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Aging, In the News, Medicine and Society, Palliative Care, Patient Care

End-of-life discussions the focus of PBS piece

End-of-life discussions the focus of PBS piece

For many, end-of-life discussions are either unpleasant, brief, or unlikely to happen at all. But, as a recent episode of PBS’ Religion and Ethics NewsWeekly emphasized, it is critically important that patients have open and honest conversations on the topic with their family members and doctors.

The piece featured Philip Pizzo, MD, former dean of Stanford’s medical school and co-author of the 2014 Institute of Medicine’s 500-page report titled “Dying in America,” and VJ Periyakoil, MD, director of Stanford’s Palliative Care Education and Training. Through the Stanford Letter Project, Periyakoil is on a quest to empower patients and help stimulate a broad national discussion on what matters most at life’s end. She says in the piece:

I think the biggest challenge is people don’t want to make plans and have discussions because the topic is so threatening to them. So what happens is because they don’t plan for it, they are subjected to treatments that are A, not helpful and B, not what they want.

I helped facilitate the interviews with Periyakoil and Pizzo last October; coincidentally around that time, my older sister suddenly fell ill and died unexpectedly. One of the things that came up was whether or not she had an advance directive and, fortunately for my family, my sister (who was just 46 years old) had written down her wishes and no one was left wondering or tasked to make a difficult decision. I know firsthand how beneficial the work of Periyakoil and others can be.

Previously: No one wants to talk about dying, but we all need toStudy: Doctors would choose less aggressive end-of-life care for themselvesHow would you like to die? Tell your doctor in a letter, Stanford doctor on a mission to empower patients to talk about end-of-life issues and Medicare to pay for end-of-life conversations with patients

Education, Medicine and Society, Stanford Medicine Unplugged

The real reason why med students only talk about school

The real reason why med students only talk about school

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

SOM sceneOn a recent Friday, I went out with a handful of classmates for some food to celebrate the end of a particularly long and tiring week of school. Interestingly, although we had spent hours each day shuttling between lecture halls, the hospital, and clinical exam rooms, the conversation kept drifting back to one, very familiar topic: school. We talked about everything we had endured that week, compared notes on our different experiences, and looked ahead to our future plans. This isn’t a new phenomenon, by any means; in fact, almost all of our off-campus gatherings are intruded by talk of school, to the extent that it only stops when somebody finally says, “Can we not talk about school for a few minutes?”

So, why is it that med students seem to only be able to talk about school when they get together after class? Contrary to popular belief, it’s actually not because we’re so busy that we don’t have time to have a life outside of school. My classmates are athletes, musicians, entrepreneurs, husbands, and mothers – there is plenty to talk about in the world that’s not medicine! Similarly, I don’t think it’s because we’re such science nerds that we just love to talk about medicine and science all the time. Most of us need a break from that every once in a while.

What I’ve discovered over time is that we talk about school so much because the process of debriefing with our peers helps us to stay healthy as students. When we’re in class, patient sessions, or the hospital, we’re (rightfully) expected to maintain a certain professional demeanor; this can prevent us from expressing our emotions and understanding the experiences of our peers in the present. Looking around the table during an emotionally charged and difficult encounter with a patient struggling with mental illness, I see only faces of peers that appear calm and composed. Only by talking about it afterwards, in private, does it become clear that several of us are undergoing strong feelings – of sadness, nervousness, discomfort. It’s incredibly easy in med school to think that you’re the only person in the room feeling a certain way, until you find out later that every person in the room was feeling the same way.

What we’ve learned from these exercises is that nobody knows better than your immediate peers what you’re going through as a med student. Faculty and mentors have been through it themselves but are many years removed from the process and may have had very different experiences. Family and close friends know you better than anybody but often have difficulty relating to the more unique aspects of medical school. This means that there is no substitute to having peers that you can rely on.

Finally, I think it’s critical to highlight the point that being able to debrief openly and honestly couldn’t be more important in a profession like medicine, where the high stress makes rates of mental-health problems particularly high. Unfortunately, physicians seem to have a long tradition of sweeping emotional challenges and mental-health issues under the rug, in fear that they’ll be judged and ostracized by their patients and colleagues. We owe it to ourselves and our patients to try to change that culture, and I’m hopeful that our tendency to keep an open conversation with peers will help to keep all of us healthy.

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

Health Disparities, History, In the News, LGBT, Medicine and Society

Film honors transgender pioneers

Film honors transgender pioneers

pride-828056_1920I knew little about the film “The Danish Girl” last weekend when, diverted from a sold-out showing of the Oscar favorite the “Revenant,” my husband and I disappointedly walked down Pacific Avenue in Santa Cruz to another theater to see the film about a transgender woman instead.

It proved to be a fortuitous diversion. “The Danish Girl” is artistically gorgeous and well acted, as today’s Academy Award nominations point out. The film received nominations for Eddie Redmayne as best actor in his role as a transgender artist, best supporting actress for Alicia Vikander, his wife who stands by him as he confesses that he believes he was born in the wrong gender and begins to dress as a woman they call Lili — and nods for costume design and production design as well.

But the film struck a more personal chord, halfway through its viewing, when I sucked in a short gasp realizing that, in addition to being a love story with a socially relevant message, the film was recounting a piece of medical history. And suddenly, the film took on a frightening edge.

I knew from my research for a story I wrote for Stanford Medicine magazine in 2012 titled “Transition point: The unmet needs of transgender people,” something of the challenges facing transgender people today as they navigate the medical world trying to get the care they need. The story describes the paucity of evidence-based medicine for transgender health care and the lack of training for physicians on how to provide care. As I wrote in the story:

The problem is that in the United States, most physicians don’t exactly know what treatment for the transgender patient entails. For an untrained professional, it’s a challenge to provide care to a patient with a penis who wants a vagina, or to a patient who has been tortured emotionally by being told she’s a boy when she knows she’s a girl. General practitioners — the majority of doctors who treat patients in the United States — are equally unprepared to care for those transgender patients after they have begun to take hormones and have undergone genital-reconstruction surgery. The lack of medical education on the topic, a near-total absence of research on transgender health issues and the resulting paucity of evidence-based treatment guidelines leave many at a loss.

The film, as I suddenly realized sitting in the darkened theater, must have been inspired by those transgender pioneers in 1920s Europe who chose to undergo the first experimental sex reassignment surgeries. Of course, as with any surgery, there had to be those first patients. I’d just never thought about it before.

In fact, I later learned, the film was inspired by the real life Lili Elbe, a Danish transgender woman born in 1882, who was one of those first patients. The film honors the memory of these brave transgender pioneers, and, perhaps, will prod others to consider the continued inadequacies of medical care today, and what can be done to improve them.

Previously: Stanford study shows many LGBT med students stay in the closet, Study shows funding for LGBT health research lacking, offers solutions and Gay, lesbian, bisexual and transgendered health issues not being taught in medical school
Photo by nancydowd

Cancer, Imaging, In the News, Medicine and Society, Women's Health

This breast cancer is mine: When doctors get sick

This breast cancer is mine: When doctors get sick

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As the death last year of neurosurgeon Paul Kalanithi, MD, reminded us all, successful physicians aren’t protected from the onslaught of medical maladies that can strike anyone at any time.

Take Kimberly Allison, MD, a breast cancer researcher whose personal experience with the disease is featured in a recent Newsweek article and whose own breast cancer cells are shown above.

In 2008, Allison found a “shelf-like formation” under her arm. Only 33, she calls the experience “completely disorienting.” One minute she’s a doctor. The next, a patient.

As a pathologist, she was equipped to examine her own cells, as described in the article:

Slow-growing cancers appear almost like normal cells under a microscope’s lens. But then, Allison says, there are “big, bad and ugly” aggressive cancers. Instead of being neatly arranged into structures, these cancer cells swell and lose their tidy alignment. That’s what Allison saw when she peered through the microscope at her own cells.

This story has a happy ending. Allison penned a book on her experience, and she is now advancing the science on the particular type of breast cancer that struck her.

For more on Allison’s experience, check out this 1:2:1 podcast with Allison and Paul Costello, chief communications officer at the School of Medicine.

Previously: “You have cancer”: On being a doctor and receiving the news, Stanford neurosurgeon/cancer patient Paul Kalanithi: “I can’t go on. I will go.” and Stanford neurosurgeon Paul Kalanithi, who touched countless lives with his writing, dies at 37
Image courtesy of Kimberly Allison

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

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

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

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

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

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

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

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

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

Applied Biotechnology, Ethics, Medicine and Society, Public Safety, Science Policy, Stanford News

Stanford experts slam government’s myopic biosecurity oversight

Stanford experts slam government's myopic biosecurity oversight

blindfoldedJust because we can, does that mean we should?

In a hard-hitting editorial in Science, three Stanford thinkers – Stanford microbe wizard David Relman, MD; synthetic biologist Megan Palmer, PhD, of Stanford’s Center for International Security and Cooperation; and political theorist Francis Fukuyama, PhD, of the Freeman Spogli Institute for International Studies – have issued a scathing wake-up call to the scientific community and the federal government, sternly questioning the latter’s current plans for ensuring biosafety and biosecurity in the United States.

“Our strategies and institutions for managing biological risk in emerging technologies have not matured much in the last 40 years,” they write, adding:

With the advent of recombinant-DNA technology, scientific leaders resorted to halting research when confronted with uncertainty and public alarm about the risks of their work. To determine a framework for managing risk, they gathered at the now-fabled 1975 Asilomar meeting. Their conclusions led to the recombinant DNA guidelines still used today, and Asilomar is often invoked as a successful model for scientific self-governance.

But, the authors suggest, Asilomar’s legacy may not be all it’s cracked up to be:

Asilomar created risky expectations: that leading biological scientists are best suited for and wholly capable of designing their own systems of governance and that emerging issues can be treated as primarily technical matters.

“Unfortunately,” the editorial goes on to say, “today’s leadership on biological risk reflects Asilomar’s risky legacy: prioritizing scientific and technical expertise over expertise in governance, risk management, and organizational behavior.” Political leaders have largely ceded a strategic leadership role, leaving it up to the scientific community itself to judge the ethical and social implications of its own work.

“Leadership biased toward those that conduct the work in question can promote a culture dismissive of outside criticism and embolden a culture of invincibility” regarding emerging biotechnology risks,” the authors write.

The world of today is not the world of 1975. Since then, the scope and scale of biological science and technology have changed radically. To wit: The increased ease of reading and writing genetic information means that securing materials in a handful of established labs is not feasible, the editorial states. Like it or not, the tools for putting potentially dangerous knowledge into practice are increasingly portable.

For a scary scenario of what such new facility portends, please see this article I wrote a couple of years ago, which begins with the rhetorical question: “What if nuclear bombs could reproduce?”

With so much at stake, we may not want to restrict oversight of scientific advances to those who are making the advances. There’s knowledge, and there’s wisdom.

Previously: How-to manual for making bioweapons found on captured Islamic State computer, Microbial mushroom cloud: How real is the threat of bioterrorism? (Very) and Stanford bioterrorism expert comments on new review of anthrax case
Photo by Mirko Tobias Schafer

Addiction, Medicine and Society, Pain, Research, Stanford News

Overprescribing of opioids is not just limited to a few bad apples

Overprescribing of opioids is not just limited to a few bad apples

8592523799_0cb9d8f3ff_zMore Americans are now dying of drug overdose each year than car accidents. And the biggest killer among those accidental deaths is prescribed opioids, according to the Centers for Disease Control and Prevention.

The CDC reports the amount of painkillers prescribed and sold in the United States has nearly quadrupled since 1999, yet there has not been an overall change in the amount of pain that Americans report.

With this public health epidemic of opioid overprescribing and overdose deaths, research has implied the problem is rooted in a small population of prolific prescribers operating out of corrupt “pill mills.”

A California physician was even recently convicted of second-degree murder in connection with the overdose deaths of three patients, in what prosecutors said was the first time a doctor was found guilty of murder for recklessly prescribing drugs.

The California Workers’ Compensation Institute found that 1 percent of prescribers accounted for one-third of schedule II opioid prescriptions and 10 percent accounted for 80 percent of prescriptions.

In a  research letter to JAMA Internal Medicine, the focus of a recemt press release, Stanford researchers investigate whether such disproportionate prescribing of opioids — such as morphine, oxycodone and hydrocodone — occurs in the national Medicare population as well.

The Stanford researchers examined individual prescriber data from the 2013 Medicare Part D (prescription drug coverage) claims data set created by the Centers for Medicare and Medicaid Services. Part D covers about 68 percent of the roughly 50 million people on Medicare, the federal insurance program for Americans who have certain disabilities or are 65 years or older.

While they found that up to 60 percent of opioid prescriptions do come from the top 10 percent of prescribers, they note this is no more skewed than Medicare prescriptions for any other drug.

Opioid prescriptions are concentrated among specialty services for pain, anesthesia, physical medication and rehabilitation. By sheer volume, however, the authors found that general practitioners dominate total prescriptions.

“High-volume prescribers are not alone responsible for the high national volume of opioid prescriptions,” writes lead author Jonathan C. Chen, MD, PhD, a Stanford Health Policy VA Medical Informatics Fellow; psychiatrist Anna Lembke, MD; psychiatrist Keith Humphreys, PhD and Nigam H. Shah, MBBS, PhD, a biomedical informatics specialist.

“Efforts to curtail national opioid overprescribing must address a broad swatch of prescribers to be effective,” the authors write.

Previously: Unmet expectations: Testifying before Congress on the opioid abuse epidemic, The problem of prescription opioids: “An extraordinarily timely topic” and Assessing the opioid overdose epidemic
Image by Trevor Butcher

Events, Medicine and Society, Stanford News

Abraham Verghese: “It’s a great time for physician leaders to embrace design thinking”

Abraham Verghese: "It's a great time for physician leaders to embrace design thinking"

Business_presentation_byVectorOpenStockNext spring, the School of Medicine and Graduate School of Business here will team up to offer a new, one-week residential program for health-care executives. Called “The Innovative Health Care Leader: From Design Thinking to Personal Leadership,” the program will be led by Sarah Soule, PhD, co-director of the Center for Social Innovation, and Abraham Verghese, MD, professor of medicine and well-known author.

I recently spoke with Verghese about the program.

This is the first time the two schools have worked together to offer a program like this. How did you get involved? 

I have admired the way the Graduate School of Business puts on continuing education programs – they have become so adept at it – so when Dean Lloyd Minor, MD, asked if I would lead this effort from our end, I was excited.

Stanford is all about learning new things and crossing disciplinary boundaries. This is the first medical school at which I’ve worked where all seven schools (business, education, law, engineering, medicine, humanities and sciences, and earth, energy and environmental sciences) are on the same campus. I thought this was a great opportunity for me to learn.

Why is this program needed?

The nature of medicine has become so much more than medicine. It’s a hugely important industry that consumes so much of our gross domestic product. There are so many things the executive has to know that is related to management, marketing, negotiations and strategy, it’s almost inevitable that these two worlds should meet.

But, it’s no use having all these strategies if you don’t ultimately deliver care in a way that’s satisfying to the patient and the people who deliver your care. Medicine is increasingly adopting the robes of business, but it can’t get too far away from what is elemental and fundamental, which is patient care. Every time it does, a disaster follows.

You’re best known for your advocacy of personal, bedside medicine. Why not have a professor who specializes in health-care economics or management lead the program?

I think it’s quite an appropriate role for some who has championed the patient-physician relationship and has been concerned about physician wellness. I’m involved because the patient is at the center, the ultimate beneficiary.

One of the startling things about health care these days is the strange dichotomy between our amazing technologies, therapies and discoveries and yet patients who are as a whole more dissatisfied than ever with the face of medicine, the cost of medicine and the lack of coordination of care. It’s also a time when many physicians are trying to figure out why the joy in medicine has left. For all those reasons, it’s a great time for physician leaders to embrace everything from design thinking to their own wellness.

Looking at it from my lens as a physician-leader of sorts in the educational field, I wish that I’d had the opportunity to attend something like this, using design thinking to examine how to lead in an environment that’s constantly changing, to hear from experts at the business school who talk about negotiating or about personal leadership and vision.

Verghese said he’d go in a “heartbeat” to attend some of the program’s scheduled speakers, including Dean Minor; epidemiologist John Ioannidis, MD, DSc; Doug Owens, MD, director of health policy; and Christy Sandborg, MD, professor of pediatrics.

Previously: Abraham Verghese: “There is no panacea for an investment of time at the bedside with students”, Physician-author Abraham Verghese encourages journalists to tell the powerful stories of medicine and A “grand romp through medicine and metaphor” with Abraham Verghese
Image by Vector Open Stock

Events, Medicine and Society

At TEDMED 2015: Behind the glitz, substantive issues

At TEDMED 2015: Behind the glitz, substantive issues

This year’s TEDMED was held Nov. 18-20 in Palm Springs, Calif. Stanford Medicine is a medical research institution partner of TEDMED, and a group of MD and PhD students who represented Stanford at the conference will be sharing their experiences here. 

TEDMED stage - Lichy HanI admit, I was skeptical heading into the TEDMED conference.

Don’t get me wrong, I love watching TED talks online, and I often listen to Guy Raz on the TED Radio Hour.

However, I’ve always viewed TED primarily as a source of entertainment, a chance to hear fascinating  personal adventures, and the popular science stories that fill us with awe. I’ve thought much less of TED as an entity that could create new knowledge, value and impact beyond storytelling and the occasional self-help guidance.

I’m happy to say that I was wrong.

TED has come under fire from some who paint it as a self-congratulatory echo-chamber of the wealthy elite that counter-productively obfuscates the missions of many speakers by burying their messages in flashy but ultimately meaningless evangelism – “things that make us feel good but which don’t work.” And while, having never attended, I couldn’t share these convictions, the curmudgeon in me could see the logic behind them.

To some extent, those concerns were realized. General admission was $5,000. Speakers were edgily rebranded as “superheroes” or “shepherds,” the kind of visionary titles that might be parodied in an episode of HBO’s “Silicon Valley.” The conference opened with a rock concert and a talk with a main takeaway that seemed to be that female baboons use their male counterparts as sexual objects. There are certainly many important issues embedded in that discussion, but the sensationalist, intentionally provocative delivery came across more Cosmo than Betty Friedan. Sex sells, it seems, even at medical conferences.

But what is it that we’re buying – and is it worth it? I believe so.

As a powerhouse of distributing ideas globally, TED has a social duty to promote not only those ideas that entertain and those that inspire, but also those that disgust, those that depress, and those that make us appreciate. With all eyes upon it, TED can bring some of the most difficult and sensitive, but necessary, topics to the forefront of the conversation.

In particular, I was impressed at the spotlight placed on mental health, an often downplayed and taboo topic that is nevertheless a core element of our profession and school, and my own experiences, friends, and hometown. Pamela Wible, MD, narrated horrifying letters of physician suicide, illustrating great failures in our medical training system. Without TED, few attendees would ever be exposed to these realities. Melissa Walker shared what it was like to have PTSD, and how art therapy could empower veterans to heal when drugs and counseling failed. The Surgeon General himself, Vivek Murthy, MD, chose to focus his TEDMED time on the importance of mindfulness and stress reduction in improving physical and psychiatric outcomes in middle school children.

Many speakers raised concerns about issues ranging from eugenics to institutional racism in healthcare, but what struck me most was how frequently “this is a big problem…” was answered immediately with “…and here’s what we’ve done to fix it…” Activist Raj Patel described how uprooting traditional gender roles was necessary to solve food shortages in Malawi. Bryant Terry recounted teaching nutritional programs to disadvantaged teens in New York. Kenneth Nealson, PhD, a USC professor, and engineer Peter Janicki described new economically sustainable methods that turn sewage and garbage into clean drinking water. All were clear to end with the message “…but there’s a ways to go.”

Is some of the TEDMED glamorization over the top? Absolutely. Are all of the ideas going to radically change the world? Maybe not. But TED has the power to bring people together to share their ideas, to collaborate on new ones, and to showcase their vulnerabilities, failures and unsolved challenges to each other and to the world. That in itself is an idea worth spreading.

Brian Hsueh is an MD/PhD student in neuroscience and bioengineering. He spends his days working on new technologies to understand and treat diseases of the brain, and his nights trying to find economically feasible ways to bring those technologies to patients.

Photo by Lichy Han

Infectious Disease, Medicine and Society, Parenting, Public Health, Research, Stanford News

California’s vaccination exemptions cluster in white, affluent communities

California's vaccination exemptions cluster in white, affluent communities

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California’s measles epidemic was no fluke; between 2007 and 2013 the percentage of kindergarteners using a “personal belief” exemption to enroll in school without vaccinations doubled.

In that year, 3 percent of kindergarteners entered school unvaccinated. In some schools, the percentage of vaccinated children was so low that it threatened herd immunity, or the ability for a population to keep a pathogen at bay, according to Stanford health-policy researcher Michelle Mello, PhD, JD.

To understand the rapid increase, Mello worked with a team led by Tony Yang, ScD, with George Mason University. Their research is published today in the American Journal of Public Health.

They found the highest resistance to vaccinations among white, affluent communities. In contrast to previous studies, however, they did not find a correlation between higher levels of education and vaccine exemptions.

“Beliefs about vaccination risk tend to be more entrenched among certain communities of mothers,” Mello said. The study didn’t investigate reasons for seeking exemption, but other studies suggest some mothers in affluent communities may believe they can adequately protect their children through “intensive parenting techniques” such as an organic diet and restricting contact with sick children, Mello said.

Although California eliminated the personal belief exemption this summer in a broad-reaching law that requires all medically eligible school students to be vaccinated, the study speaks to how other states might approach the problem of vaccine exemptions, Mello said.

Similar clusters of vaccine resistance exist elsewhere and the findings could help public health agencies refine outreach methods, she said. For example, by specifically targeting local groups and reaching out to community leaders, officials may have more success providing education about vaccine risks and benefits, Mello said.

The results are particularly striking given the history of vaccination efforts, she said. In the first half of the twentieth century, public health officials struggled to ensure vaccines reached disadvantaged communities. Now, as fear of the targeted diseases has paled, parents may be more fearful of vaccines, leaving the entire population vulnerable.

Previously: Infectious disease expert discusses concerns about undervaccination and California’s measles outbreak, Stanford researchers analyze California’s new vaccine law and The earlier the better: Study makes vaccination recommendations for next flu pandemic
Photo by woodleywonderworks

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