. Klass is a professor of journalism and pediatrics at New York University and a children’s author who is involved with Reach Out and Read, a non-profit encouraging early childhood literacy in pediatric clinics.

“Funny enough,” Nedelman told me, “all the med students who showed up to the [book] meeting were my classmates – third-years who should’ve probably been falling asleep on a couch somewhere. Things really clicked when we found Emma, whose visual style was perfect for the project.” I recently spoke with Nedelman and the other group members over email, as coordinating their busy schedules was like herding cats!

Where does your perspective on a hospitalized child’s experience come from? 

Hong: I’m currently on my pediatrics rotation and I see a lot of children who would get some reassurance from a book like ours. Just today, I was talking to a little boy who really wanted to take his IV out. You have to keep your arm straight for days on end and deal with the uncomfortable feeling of having a needle in your arm – who would want that if they didn’t understand why it’s there? We talked about how the clear plastic tube delivers a magic “potion” into his system to fight off his infection and it was amazing how fast his attitude changed. This isn’t always the case with every patient but it’s nice to see the power of imagination at work.

Sayyid: I remember distinctly the first book series that I couldn’t put down: Lurlene McDaniel’s young adult books, which focused mainly on girls who were struggling with chronic illnesses and death. Each of her stories focused on a different girl with a different disease, almost all of which were fatal. Although I luckily did not experience much time in the hospital as a child, I remember reading those stories and thinking, “Wow, this could have been me.”

Shakir: I grew up in a house with two pediatrician parents, which meant I never went to a doctor’s office, let alone a hospital. It wasn’t until I came to medical school that I realized that kids without physician parents have a totally different take on medicine than I did. It’s completely unfamiliar to them, and things aren’t often explained in a way that a kid can understand. That perspective has fueled me to empower patients (both adults and kids) with knowledge about their care and their bodies. In addition, being in medical school gives us the unique perspective of being young in our training (the ‘kids’ of medicine) where things are still new and strange, but also being medical ambassadors for our patients. We have enough knowledge to explain concepts without forgetting what it was like to not understand them. Writing this book has been a great reminder of the importance of that communication.

hallwayWho do you hope will read the book? How do you hope it will be distributed?

Nedelman: There are lots of people I’d love to see connect with the book: The 5-year-old chemo patient, seeing the hospital through a new lens. Or his classmates, who may not understand why he always seems to be missing class. Or the attending physician, perhaps with young kids, who understands that a little bit of imagination can really help reframe an unfamiliar and at times uncomfortable experience.

Shakir: Our ultimate hope is that our book reaches the children we are writing it for. We intentionally made our protagonist a character who was easily accessible to as many kids as possible.

Nedelman: We don’t know what condition this character has; it’s all in first-person so even the child’s gender is interpretable by the reader. And even though our protagonist is seen flying, floating in space, and rolling in a wheelchair, we actually never see this character walking around.

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Anesthesiology, Ethics, Medicine and Literature

“Write what you know”: Anesthesiologist-author Rick Novak discusses his debut novel

419jAUWZsYLThe Doctor and Mr. Dylan is a murder mystery, a medical puzzler and a tale about love and parenting. And, it stars Bob Dylan, who may, or may not be, the real Bob Dylan. It’s also the debut novel by Rick Novak, MD, an adjunct clinical associate professor of anesthesiology, perioperative and pain medicine at Stanford.

Novak took the time recently to answer a few questions about the book, writing and his work as a doctor.

How did you become interested in writing?

I’ve enjoyed creative writing since my high-school English classes. My college essay for a successful Harvard application was a short story in which God revealed himself to the patrons of a Minnesota tavern. For the past three years I’ve authored a website called theanesthesiaconsultant.com, which receives 250,000 hits per year from both anesthesia professionals and laypeople interested in the nuances of my specialty.

Why did you choose to write about an anesthesiologist – and do you have much in common with Nico, the primary character, who is also an anesthesiologist?

Wise advice to authors is, “Write what you know.” I’ve been an anesthesiologist for three decades, so I know a great deal about the practice and malpractice of anesthesia. The science and art of anesthesia are fascinating. We enter patients’ lives abruptly, at short notice, and have immense power to save lives and to do harm. The unequal nature of this relationship is fertile ground for storytelling.

The Doctor and Mr. Dylan is fiction, but yes, I do have a lot in common with Nico. I grew up in Hibbing, Minnesota, graduated from Hibbing High School, migrated to Stanford, and became a clinical faculty member here. I grew up 5 blocks from Bob Dylan’s home, am a huge fan of his music, and knew several members of his family. I’m the single father to three boys, and I’ve dealt with the highs and lows of the father-son relationship such as Nico has with Johnny, and the stressors of a failed marriage just as Nico does.

What motivated the plot of your story?

Anesthesiologists have control of dozens of powerful medications, and if misused, they can be lethal. One day I heard someone describe his significant other by saying, “I don’t want to pray that a bus runs her over, but my life would be a lot simpler if one did.” Combining these two ideas led to a plot where a physician seemingly makes use of an anesthetic as a tool to eliminate his troublesome wife. I have an active medical-legal practice of expert witness work, and this experience led me to set the second half of the novel in the courtroom, where tension runs high and mysteries can be posed and solved.

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Events, Medical Education, Medicine and Literature, Medicine and Society, Stanford News

Stanford’s Medicine & the Muse event mixes music, dance and pediatrics

Stanford's Medicine & the Muse event mixes music, dance and pediatrics

The annual Medicine & the Muse symposium is one of senior associate dean Charles Prober’s favorite events of the year, and now it’s one of mine too. Prober, MD, the senior associate dean of medical education, kicked off the evening with introduction of this year’s theme, “transformation and triumph.”

It’s a talent show Stanford Medicine style, with medical students providing the singing (ranging from an Italian opera duet to a foot-tapping mariachi tune), dancing (a group modern piece), film (gritty images from the aftermath of Typhoon Haiyan) and readings (a children’s book replete with illustrations of a mop-headed kindergartner who lost her teddy bear in the hospital and a witty novel excerpt about an incoming medical student leaving her plush Upper East Side existence).

Then, throw in chief communications officer Paul Costello’s thought-provoking interview with author and pediatrician Perri Klass, MD, and you have a full evening of entertainment. Klass has written novels, non-fiction books, and numerous essays and journalism articles.

“Transformation and triumph” is a message that captures both the transition of medical students into full-fledged doctors and many aspects of pediatrics, Klass said. She went on to discuss her drive to write; the urge that keeps her at her computer late in the night, spilling out her reflections on that day’s cases. And she explained her work as the national medical director of Reach Out and Read, a non-profit that provides books to low-income children.

The goal as a pediatrician is to get illnesses and other afflictions out of the way so children can blossom and reach their potential, she said. For some families, that means quite literally providing a book, which can serve of the basis for parents to develop an interactive, close relationship with their children.

Klass also offered advice for physicians hoping to hone their writing chops: “Just read good stuff, and write good stuff.”

Previously: A lesson in voice and anatomy from an opera singer, Stanford Medicine Music Network brings together healers, musicians and music lovers and Stanford’s Medicine and the Muse symposium features author of “The Kite Runner”
Photos by Norbert von der Groeben

AHCJ15, Events, Medicine and Literature, Palliative Care, Patient Care, Stanford News

Physician-author Abraham Verghese encourages journalists to tell the powerful stories of medicine

Physician-author Abraham Verghese encourages journalists to tell the powerful stories of medicine

P1080715Stanford’s Abraham Verghese, MD, greeted hundreds of journalists at the Association of Health Care Journalists 2015 conference last evening with a talk centered on the power of stories and of medicine.

The conference, held this year in Santa Clara, Calif., and co-hosted by Stanford Medicine, brings together journalists from a variety of outlets to solidify their scientific knowledge, enhance their journalism skills and network with colleagues. (As a reminder, we’ll be live tweeting from the conference today and tomorrow; you can follow us at @StanfordMed.)

Verghese is a physician and educator, born in Ethiopia to Indian parents. But he’s also an established writer, author of numerous essays and several books, including Cutting for Stone and My Own Country. In that way, he is “really one of us,” said Karl Stark, president of the AHCJ.

Like journalists, Verghese has an abiding interest in storytelling. But his stories stray from the researchers-made-this-discovery narratives that often occupy health-care journalists. Verghese’s stories are tales of lost loves and the act of toasting death with a glass of champagne. They’re the stories of people, of patients, and of the importance of listening and being present.

There are many types of stories that need to be told, Verghese encouraged his audience. Tell about the company that dominates medical-record keeping, of families who can’t allow their loved ones to pass away peacefully, of young physicians and students who are determined to place patients first, despite the dominance of technology.

And perhaps most importantly, writers should tell the story of medicine itself: of what it can and cannot do, of where it has been and where it is going.

In that vein, Verghese shared a story with his rapt audience. As a physician in rural Tennessee in the 1980s, he cared for many patients with HIV/AIDS. At the time, doctors had no drugs, nothing that could thwart the disease’s progress. Yet when one patient’s mother called the clinic one day, saying her son was too sick to come in, Verghese said he felt compelled to visit the family in their rural trailer home. He wasn’t ready for the patient to die without seeing him again. “My visit had a profound effect on him and the family. It helped them come to terms and that I wouldn’t abandon them,” Verghese said.

This was a revelation, he admitted. This is what doctors did before antibiotics and sterile operating rooms and medical devices galore. “They were able to heal, even when they could not cure.” And that is a power that today’s doctors should never forget that attests to the power of the patient-physician relationship, he said.

Medicine has other stories to share as well. In the past, metaphors abounded in medicine: the strawberry tongue of scarlet fever, the apple-core lesion of tuberculosis, the saber shin of the tibia, Verghese said. Yet now, despite the abundance of new conditions, metaphors are achingly absent, signifying a growing gap between the doctor as data scientist and the patient.

And then there’s the story of the body itself, one that future physicians may not know how to read, Verghese said. He said he jokes that if a patient came in with a missing limb, doctors wouldn’t be able to confirm the diagnosis without a variety of tests. “We really have stopped looking at the patient,” he said.

And that is one reason why journalists, as storytellers, are important. “Stories are the units of life; they’re how we extract meaning,” he said.

Previously: Live tweeting from Association of Health Care Journalists conference, A “grand romp through medicine and metaphor” with Abraham Verghese, Abraham Verghese: “A saintliness in so many of my patients”, Abraham Verghese discusses stealing metaphors and the language of medicine at TEDMED, Abraham Verghese urges Stanford grads to always remember the heritage and rituals of medicine and Stanford’s Abraham Verghese honored as both author and healer
Photo courtesy of Abraham Verghese

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