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Events, Medicine and Society, Stanford News

Anna Deavere Smith explores “crossing the line” of being sick and dying

Anna Deavere Smith explores "crossing the line" of being sick and dying

ADSThe New York Times has written that Anna Deavere Smith, playwright, actress and professor, is the “ultimate impressionist. She does people’s souls.” It was Jonathan King’s soul that Smith summoned up at the Jonathan King Lecture on campus earlier this week. The lecture series, celebrating its 25th year, honors King, who earned a master’s degree and PhD in computer science at Stanford and who became an advocate for patients’ rights after his cancer diagnosis in 1989. The series was created by friends and family to honor King’s memory and to carry on his message of “walking in the shoes of your patients.”

The event opened with a video of King during his life and battle with cancer, including portions of a talk he gave to medical students in which he said, “There is a line that divides people who have passed over to the condition I am in from everybody else.”

Smith weaved those words throughout her performance, as she brought to life patients she had interviewed in the course of her research for her landmark one-woman show “Let Me Down Easy.” Those real life patients included Hazel Merritt, a diabetic patient who had compelling reasons to refuse dialysis treatment; Ruth Katz, former associate dean of administration at Yale Medical School; Ann Richards, former Governor of Texas; and Eduardo Guerro, a patient who said, “You can’t turn dying into a picnic.”

What medical professionals CAN do however, Smith said, is recognize the whole person in the patient. “Take in everything they are, and that starts when you walk in the room and touch the patient,” Smith said. She then echoed King’s advice saying, “Get as close to your patients as possible.”

Smith also addressed the “line” that King referred to. “There is a matter of, of… aloneness for those who have passed over that line, and we can do better as humans and as a society to work to get over it. We need to imagine crossing that line, because we are all human, and we are all going to die.”

In the Q&A portion of the lecture, medical student Arunami Kohli thanked Smith for her moving performance and asked her how she got patients to speak so candidly. Smith’s answer: “I have found when people are in crisis, they want to restore their dignity, and when they do, they are so eloquent, they sing. Just remember to give patients that opportunity, to restore their dignity.”

Jacqueline Genovese is assistant director of the Medicine & the Muse Program within the Stanford Center for Biomedical Ethics. The center hosts the Jonathan King Lecture.

Previously: Actor Anna Deavere Smith on getting into and under the skin of a character

Medical 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

In the News, Medicine and Society, Patient Care

Stanford bioethicist weighs in on California’s new end-of-life law

Stanford bioethicist weighs in on California's new end-of-life law

Earlier this week, California Governor Jerry Brown signed the controversial “End of Life Option Act,” which will take effect in 2016 and allow medically assisted suicide in the state. The news was the topic of KQED’s Forum yesterday, and Stanford bioethicist David Magnus, PhD, was one of the featured guests.

Magnus noted that the law is likely to affect a very small percentage of the population, and he thinks the debate surrounding it “reflects a much, much deeper problem in how we deal with communication and care at end of life. This isn’t really going to solve that problem…” Another show guest, Toni Broaddus, California campaign director of Compassion & Choices, agreed that more conversation between doctors and patients is needed, but said this can help: “We hope that what part of this law does, in addition to providing relief from those who need it at the end of life [is] create the room and the opportunity for doctors to talk with their dying patients about all of the options…”

The entire conversation is worth a listen.

Previously: How would you like to die? Tell your doctor in a letterStudy: Doctors would choose less aggressive end-of-life care for themselvesStanford experts weigh in on spate of “right to try” laws for the terminally illOn a mission to transform end-of-life care and The importance of patient/doctor end-of-life discussions

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

Medical students and physicians share their writings on “becoming a real doctor”

Medical students and physicians share their writings on "becoming a real doctor"

louisewenreading_CROPPEDThe dilemma of being a medical student on clinical rounds who wants to help patients but can’t was captured by third-year student Raymond Deng in his essay “Performing Grief,” at a recent reading held by Stanford’s Medicine and the Muse Program and Pegasus Physician Writers group.

The event, titled “Becoming a Real Doctor: Writings on Medical Education and Training,” also featured a poetry reading by fourth-year medical student Lauren Pischel, a book excerpt by Cornell physician Matt McCarthy, MD, and essay readings by Emily Liu, a second-year medical student, and Louise Wen, MD.

The audience of medical students, physicians, residents, nurses and community members listened attentively as Deng described what it can feel like to be a medical student:

For a year or two, you will inch your way on the tightrope towards white-coated authority from diligently reproduced sham. What you lack in clinical knowledge, you will compensate for with the appropriate attire. Be meticulous. Put on your requisite, freshly-pressed white coat. Hang your stethoscope across the nape of your neck. Cram the pockets of your white coat so full of notes and reference guides that they sag. Ignore the nagging incongruence: the fact that you’re not a doctor but you look like one. You want to help patients, but will settle for watching… You will feel like a cardboard marionette, dancing to the steady rhythm of acting competent and acting ignorant of your acting.

For Wen, it was acting against the rules of eating in the area of clinical care that afforded her the opportunity to connect with her patient, Sara, on a personal level:

Hey doc, here’s a treat for you, I know you guys work hard… Here, try some Afghani bread.” She looks up, eager to connect, and my own yearning to know this women beyond her illness swells within my chest. I can recite numerous details and data points about her medical history and hospital course, but her life as a human being is a gaping void.”

Eating the homemade bread, with “the inside as soft as pillowy sponge cake,” led to a sharing of photographs of Afghanistan and a filling of the void for Wen.

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Medical Education, Medicine and Society, Stanford Medicine Unplugged

Learning how to learn medicine

Learning how to learn medicine

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.

A few weekends ago, I saw a patient with bloated shins at our school’s free clinic, and I marked in my notes that she exhibited “peripheral edema,” an esoteric phrase that means little to those outside of the medical community. That experience only highlighted the tendency in medicine to inflate common bodily functions into opaque medical jargon. Its use can be frustrating for patients who are trying to understand their illness — and at times even for the uninformed medical student who is trying to learn about his patient.

As medical students, we feel as if we’re training to become glorified breathing-and-walking medical dictionaries

It doesn’t help that the list of jargon is endless. Itchiness becomes pruritus. Listening to the body’s internal noises condenses into auscultation. When you urinate, you’re really micturating, and if you have trouble doing so, you also have dysuria. Having a rash turns into having erythema. An abnormally large liver translates to hepatomegaly. An unhealthy level of cholesterol is labeled as hyperlipidemia. Chest pain is referred to as angina. Even the simple act of sweating is termed hidrosis. For vast majority of the first two years of medical school, we spend our time learning this vast and complex language that seems to have a word or phrase for every single bodily event — health and unhealthy, normal and abnormal.

But that is what medical training and much of medicine are — making observations of the human body and noting them with memorized jargon. And once we have acknowledged all the relevant observations, we connect the dots to form a story. If we’re astute and lucky enough, that story will end with the name of the disease along with its possible treatments and cures.

One would think that in order to provide adequate treatment to our patients, our education would possess more depth into the mechanisms behind drugs and diseases. But we only graze their physiological and molecular basis. It isn’t a reflection on our lack of curiosity. Rather, unfortunately, medicine is still limited by our dearth of knowledge. Despite the trillions of dollars poured into research, our advances in human genomics, and the fancy gadgetry, the human body remains a stubborn black box. Most of the time, all we can do is look at the inputs and outputs. Take aspirin, for example. Cardiologists recommend patients with a history of cardiovascular disease to take a baby aspirin every day to reduce their chances of a heart attack. But how this drug — first discovered by the ancient Egyptians — leads to decreased risk of death still remains a mystery.

These days, patients can sequence their entire genomes at a speed and price that was unimaginable a decade ago. They can scan their entire bodies to produce images with unprecedented detail. But in a unexpected twist, in order to confirm a diagnosis, physicians may still resort to the primitive practice of taking a gross piece of tissue from the patient and viewing it under a compound microscope, a contraption invented nearly half a century ago. Our expensive technology has been only able to expand our ability to observe and has done little peel back the veil covering the underlying mechanisms of human diseases.

But that is not to say that we should lose faith in medicine and underestimate the importance of labeling our observations. For the patient, putting a name on an abnormality, even if there may be no treatment available, can be comforting and give hope for recovery. For the caretaker, being able to identify an important physical finding can point to a set of suspect diseases. For my patient, leg swelling strongly suggested that he might be suffering from congestive heart failure.

As medical students, we must feel as if we’re training to become glorified breathing-and-walking medical dictionaries. Make no mistake — we are. We’re learning to make observations, note them down, and make sense of them down the road. And we shouldn’t underestimate the power of this process. It is at the core of the scientific process, and it’ll be how we ultimately serve our patients.

Steven Zhang is a second-year medical student at Stanford. When he’s not cramming for his next exam, you can find him on a run around campus or exploring a new hiking trail.

Photo in featured entry box by Patrick

Aging, Events, Medicine and Society, Medicine X, Stanford News

Living long and living well: A conversation on longevity at Medicine X

Living long and living well: A conversation on longevity at Medicine X


There were big-time laughs, and the expected misty eye or two, at today’s Medicine X session on aging and longevity. Natrice Rese, a retired personal support worker, began the conversation with a moving ePatient Ignite! talk about how life for many older adults is less than “golden.” She told the audience how difficult time spent in a nursing home or care facility can be: “So many people wait to be fed, wait to be dressed, wait to be undressed, wait to be taken outside… When you’re dependent on care from others, your life is reduced to a waiting game.”

Her mother found herself in one such place at the age of 85, and Rese recalled how her mom pulled her aside one day and said, “Don’t come near these places – it’s not good here.” Her mother was in the throes of Alzheimer’s and unable to offer further details, but “her words stay with me today,” Rese somberly told the audience.

Rese said her mom’s comments ultimately reinforced her desire to work to make sure older adults feel appreciated and are able to “create memories that matter.”

Fellow panelist Barbara Beskind is certainly doing that – and more. The 91-year-old former occupational therapist made headlines when she landed a job at Silicon Valley design firm IDEO. Appearing at the conference alongside Dennis Boyle, a partner and founding member of the firm, she goes to the office every Thursday and is now working on a variety of projects related to aging – including a redesigned walker.

Younger designers “can’t put themselves in the shoes of the elderly,” Beskind told USA Today earlier this year. “People who design for the elderly think they need jeweled pill boxes or pink canes. We need functional equipment.”

“I admire you,” Rese told Beskind during a panel discussion, after hearing about Beskind’s contributions. “You shouldn’t be one of a few – you should be one of many.”

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Events, Medical Education, Medicine and Society, Medicine X, Patient Care

Medicine X | Ed keynote speaker: “Networks are fundamental to what it means to be human”

Medicine X | Ed keynote speaker: "Networks are fundamental to what it means to be human"

Larry Chu's jacketToday marked the opening of the first-ever Medicine X|Ed conference, a two-day event dedicated to delving into important issues related to medical education in the digital world. The aim of the event is to help attendees understand the medical learners of today and to shed light on how technology and social media affect the way future doctors learn and interact with patients.

Larry Chu, MD, Stanford anesthesiologist and executive director of Medicine X|Ed and Medicine X, got the conference rolling, bounding onstage sporting a life-sized image of his dog, Zoë Chu, on the back of his suit jacket. “We want to create a culture of health where everyone is trusted and respected for their expertise,” he told attendees. “Join us in the future of imagining medical education…”

Chu’s infectious enthusiasm set the tone for the day of TED-style talks, learning labs and panel discussions that emphasized the value of shared knowledge and the importance of doctors and patients informing and educating one another. Howard Rheingold, the opening keynote speaker and bestselling author of several books, underscored the importance of networked patients with a simple yet powerful opening.

“I’m really happy to be here,” he told the audience. “I’m a cancer survivor, so I really mean that. I’m grateful to my oncologist and to a network of people online, some of whom I knew before, and many of whom I did not know before.”

“I was diagnosed with cancer in 2010,” he continued. “It was a kind-of an embarrassing cancer, anal cancer, but I knew I’d need to talk about it.”

Howard Rheingold on stageRheingold started a blog, called Howard’s Butt, where he could turn to other networked patients for information and support. “It became an important source of catharsis for me,” Rheingold explained. “I came back from a treatment, and I needed to get my feelings out. I’ve been cancer-free for 5 years, and [this experience] gave me a deep appreciation for the power of social media.”

“Networks are fundamental to what it means to be human,” Rheingold said. “When you face a crisis, you need to connect with other people. Technology enables this in a way that wasn’t possible before.”

Yet, networked patients face some pitfalls too, Rheingold cautioned. “Cyberchondria” (where patients Google their disease, and what they find online is worse than what they actually have) and overconfidence are two big issues. Networked patients need to learn how to separate the bad information from the good, and they need to evaluate how much they really know, he explained. “I call it crap detection,” Rheingold said. Being a networked patient, as well as being a doctor that works with the networked patient, takes time and practice, he said.

After his talk Rheingold told me, “Many doctors and physicians don’t get or understand the networked patient. But there’s an emerging group of physicians that are attuned to this.” He looked around at the packed conference hall and said, “By virtue of being here, people are interested… This is how things start.”

More news about the conference is available in the Medicine X category. Those unable to attend the event in person can watch via webcast; registration for the Global Access Program webcast is free. We’ll also be live tweeting the keynotes and other proceedings from the conference; you can follow our tweets on the @StanfordMed feed.

Photo of Larry Chu (top) by Holly MacCormick; photo of Howard Rheingold courtesy of Stanford Medicine X

Medical Education, Medicine and Society, Patient Care, Stanford Medicine Unplugged

Lessons from the parking lot: How roles in medicine define relationships

Lessons from the parking lot: How roles in medicine define relationships

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.

parking lotI was about halfway through my family medicine rotation, and I felt like I was hitting my stride. It was almost the end of the day on a Thursday, and I only had one patient left to see – I’ll call her Mary. Mary had a complaint of hearing loss but was otherwise healthy.

I had seen patients with similar issues during the rotation, and I was confident that this encounter would go smoothly. Of course, I was often uncertain about the best way to treat patients – but I came to learn that what was more important was that I established good relationships with them. Even though I always introduced myself as a medical student, many patients assumed I was a doctor and treated me like one. They told me their problems and asked me questions about how to solve them. I was happy to have these conversations: I felt like I got to know my patients and was able to help them.

So as I knocked on the door to see Mary, I expected to have a productive encounter – and I did. There are a lot of possible causes for hearing loss, including serious neurologic disorders and systemic syndromes, but one common cause of hearing loss is glaringly simple: earwax build-up. I looked in Mary’s ears, and sure enough, there were balls of wax sitting in the canals.

As I explained this to her, one of the medical assistants came in to complete the process of flushing her ears and getting the wax out. Afterwards, Mary and I talked briefly about some of the things that could have led to the buildup.

Mary was deeply appreciative throughout the encounter. Even though she had a relatively simple problem, she constantly thanked me for helping her out as we wrapped up. Since she was the last patient of the day, I left the exam room, gathered my things, and headed out of the clinic. My ego was riding high because she had been so effusive in her praise.

Then, as I was pulling out of the parking lot, a car cut me off. When I looked, it turned out the driver was Mary! She honked as she drove by, and then for good measure, she rolled down the window and flipped me off.

I’m fairly sure Mary didn’t realize I was the driver that she had just cut off. Regardless, my initial response was something along the lines of comical outrage. I had just helped her! We had bonded! How could she do that?!

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Aging, Medicine and Society, Mental Health, Patient Care

Stanford longevity design winner brings dementia place setting into production

Stanford longevity design winner brings dementia place setting into production

eatwellprimaryHelping people live not just longer but better lives is the goal of Stanford’s Center on Longevity, and last year it held a Design Challenge to scope out great ideas for doing so. The winner of that competition is no longer just a design; Eatwell is moving into production.

Eatwell, a place setting for those with cognitive and motor impairments from dementia, features subtle alterations to the colors, textures, weight, and shape of traditional dishes and cutlery. For example, bright colors make food more appetizing, and blue surfaces make it less likely that users will confuse their food with the dish. Slanted bottoms help keep food together and make it easier to scoop, and weighted bottoms with skid-resistant texture make spills less likely. There are even placemat attachments for a napkin to catch drips.

I recently corresponded with Eatwell’s designer, Sha Yao, via email while she was in Asia overseeing the manufacturing of her innovative product. The 20 design features of the 9-piece set emerged from a four-year research process involving one-on-one observation and volunteering in adult day care centers. “Along the way,” Yao told me, “I had many opportunities to come in contact with people who work with people with Alzheimer’s. I did more than a hundred mock-ups and asked my target users to give me feedback.”

Yao was surprised by the number of things caregivers have to be aware of. “Our loved ones may have visual impairment, and they may have depth perception problems with gripping things in front of them. Simple tasks can become difficult for them and I didn’t even know that before I did research on it and watched them struggle to eat.”

Although Yao has worked on a variety of products while completing her MFA in industrial design, this is the first project she developed from an idea to mass-production. Her impetus was a close connection with her grandmother, who took care of Yao and her sister as children while their parents worked.

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In the News, Medicine and Society, Nutrition, Parenting, Research, Women's Health

Research elaborates on how moms can protect their daughters’ body image

Research elaborates on how moms can protect their daughters' body image

6945839301_9d61091329_zIt’s been my experience that women struggle with their body image at some point on the way from girlhood to womanhood – this may be brief and exploratory, or get tangled with eating disorders and other destructive behaviors. When I had a period of bulimia in my early 20s, I reflected on (among other things) my mother’s relationship with food and body image, and so some new research from Ben-Gurion University in Israel struck a chord.

Maia Maor, PhD, a sociologist, and Julie Cwikel, PhD, a professor of social work and director of the Center for Women’s Health Studies and Promotion, invited adult mother-daughter pairs to reflect on various strategies the mothers used to instill resilience about body image in their daughters. The researchers identified five methods commonly used to resist or reject negative and oppressive messages about body image:

  1. Filtering: being cautious and sensitive regarding body image issues 
  2. Transmitting awareness of the dangers of eating disorders, which can cause illness and death
  3. Positive reinforcement, using affirmative language in regard to their daughters’ bodies
  4. Discussion: providing tools for criticism of dominant body-related messages
  5. Positivity: shifting the focus of food and body-related discussions away from weight loss and towards health and taking pleasure in food. 

In a press release from last week, Maor explained that “the focus on protective strategies was intended to achieve two goals: to emphasize the positive in mother-daughter relationships and to identify a repertoire of strategies available to parents and allied health professionals who wish to help their daughters or young women build a stable, positive body image.”

Feelings about food and bodies have long chains of intergenerational transmission. According to the release, “some of the mothers in the study recalled how their own mothers’ negative comments to them about eating too much led them to associate food with guilt and bad feelings. They raised their own daughters by instead talking about the quality of food, importance of food choices and its relationship to developing respect for their own bodies.”

The study appears in the journal Feminism & Psychology.

Previously: Incorporating the family in helping teens overcome eating disorders, Stanford study investigates how to prevent moms from passing on their eating disorders, Promoting healthy eating and a positive body image on college campuses, What a teenager wishes her parents knew about eating disorders, and Social website shown to boost teen girls’ body image
Photo by Thanasus Anastasiou

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