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Big data, Events, Medical Education, Medical Schools, Medicine and Society, Stanford News

Stanford Medicine’s Lloyd Minor on re-conceiving medical education

Stanford Medicine's Lloyd Minor on re-conceiving medical education

Stanford Dean of Medicine, Dr. Lloyd Minor.Stanford Medicine is no stranger to pioneering changes in medical education, so a panel on re-inventing health provider education at the Association of Healthcare Journalism 2015 conference this past weekend was the perfect fit for Lloyd Minor, MD, dean of Stanford’s School of Medicine. During his talk, Minor highlighted three topics that the school is pursuing in order to “re-conceive education so it better meets” today’s needs: team work, data sciences, and value-based health-care delivery.

Eschewing the old model of the omnipotent and self-sufficient doctor, Minor called for schools to “embrace from the very earliest stages that the delivery of health care is a team endeavor.” (The days of “see one, do one, teach one” are hopefully over, he said.) As paper records become a thing of the past and genome sequencing becomes even less expensive, we also need doctors who are very comfortable analyzing “big data.” “We have available to us a huge amount of data from which we are not extracting enough information,” he said before noting that many Stanford med students take classes in computer programming and data science. And, after highlighting the work of Stanford’s Clinical Excellence Research Center, Minor described how the new cohort of medical professionals has to have expertise in analyzing innovations based on value, defined as “outcomes divided by cost” – simply improving outcomes is not enough.

According to Minor, the basic goal of innovation should be to embed within the medical school curriculum as much flexibility as possible, since the workforce of the future needs to be diverse in terms of its talents and abilities. After discussing how many medical schools are exploring the “flipped classroom,” he noted that “Rote memorization is not the learning technique that’s going to address the problems that society has every right to expect health-care professionals to address. One project, one intervention at a time will achieve that transformative impact.”

Fellow panelist Henry Sondheimer, MD, senior director of medical education at the Association of American Medical Colleges, also discussed “seismic shifts” in medical education that require “a different culture, a different kind of student, and a different kind of physician.” This move from being hierarchical, autonomous, and competitive to being collaborative, service-oriented, and patient-centered is facilitated and reflected by changes such as the new MCAT, which assess not what students know but how well they can use what they know, and includes a new section addressing the psychological, social, and behavioral determinants of health. He stated that in a world where 32 percent of 2nd-year medical students attend lectures rarely or never, 14 percent regularly attend lectures at other medical schools, 40 percent source medical information from YouTube, and 87 percent from Wikipedia, education is not about memorization, but about connectivity. And this is not just in the U.S.: Speaking about a recent trip he took, Sondheimer reported that “Every single medical student at the University of Zimbabwe has a tablet.”

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Aging, Medicine and Society, Pain, Palliative Care, Patient Care, Stanford News, Videos

“Everybody dies – just discuss it and agree on what you want”

"Everybody dies - just discuss it and agree on what you want"

Earlier this week, my colleague pointed to a New York Times essay penned by VJ Periyakoil, MD. In it, Periyakoil calls for a role-reversal in talking about end-of-life issues and encourages patients to take the lead in starting such conversations with their doctors. “Without these conversations, doctors don’t know what the patients’ goals are for living their last days,” she writes. “What are their hopes, wants, needs and fears? Do they want to die at the hospital connected to a machine? Do they want to die at home? The current default is for doctors to give patients every possible treatment for their condition, regardless of its impact on the patient’s quality of life, the cost or the patient’s goals.”

Periyakoil goes on to describe a letter that she and her colleagues created to help facilitate these patient-doctor conversations. The video above expands upon the Stanford Letter Project, which helps patients map out what matters most to them at the end of life, and includes the candid thoughts of numerous older adults.

“If I’m brain-dead, unplug me,” one woman says matter-of-factly. “And I want to die painless. No pain – just put me to sleep and don’t let me wake up.”

In the doctor’s office, one man shares his reason for writing a letter and expressing his wishes: “One of the worst things in the world that you can have happen [is you’re on] your deathbed and you’re putting the burden of life-altering decisions on a family member that has no clue of what you really want or don’t want.”

Advises another older man: “Don’t be ashamed of it – everybody dies. Just discuss it and agree on what you want.”

Previously: How would you like to die? Tell your doctor in a letter, In honor of National Healthcare Decisions Day: A reminder for patients to address end-of-life issues, Study: Doctors would choose less aggressive end-of-life care for themselves, On a mission to transform end-of-life care and The importance of patient/doctor end-of-life discussions

Events, Health Disparities, Medical Education, Medicine and Society, Public Health

An ounce of action is worth a ton of theory: Med student encourages community engagement

An ounce of action is worth a ton of theory: Med student encourages community engagement

IMG_0775Right after graduating from Stanford, Steve (Suk) Ko moved to East Palo Alto with some friends who were also recent graduates. They put all their effort into becoming engaged in their new community, starting and running a tutoring program out of their apartment – which could get really crowded, judging by the pictures he showed last week while speaking to undergraduates interested in public health.

Soon after making East Palo Alto his new home, Ko started medical school at Stanford and continued his service work throughout. “We at Stanford are good at thinking and debating, but less good at action,” Ko said during this talk. “I felt some guilt about indulging in socioeconomic affluence when there was this community right next door.”

Ko’s talk was part of the Primary Care, Public Health, and Health Disparities Lecture Series sponsored by Stanford’s Center of Excellence in Diversity in Medical Education, which aims to produce leaders who can eliminate national-health inequities. Ko shared his personal experience and offered three points of advice:

1). Never lose what makes you special. 

If you’re thinking about how to improve public or global health, “don’t fake it – do what you’re passionate about.” This will lead you in the right direction. As for medical school applications, there are all kinds of ways to have a “research background,” he said.

For Ko, a Korean ethic of hard work and his Christian faith enabled his interest, experiences, and goals in public health. During an undergraduate service learning trip to Oaxaca, Mexico, he shadowed an OB/GYN at a public hospital and was moved both by the beauty of birth and the limited opportunities these newborns faced. Born resource poor and in a society with high gender inequality, “this baby girl had not made a single choice, but 99 percent of her life was already decided,” Ko said. He wanted to think about health in a broader context.

2). An ounce of action is worth a ton of theory.

Last summer, Ko implemented a 5-week summer meal program in East Palo Alto that served kids and their families. The suggestion to focus on food insecurity came from Stanford pediatrician Lisa Chamberlain, MD, Ko’s mentor. The YMCA, Stanford Medicine, and Revolution Foods supported the project, which served 270-370 kids and 4-30 adults every day, and provided a total of 2,525 take-home meals. Ko said it’s “like pulling teeth” to get kids to eat healthy food, but shaping tastes early is key to forming long-term habits. The team ran both quantitative and qualitative analyses of the program, gathering insights like that families are hungrier in bad weather because those who work outdoors or in construction cannot earn money, and that libraries could be great food distribution points.

One of Ko’s most rewarding recent memories was when several of the high-school students he works with made a documentary film about East Palo Alto. They wanted to challenge its unfair portrayal in the news media – although it had the highest homicide rate in the country in 1992, gentrification is now starting to be a bigger problem than crime. “The 90’s were a long time ago,” the students pointed out.

3). Community engagement is difficult, and therefore a privilege.

It was very hard for Ko to gain the trust of his adult neighbors (he says kids are easy: just smile at them). After living there for years, he felt gratified last week when he was ill and a neighbor brought him soup. Trust comes slowly; you have to prove you’re there for the long haul. Even so, circumstances are just hard – what do you do when a student tells you a family member just died from gang violence? Ko coped with the emotional and physical difficulty through his faith and by finding joy in the process, not the outcomes.

One of the audience members asked a question about “white knight syndrome” – the problematic idea that someone from a different community is able (and welcome) to storm in and fix everything. Ko agreed that good intentions can hurt vulnerable people. Temporary involvement doesn’t require accountability and invites the community to be jaded and skeptical, focusing on the impact of the last person/organization. For this reason, it can be much better to join an existing project than to start a new one, he said. But above all, Ko favors humility and a sense of wonder, not just going in and”fixing it”.

Previously: A quiz on the social determinants of health, Stanford researchers use yoga to help underserved youth manage stress and gain focus, Med students awarded Schweitzer Fellowships lead health-care programs for underserved youth, Nutrition and fitness programs help East Palo Alto turn the tide on childhood obesity and Doctors tackling child hunger during the summer
Photo, of Steve Ko (right) and Marcella Anthony of Stanford Medicine’s Community Outreach, by Andrea Ford

 

Events, Medicine and Society, otolaryngology, Science, Stanford News

A lesson in voice and anatomy from an opera singer

A lesson in voice and anatomy from an opera singer

IMG_0766This past Thursday, I watched an opera singer’s throat as he sung. Not the bulging Adam’s apple above his shirt collar, but the shiny lumps and taut cartilage of his larynx, the mucus on his vocal folds, all healthy pink and slick and breathing.

It was a curious combination, opera and anatomy, and I didn’t know what to expect from this World Voice Day event – “Anatomy of An Opera Singer” – which was offered as a collaboration between the Stanford Medicine Music Network (part of Medicine and the Muse), Stanford Live, and the Department of Otolaryngology: Head & Neck Surgery. Surrounded by community members of various ages and people in scrubs, I entered Berg Hall to the sound of Cake’s “Opera Singer”: I am an Opera Singer, I stand on painted tape; It tells me where I’m going, and where to throw my cape. 

Stanford’s C. Kwang Sung, MD, MS, who has a professional background in both singing and otolaryngology, started the evening by performing a song honoring his parents’ inspirational role in his life – after which he introduced his parents sitting in the front row! After giving us a basic introduction to throat anatomy, he introduced internationally acclaimed opera singer Eugene Brancoveanu, who performed a song from “The Rape of Lucretia,” accompanied by Stanford pianist Laura Dahl. Brancoveanu’s beautiful voice and elaborate variety of facial expressions was stirring.

What followed elicited gasps and laughter from the audience – the view from a laryngoscopic camera in Brancoveanu’s throat was projected on big screens while Sung and Elizabeth DiRenzo, PhD, vocal fold biologist and assistant professor of otolaryngology, explained what we were seeing. The video tour had been recorded prior, and throughout the evening new twists and turns were revealed. Sung and DiRenzo had recorded Brancoveanu while he sang, while he played with falsetto and passaggio and while he varied the vowel sounds, and they walked us through this intimate demonstration of living vocal anatomy.

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Events, Medicine and Society, Stanford News

“You just get lifted away from the earth”: Film spotlights dance program for Parkinson’s patients

“You just get lifted away from the earth": Film spotlights dance program for Parkinson’s patients

capturing grace still

Tomorrow and Saturday, “Capturing Grace,” a documentary film following participants of a dance program for people with Parkinson’s disease generated by New York’s Mark Morris Dance Group (MMDG), will be screened at Stanford. Filmmaker and former KQED Forum host Dave Iverson, and David Leventhal, previously a leading dancer of MMDG and now the director of Dance for PD, will also be on campus holding workshops and discussions.

A Stanford News piece today describes the film as “the centerpiece of a two-day exploration of the intersection of dance and medicine” and offers these details:

Since his Parkinson’s diagnosis in 2004, Stanford alumnus Iverson has been an education champion for the progressive disorder of the nervous system that affects movement. He wrote, reported, directed and co-produced the 2009 PBS Frontline documentary My Father, My Brother and Me, using his family’s saga with the disease as a starting point to explore the larger issues of scientific research, the quest for a cure and the political controversies surrounding stem cell transplants. He also works as a contributing editor for the Michael J. Fox Foundation for Parkinson’s Research.

[Said Iverson:] “One thing I’ve come to believe about Parkinson’s is that it’s a disease of subtraction. It takes things from you one by one. And one of the many things I learned from the people in the class is that if you are confronted with a disease of subtraction, you better believe in addition. You better start adding things back into your life. For the people we profiled in Capturing Grace, I think dance helped get them back on the plus side of the ledger.”

I recently talked with Iverson, who told me that, despite his Frontline documentary’s title, “Capturing Grace” has proved more personally involving. “It’s more about what happens to people when they have to respond to something that’s unwelcome in their lives,” he said. The participants featured in the film gather at the MMDG studios in Brooklyn to take classes given by professional dancers of one of the world’s leading modern dance troupes, and they learn repertory to perform, including dances by Mark Morris.

“It isn’t a miracle and it’s not a treatment,” Morris says in the film. Different from art therapy, the program provides instruction in movement and an opportunity to share what professional dancers experience daily – the heightened sense of awareness found by coordinating one’s body and mind to move freely and deliberately through space, guided by music, in communion with others – with a deadline of a performance offering additional motivation to show up, practice, and stay focused on a goal.

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Aging, Medicine and Society, Videos

In honor of National Healthcare Decisions Day: A reminder for patients to address end-of-life issues

In honor of National Healthcare Decisions Day: A reminder for patients to address end-of-life issues

When San Jose, Calif. residents Shirley and Eddie Jones wanted to discuss their end-of-life wishes, they encountered resistance from an unexpected source. As detailed in the video above, their beloved children refused to participate in the conversation.

As with the Jones, the people who love you the most may not be willing to help you because they care too much – and your doctors may be largely silent as they’re uncomfortable broaching this sensitive topic for fear of offending you. So, when it comes to end-of-life planning, you’re largely on your own. And it’s important that you take the first step and break this wall of silence.

Even as you’re reading this, you may be thinking that the topic of end-of-life decision making is not relevant to you right now – that it’s too early. Or it may be that you’re uncomfortable thinking about death. You may even be waiting for your doctor to broach this subject with you and lead the way. After all, as long as you do what the doctor tells you to do, you can get pretty good results with your health care. But, this ‘wait-for-your-doctor’ strategy isn’t going to serve you well when it comes to end-of-life decision making and planning.

Don’t believe me? Then just take a moment to review the evidence (link to .pdf): Eighty percent of people say that it’s important to have end-of-life wishes in writing, but only 23 percent say they have have done so. Eighty percent wish to have end-of-life conversations with their doctor but only 7 percent get to do this. Research also shows that most doctors have neither the training nor the time to skillfully conduct end-of-life conversations with their patients.

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Emergency Medicine, Medicine and Society, Public Health, Public Safety, Research

Study: ER statistics could be used to help reduce gun violence

Study: ER statistics could be used to help reduce gun violence

ER shot

Emergency room doctors treat many patients who have been involved in violent assaults. New research shows that these patients are far more likely than other ER patients with otherwise similar demographics to seek treatment for gun-related injuries in the near future.

These findings “could help injury researchers, emergency department physicians, and social service agencies focus their intervention efforts to prevent future firearm incidents and other violent incidents among high-risk youth populations,” explains a University of Michigan press release published Monday.

The study, published in Pediatrics, followed nearly 600 drug-using youth in Flint, Mich. for two years after they were admitted to the emergency room. Nearly 60 percent of those admitted for assault-injury care became involved in a violent incident involving a firearm within the next two years, and of those, the majority did so within six months after the initial visit. Between two people with highly similar demographic factors, someone admitted for assault is 40 percent more likely to be involved in gun violence than someone admitted for a cold.

The results also calculated the statistical correlations of various markers, such as race, gender, drug abuse, PTSD, possession of a firearm, and tendency toward retaliation (see the release for the details). ERs that track such markers could identify the highest-risk youth and help them receive targeted treatment. The release quotes Patrick M. Carter, MD, an assistant professor of emergency medicine at UM, member of the UM Injury Center, and first author of the study, saying the results “support using the ER as the site for intervention, especially during the ‘teachable moment’ that immediately follows an initial assault or fight.”

Previously: Pediatricians’ role in gun control: Recommendations from the American Academy of Pediatrics, Emergency-room interventions may reduce alcohol-based violence among teens and Emergency room as soup kitchen
Photo by Military Health

Medical Education, Medicine and Literature, Medicine and Society, Mental Health, Patient Care

Using graphic art to understand the emotional aspects of disease

Using graphic art to understand the emotional aspects of disease

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When it comes to describing the feelings of hopelessness of depression, the fear and anxiety of having an operation or the unrelenting pain of a chronic condition, sometimes words are not enough. But, as some patients have discovered, art can be a powerful medium for portraying and translating these complex emotional experiences. Cartoons can also help future medical professionals empathize with patients and consider their experience from more than a clinical perspective.

An article published last week on the anthropology blog Teaching Culture explores the use of graphic art in medical anthropology courses. It takes its inspiration from Allie Brosh’s comic Hyperbole and a Half, in which she uses a crudely drawn figure to transport readers through the painful inertia and numbness of her depression. I stumbled upon this comic a few years ago when a dear friend was depressed. At the time, I didn’t understand how that could be or what that meant. Brosh’s bizarre, raw, and yes funny, comic resonated not only with what I saw my friend going through, but with my own experience, even though I was not depressed. It enabled me to empathize and to offer her support that was more relevant.

The article also describes a curriculum that incorporates “graphic pathographies” – graphic novels and comics about experiencing illness – into a course for pre-med students. The coursework “examines the multifaceted relations between biomedicine, culture, and the art of care, and places a special emphasis on how creative and humanistic approaches to illness and healing might enrich clinical practice.”

When I asked for his thoughts, Errol Ozdalga, MD, a professor of general medicine involved with the bedside medicine Stanford 25 initiative, commented:

Graphic art is an expression that is probably under-utilized. At Stanford, our guest services offers patients the chance to do guided imagery by expressing their feelings via drawing. Many physicians are unaware this service exists. It’s an opportunity to better understand our patients’ perspectives and promote the importance of connecting to patients among our students.

Previously: Engaging with art to improve clinical skills, Image of the week: a medical-focused manga comic and Stanford nurse’s whiteboard artistry brings cheer to patients, co-workers
Photo by Krystal T

Ethics, Genetics, History, In the News, Medicine and Society, Microbiology, Stanford News

Stanford faculty lend voices to call for “genome editing” guidelines

Stanford faculty lend voices to call for "genome editing" guidelines

baby feetStanford law professor Hank Greely, JD, and biochemist Paul Berg, PhD, are two of 20 scientists who have signed a letter in today’s issue of Science Express discussing the need to develop guidelines to regulate genome editing tools like the recently discovered Crispr/Cas9. Researchers are particularly concerned that the technology could be used to alter human embryos. From the commentary:

The simplicity of the CRISPR-Cas9 system enables any researcher with knowledge of molecular biology to modify genomes, making feasible many experiments that were previously difficult or impossible to conduct. […]

We recommend taking immediate steps toward ensuring that the application of genome engineering technology is performed safely and ethically.

We’ve written a bit here before about the Crispr system, which essentially lets researchers swap one section of DNA for another with high specificity. The potential uses, for both research or therapy, are touted as nearly endless. But, as Greely pointed out in an email to me: “Making babies using genomic engineering right now would be reckless – it would be unknowably risky to the lives of those babies, none of whom consented to the procedure. For me, those safety issues are paramount in human germ line modification, but there are also other issues that have sparked social concern. It would be prudent for science to slow down while society as a whole discusses all the issues – safety and beyond.”

The list of others who signed the commentary reads like a veritable who’s who of biology and bioethics. It includes Caltech’s David Baltimore, PhD; U.C. Berkeley’s Michael Botchan, PhD; Harvard’s George Church, PhD; and George Q. Daley, MD, PhD; University of Wisconsin bioethicist R. Alta Charo, JD; and Crispr/Cas9 developer Jennifer Doudna, PhD. (Another group of scientists published a similar letter in Nature last Friday.)

The call to action echos one in the 1970s in response to the discovery of the DNA snipping ability of restriction endonucleases, which launched the era of DNA cloning. Berg, who shared the 1980 Nobel Prize in Chemistry for this discovery, organized a historic meeting at Asilomar in 1975 known as the International Congress on Recombinant DNA Molecules to discuss concerns and establish guidelines for the use of the powerful enzymes.

Berg was prescient in an article in Nature in 2008 discussing the Asilomar meeting:

That said, there is a lesson in Asilomar for all of science: the best way to respond to concerns created by emerging knowledge or early-stage technologies is for scientists from publicly-funded institutions to find common cause with the wider public about the best way to regulate — as early as possible. Once scientists from corporations begin to dominate the research enterprise, it will simply be too late.

Previously: Policing the editor: Stanford scientists devise way to monitor CRISPR effectiveness and The challenge – and opportunity – of regulating new ideas in science and technology
Photo by gabi manashe

Behavioral Science, In the News, Medicine and Society, Research

Research prize for helping make mice comfy – and improving science

Research prize for helping make mice comfy - and improving science

OLYMPUS DIGITAL CAMERAA Stanford researcher has won accolades for a research paper that could help ease the lives of millions of laboratory mice – and improve the outcomes of research studies.

Joseph Garner, PhD, an associate professor of comparative medicine, and his colleagues observed that mice are routinely housed in cold conditions, which put stress on the animals. The mice compensate with physiologic changes that can skew the results of laboratory studies. For instance, temperature has been shown to affect immune function and tumor development in mice, among other factors. So cold stress in mice raises concerns not only for animal welfare but also for science.

Garner and his colleague, Briana Gaskill, PhD, proposed a simple solution: Give the animals some nesting material, and they’ll build a cozy home to regulate their temperatures. These comfy mice would be more physiologically comparable to humans, making them better research subjects, the researchers said. But one obstacle to adopting this simple solution was the question of how much nesting material is enough? In their prize-winning experiment, the researchers asked the mice how much nesting material they needed to give up a warm cage for a cold cage with a nest. The scientists found that between 6 and 10 grams of nesting material could effectively reduce cold stress in the animals – a standard now starting to be adopted in labs around the world.

The paper, published in 2012 in PLoS One, won a high commendation recently from the National Centre for the Replacement, Refinement & Reduction of Animals in Research, a leading, UK-based scientific organization that supports research which aims to minimize the need for animals in research and improve animal welfare.

The group said that the research results “have the potential to positively impact the welfare of millions of laboratory mice all over the world.”

Garner and Gaskill both traveled to London to receive the prize.

Previously: Stanford students design “enrichments” for lions, giraffe and kinkajou at the San Francisco Zoo, Nesting improves mouse well-being, could aid research studies and Stanford researcher’s easy solution to problem of drug testing in mice
Photo, which originally appeared in Stanford Medicine magazine, by Brianna Gaskill

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