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Medicine and Society, Podcasts, Public Health

The vanishing U.S. surgeon general: A conversation with AP reporter Mike Stobbe

The vanishing U.S. surgeon general: A conversation with AP reporter Mike Stobbe

surgeon general drawing - small

There is currently no U.S. Surgeon General. Like everything else in Washington today, a confirmation vote by the U.S. Senate on President Obama’s choice, Harvard physician Vivek Murthy, MD, has been squashed by politics. Last spring, White House press secretary Jay Carney said that the administration was “recalibrating and assessing our strategy on moving forward with the nominee.” In March, The Hill newspaper reported that up to 10 Senate Democrats signaled they would oppose Murthy’s confirmation after the National Rifle Association made it clear Murthy’s support for bans of certain types of firearms and ammunition purchases made him an unthinkable choice.

Now if you’ve forgotten there even is a position called the U.S. Surgeon General post, think C. Everett Koop, MD, or Joycelyn Elders, MD. Koop and Elders were two recent appointees who used their bully pulpit to raise a national discussion about AIDS and teen pregnancy. (Both were  lightening rods within their respective administrations – Koop in Reagan’s and Elders in Clinton’s. Elders was eventually dismissed by the White House after wading into too many contentious issues.)

Does the position even matter anymore? Associated Press medical reporter Mike Stobbe thinks it does. He’s written a fascinating book (Surgeon General’s Warning, University of California Press) about the history of the position and those who served. The book explains how the surgeon general became the most powerful and influential public health officer in the country and how those powers were later stripped away. An excerpt from Stobbe’s book appears in the current issue of Stanford Medicine magazine, where he catalogs the ups and downs of the individuals who held the position. The strong ones and the weak ones. Those who made a difference and those who faded away in controversy or without making a mark on the nation’s public health dialogue.

He writes, “Surgeon generals have played that crusader role better and more often than any other national public health figure. Absent such a crusader, the public’s health is prey to the misinformation and self-interest of tobacco companies, snake-oil salesmen and other malefactors.” Listen to my 1:2:1 podcast with Stobbe to hear more of his thoughts.

Illustration, which originally appeared in Stanford Medicine, by Tina Berning

Events, Medicine and Society, Stanford News

On death and dying: A discussion of “giving news that no family members want to hear”

On death and dying: A discussion of "giving news that no family members want to hear"

The standing room only crowd at the Stanford Humanities Center had come to hear physicians read their own writing about the most difficult of topics: “I Am Afraid I Have Bad News: Death and Dying in Medicine.” The enthusiastic response to the topic demonstrated the interest in and need for such a forum. “This is a topic we just don’t talk about enough, in medicine and in society,” said Ward Trueblood, MD, a member of Stanford’s Pegasus Physician Writer’s group who curated the event.

Trueblood’s own experiences as a trauma surgeon, particularly during the Vietnam War, affected him deeply. “When I went to medical school, they didn’t teach you about death and dying,” he explains. Trueblood has found writing to be a powerful way to process his experiences. His memoir, Blood of the Common Sky: A Young Surgeon in Vietnam, will be published this year, and his book of poetry To Bind Up Their Wounds is available on Amazon. Trueblood appreciated being able to give fellow physicians an opportunity to share their experiences with death and dying through personal poetry and essays.

Gregg Chesney, MD, a critical care fellow, read two poems, including “Lost in Translation”:

In trying to explain how “she hit the floor with a thud”

now means “she never woke up

and never will,” something was lost.

Yes, that is her heart tracing its beat across the monitor, but that swollen tangle

of blood, wrapped and knotted at the base of her brain

has pressed the leafless stalk of her medulla and left her

brain dead.  There is no one-more-test, no

chance-for-recovery, but at 2am, rendered in secondhand Mandarin,

that point might be missed, or left to dangle precariously,

soured and unplucked,

as he works out how to raise a 3 year-old on his own.

As Chesney finished the poem, his six-month old son cooed in his mother’s arms. The irony of the moment was not lost on the audience, as they contemplated the fate of the young father in Chesney’s poem.

Bruce Feldstein, MD, Stanford’s hospital chaplain, read “At My Father’s Bedside,” in which he shared what he had learned from his patients with his dying father:

The moment itself is peaceful, I’m told. No fear. Simply letting go. Smooth, like a hair being pulled from milk… You know, we human beings have been dying for a long time. Your body has a natural wisdom built right in for shutting itself down. The body knows just what to do. And there are medicines along the way to keep you comfortable.

During the Q&A session, an audience member asked Feldstein if there was anything he wished patients knew about their physicians. “Yes, how much doctors care,” Feldstein responded. “And that this effects them too. How difficult it can be to be the medical professional in that instance, giving news that no family members want to hear about their loved one.”

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Medicine and Society, Pregnancy, Research

Study offers clue as to why parents of daughters are more likely to divorce

Study offers clue as to why parents of daughters are more likely to divorce

poppy2Here’s something that caught my attention this morning (likely because I’m the mom of two girls): A new study provides a possible reason behind reports that parents with firstborn daughters are more likely to divorce than those with firstborn sons. According to researchers from Duke and University of Wisconsin-Madison, it could be due to girls being “hardier than boys, even in the womb.”

A recent university release further explains:

Throughout the life course, girls and women are generally hardier than boys and men. At every age from birth to age 100, boys and men die in greater proportions than girls and women. Epidemiological evidence also suggests that the female survival advantage actually begins in utero. These more robust female embryos may be better able to withstand stresses to pregnancy, the new paper argues, including stresses caused by relationship conflict.

Based on an analysis of longitudinal data from a nationally representative sample of U.S. residents from 1979 to 2010, Hamoudi and Nobles say a couple’s level of relationship conflict predicts their likelihood of subsequent divorce.

Strikingly, the authors also found that a couple’s level of relationship conflict at a given time also predicted the sex of children born to that couple at later points in time. Women who reported higher levels of marital conflict were more likely in subsequent years to give birth to girls, rather than boys.

“Girls may well be surviving stressful pregnancies that boys can’t survive,” Hamoudi said. “Thus girls are more likely than boys to be born into marriages that were already strained.”

The intriguing findings appear in the journal Demography.

Image courtesy of Michelle Brandt

Medical Education, Medicine and Society, SMS Unplugged

The woman in the elevator: dealing with death in medical training

The woman in the elevator: dealing with death in medical training

SMS (“Stanford Medical School”) Unplugged was recently launched as a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.

flowersAlmost every patient I meet gives me the gift and curse of forcing me to confront a new side of my own vulnerability. I see new ways to die, new ways to suffer, new kinds of setbacks or losses. Of course, very little of this knowledge is technically new: My mother taught me that everyone dies, life isn’t fair, and so on. But since starting clinical training, what is new is the intimacy with which I live that knowledge.

On my neurology rotation, I was sent to examine a little boy in the ICU who had become unresponsive. I will never forget what I saw when I lifted his eyelids. His right pupil was rapidly changing shape from lumpy oval, to diamond, to a slit like a cat’s eye.

I alerted my attending, who somberly explained that that the boy’s brain was probably herniating – in other words, it was under so much pressure that it was being pushed into places it shouldn’t go. A few minutes later, a CT scan showed massive bleeding in his brain. The neurosurgeons were called, but determined they couldn’t save his life. As we left, a curtain was pulled in front of the room.

A few minutes later, already back to work in other parts of the hospital, my team stepped into an elevator. Before the door could close, a young woman ran in behind us. As the elevator ascended, she sunk to the ground and wailed, “Am I going to lose my baby? Please don’t let me lose my baby.” When the doors opened, she sprinted toward the ICU. With horror, I realized the woman was my patient’s mother. Her baby was already gone.

The next morning was a gorgeous Saturday. I had the weekend off so I put on my grungiest clothes and headed to my community garden plot, determined to separate myself from the week’s experiences. Weeds had crept in during a few especially difficult clinical months. I placed a shovel in the dirt, put all my weight on it – and it didn’t budge. I tried again, but the soil wouldn’t yield. I discarded the shovel and reached to pull a huge weed. The dead branches crinkled off in my hand, roots still entrenched in the hard, dry California earth. I sat down among the weeds, defeated, face in my hands.

A woman working another plot – a fellow student gardener I had never met – walked over and asked, “Are you okay?”

“I’m just not strong enough to do this. I should give up my plot.”

“I’ll help you clean it up,” she offered.

“Thanks… Sorry… I’ve just had a bad week.”

“Lots of final exams?”

“No. But I watched a little kid die yesterday.”

My new friend didn’t miss a beat. She knelt down, gave me a hug and said, “You are strong enough. Let’s get your garden cleaned up.”

I believed her, and kept gardening. I proudly told myself I had found an outlet to successfully cope and put the horrible experience behind me.

But it turns out things like watching that child die aren’t processed and compartmentalized so neatly, and can come back to haunt even the best and most personal times. A few months later, on the night before my daughter was born, my husband and I arrived at the hospital full of excitement, and stepped onto the elevator on our way to Labor and Delivery. But as the doors slid shut, I couldn’t suppress the mental image of the last time I rode that same elevator: a desperate young woman on her knees, repeating “Am I going to lose my baby?” For the thousandth time in medical school, I knew the fragility of my own blessings.

I have come to believe that coping doesn’t mean finding a way to separate “personal” life from “professional” experiences. There is no healthy coping mechanism that will let me walk away from experiences like this unaffected. Instead, I just keep telling stories like this one over and over – to myself, my friends and family, and now you – hoping that in the retellings I will find some meaning, some wisdom, some gratitude, or some peace.

Jennifer DeCoste-Lopez is a final-year Stanford medical student applying to residency in Pediatrics this year. She was born and raised in Kentucky and went to college at Harvard. She currently splits her time between clinical rotations, developing a new curriculum in end-of-life care, and caring for her young daughter.

Photo courtesy of Jennifer DeCoste-Lopez

Ethics, Genetics, Medicine and Society, Parenting, Pediatrics, Stanford News

Genome testing for children: What parents should consider

Genome testing for children: What parents should consider

Genome testing: Would you do it?

Okay, next question: Would you have your child’s whole genome tested?

In the recent issue of Stanford Medicine News, Louanne Hudgins, MD, chief of medical genetics and director of perinatal genetics at Lucile Packard Children’s Hospital Stanford, weighs in on the issue: “I strongly advise parents against whole-genome testing for their children unless performed in the context of a medical evaluation following formal counseling regarding its utility, limitations and possible unrelated findings,” she said.

In the piece, Hudgins comments on privacy and ethics considerations, and explains why what we partially know (for instance, if your child is found to have a gene predisposing him or her to a disease) can sometimes provide more cause for worry or false hope than helpful or conclusive information.

The whole piece (a short one) is worth a read.

Previously: Stanford patient on having her genome sequenced: “This is the right thing to do for our family”, Personal molecular profiling detects diseases earlier, Stanford geneticist discusses genomics and medicine in TEDMED talk and Medical practice, patents, and “custom children”: A look at the future of reproductive medicine

Medicine and Society, Science, Stanford News, Technology

Residential learning program offers undergrads a new approach to scientific inquiry

Residential learning program offers undergrads a new approach to scientific inquiry

SIMILE studentsTwenty-two Stanford freshmen spent the last school year living, studying and socializing immersed in scientific inquiry. In its inaugural year, the residential education program SIMILE: Science in the Making Integrated Learning Environment drew interest from and selected a diverse group representative of the student body, many of whom don’t intend to become physicians or scientists or even plan to major in related fields. SIMILE students take pre-major requisites including writing, rhetoric and breadth requirements focused on the historical, cultural and social contexts of science. They also complete hands-on projects, attend field trips and regularly interact with faculty and guest lecturers in the program. Housed in the all-freshman Burbank House with ITALIC (Immersion in the Arts: Living in Culture), SIMILE students attend lectures and discussion sections in-house and have some shared activities with the new arts-focused residential academic program there.

A recent Stanford Report piece notes:

In the fall, Paula Findlen, [PhD,] a professor of Italian history and director of SIMILE, and Reviel Netz, a professor of classics, team-taught Inventing Science, Technology and Medicine. The class explored how those scientific fields emerged from the human desire to understand nature – empirically, mathematically and philosophically – and to control the environment.

Findlen said the program offered a “big picture view” of how human interactions have changed over the centuries, using history as the lens to understand the invention of science, technology and medicine.

“Fundamentally, SIMILE is a program about the history of knowledge,” she said.

Previously: Exploring global health through historical literatureThoughts on the arts and humanities in shaping a medical career and Intersection of arts and medicine a benefit to both, report finds
Photo by Jeremy Moffett

Medicine and Society, Stanford News

Man on a mission: Working to help veterans who have lost limbs

Man on a mission: Working to help veterans who have lost limbs

vet - smallerThe student riding the Segway stands out on the bicycle-laden Stanford campus. His short hair and erect bearing suggest he is a veteran. The prosthetic legs that extend from his torso to the Segway stand confirm it.

I had seen Dan Berschinski one day on campus and asked Tim Hsia, student president of the Military Connected Network, if he could introduce me. Berschinski, I learned, had just finished his first year at the Stanford Graduate School of Business – and he’s on a mission. As was highlighted in a CBS News story last fall, he’s at Stanford to learn how to grow his current business into a thriving enterprise, hopefully one that employs veterans with disabilities.

Ever since he woke up in Walter Reed National Military Medical Center after having his legs blown off by an improvised explosive device (IED) in Afghanistan, the West Point graduate has been thinking of ways to help veterans.

“Look, I was an officer,” he told me recently. “I couldn’t sit there feeling sorry for myself. My soldiers were still in Afghanistan, still getting killed. And the hospital was full of guys with injuries as bad or worse than mine.” Berschinski was sitting with me at a campus cafe, his Segway and cane propped against the door. The fact that he’s able to walk on his prosthetic legs is a miracle, although, he said with a small laugh, his doctors were hesitant to use that word. “Let’s just say that nobody with my injury has ever walked out of Walter Reed,” he said, hands firmly placed on his thighs.

Berschinski’s right prosthetic leg attaches to his hip – there was nothing left of his leg to salvage. On his left side, he must force the portion of his thigh that is left into a sleeve. He explained this all to me matter-of-factly. In fact, Berschinski is quick to point out that he feels lucky. Pointing to his left hand, which is missing a finger and is marked by a large portion of a skin graft, he said, “Hey, they were able to save this hand. If they hadn’t, I would be a triple amputee.” Shaking his head, Dan continued, “Those guys have it rough.”

The use of IEDs and the length of the wars in Iraq and Afghanistan mean that there are veteran amputees in numbers not seen since the Civil War. But in a society where only less than 1 percent of the population participated in those wars, these veterans are somewhat invisible. Berschinski is out to change that by raising the visibility of veterans who have lost limbs. In addition, he wants to shine light on civilian amputees, particularly children, who often cannot afford prosthetics. He serves on the board of the Amputee Coalition, using what he describes as this “new change in my life” to help others who he believes aren’t as fortunate as he. “I have the advantage of being cared for by the government. I have access to cutting edge prosthetic limbs and care. Most people don’t have that.”

Asked if he has advice for current medical students who might be treating patients who have lost limbs, he was quick to answer. “Yes. Your optimism, and your support are critical. Yes, the medical skills are important. But you have to understand that patients are looking to you for hope. And don’t ever underestimate the willpower of your patients. Certainly don’t give up on them.”

Jacqueline Genovese is assistant director of the Arts, Humanities, and Medicine Program within the Stanford Center for Biomedical Ethics.

Previously: Battling hearing loss on and off the battlefield and Stanford graduates partner with clinics in developing countries to test low-cost prosthetic
Photo courtesy of Dan Berschinski

Addiction, In the News, Medicine and Society, Research, Stanford News

As AA approaches 79, a look at its effectiveness for sobriety

As AA approaches 79, a look at its effectiveness for sobriety

stairsAlcoholics Anonymous, a nonprofessional, international fellowship for people who have had a drinking problem, is approaching 79 years of existence. This morning, Keith Humphreys, PhD, a Stanford addiction expert, writes in Washington Post‘s Wonkblog about how medical experts have viewed the organization during its tenure and what can be made of results from studies measuring AA’s effectiveness.

From the piece:

For most of the 12-step fellowship’s existence, professionals in the addiction field held widely varying opinions of its value. Some praised AA as an extremely valuable resource for people seeking recovery, but others viewed it as unsophisticated folk medicine and even a bit cultish. Other tensions emerged from turf issues: Medical professionals can be dismissive of – at times even hostile to – those they consider well-intentioned amateurs. Just as some obstetricians resent midwives, some addiction treatment professionals looked down on the non-professional AA members in their midst.

Humphreys notes that results from Project MATCH, the largest study of alcohol-dependence treatment, and a subsequent randomized clinical trial have changed some skeptics’ minds. More from the piece:

Studies such as these dramatically reduced the ranks of AA critics among scientists. AA’s value is still questioned in a few quarters, but as Harvard Professor of Psychiatry John Kelly [PhD] notes, this is becoming less true as the years go by: “The stronger scientific evidence supporting the effectiveness of AA is relatively new. It takes time for evidence to disseminate into clinical practice as well as into broader society.”

Previously: What’s the best way to handle the chronically intoxicated?, Examining how addiction in the U.S. has changed over the last decade and A discussion of the history and effectiveness of Alcoholics Anonymous
Photo by Kristin Charles-Scaringi

Aging, Health Policy, Medicine and Society, Podcasts, Research, Stanford News

More on doctors and end-of-life directives

More on doctors and end-of-life directives

Earlier this week, my colleague wrote about a study showing that the majority of doctors surveyed said they would forgo aggressive end-of-life care for themselves. Now, in the latest 1:2:1 podcast, researcher VJ Periyakoil, MD, director of palliative care education and training at the medical school, talks in depth about the study and why doctors appear to want one thing for themselves at the end of life and quite another for their patients.

Previously: Study: Doctors would choose less aggressive end-of-life care for themselves

Medicine and Society, Mental Health, Technology

Reflections on dying, contained in 140 characters

Reflections on dying, contained in 140 characters

A piece on Medium.com shows how boundaries, such as the 140-character limit of a tweet, can provide stability and comfort during times of uncertainty. Writer Amber Adrian describes how Twitter’s forum provided a structure for the expansive emotions she experienced as her father lay dying as Thanksgiving 2012 approached. On the microblogging service, she was also able to record in vivid detail what her family experienced – from the mundane to the morbid, comical, sweet and tragic final moments, stretched out across a series of tweets – and receive support from friends and family who shared memories of her dad.

Tweets from the piece, which Medium notes is a five-minute read:

Medical directive overturned by unanimous family consent. Morphine at the ready. All right, Great Beyond. Let’s get this party started.

Now that the drugs have stopped and people aren’t prodding him every hour, Dad’s sense of humor is coming back. His puns: as bad as ever.

My one rant: Absurd that we have the death penalty but we can’t help along someone we love who desperately wants out of a broken body.

Dad always made the Thanksgiving turkey. Brined in booze and stuffed with cornbread and fresh herbs. I never got the recipe. Damn it.

“I’m excited for you, Dad. You’re about to go on an adventure.” Boom. My brother nails it.

Previously: The role of social media in end-of-life conversations and Grieving on Facebook: A personal story

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