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Behavioral Science, Medicine and Society, Men's Health, Mental Health, Research, Women's Health

Living with a partner boosts your health

lonely-273629_1280Partners help. They help with daily activities like dishwashing and dog-walking, but they also provide the all-valuable emotional support needed to cope with everything from a rough commute to the death of a family member.

And those without a partner, perhaps due to divorce, are more likely to suffer from depression or anxiety, according to a new study (in Spanish) in the Spanish Journal of Sociological Research. Women have it the hardest, says lead author Carlos Simó-Noguera from the University of Valencia, who is quoted in a recent Medical News Today article.

Women who have lost their partner “show poorer health than men with the same marital and cohabiting status, and are more likely to suffer from chronic anxiety and chronic depression,” Simó-Noguera said.

Men are also affected, however. Separated or divorced men “have higher risk for chronic depression than the rest of men,” he said.

The team gathered data from the European Health Survey on people between ages 25 and 64.

“The key is not marital status per se, but is found in the interaction between marital status and cohabitation status. Therefore, living with a new partner after the dissolution of marriage preserves the health of the people involved,”Simó-Noguera said.

Previously: Practicing forgiveness to sustain healthy relationships, “Love hormone” may mediate wider range of relationships than previously thought and Study offers clue as to why parents of daughters are more likely to divorce
Photo by cocoparisienne

Health Policy, In the News, Medicine and Society

Medicare to pay for end-of-life conversations with patients

Medicare to pay for end-of-life conversations with patients

800px-Doctor_and_couple_talking_(1)Remember “death panels?” In the summer of 2009, in the midst of the debate about the Affordable Care Act, aka Obamacare, a small item in the legislation allowing Medicare to reimburse physicians for end-of-life conversations with patients unleashed a tsunami of criticism. Opponents charged that so-called “death panels” – anonymous Washington bureaucrats – would be making decisions about rationing health care and ultimately deciding who would live and who would die. As foolish as that charge was, the Obama administration choose not to fight the opposition and the payment proposal was dropped.

Now, the Centers for Medicare and Medicaid Services has announced a new policy. Beginning January 1, 2016, the government will reimburse voluntary end-of-life conversations that Medicare physicians have with their patients.

We asked Stanford’s VJ Periyakoil, MD, a nationally recognized leader in palliative care, for comment, and she said, “Medicare’s proposal to reimburse doctors to have a conversation with the patient about their values and preferences for care is a quantum leap forward towards the lofty goal of improving quality of care for all Americans at the end-of-life.” But she emphasized that this is just one part of the solution:

Advance care planning is not an event but a process. The key is having conversations in plural, over time as patients’ goals of care change as their illness progresses.

Early in the illness, most patients prefer to have a trial of high-intensity treatments including life support, and this is a very reasonable thing to do. However, there is a tipping point in the illness trajectory where we go from prolonging life with quality to prolonging the dying process. Beyond this tipping point, most patients, if given a choice, prefer to die gently and naturally at home minimizing the burden to their loved ones. But in order for this to happen, we need doctors who are well trained and highly skilled at conducting end-of-life conversations with their patients. We need to ensure that patients and their proxy decision makers are well supported to make end of life decisions. Finally, it takes significant support of both the patient and caregiver by a skilled team of clinicians to ensure a gentle and peaceful death at home.

Unless we have all these components in place, we can’t expect to see major and sustained improvements in end-of-life care.

Previously: “Everybody dies – just discuss it and agree on what you want”In honor of National Healthcare Decisions Day: A reminder for patients to address end-of-life issuesA call to “improve quality and honor individual preferences at the end of life”Study: Doctors would choose less aggressive end-of-life care for themselves and On a mission to transform end-of-life care
Photo by National Cancer Institute

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

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

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

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

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

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

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

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

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

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

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Behavioral Science, In the News, Medicine and Society, Pregnancy, Public Health

Walking on sunshine: How to celebrate summer safely

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Normally, I spend the Fourth of July on the shores of a Wisconsin lake, getting eaten alive by mosquitos, burning to a bright shade of pink, lighting sparklers and eating potato salad that has sat in the sun for hours. Heaps of fun, but also plenty of opportunities to fall ill.

This year, I’ve been barred from that fun trip by my oh-so-practical doc, who thinks unnecessary travel isn’t the smartest option for someone who is eight-months pregnant. Instead, I’ll have to be satisfied with reading a Washington Post article, published earlier this week, about all the summer health hazards I’m avoiding by celebrating the holiday in my coastal California home.

First is athlete’s foot, a fungus that “lingers on warm, wet surfaces such as poolside pavement and the floors of locker rooms and public showers” that produces an oozing pus. Or its relative, a toenail fungus that leads to yellow, thickened nails. And I thought a big belly was a bit of bother.

There’s also coxsackie virus, known for causing hand, foot and mouth disease, which thrives in kids’ wading pools courtesy of the occasional leaky diaper. The virus usually causes blisters; in rare cases it can lead to heart failure, says Stanford pediatrics professor Bonnie Maldonado, MD. Note to self: Keep baby out of unchlorinated kiddie pools.

We’re just getting warmed up here. There’s the summertime regulars of food poisoning, heat exhaustion and heat stroke. So yeah, that potato salad, while still yummy, probably isn’t a good idea, nor is the all-afternoon exposure to 95-plus degrees.

Don’t forget swimmer’s ear, an infection of the ear canal that, according to otolaryngologist Richard Rosenfeld, MD, from New York can “really, really, really hurt and ruin a vacation.” And a walk in the woods can quickly yield a ravaging rash from poison ivy or oak.

Throw in insect-borne plagues like West Nile and Lyme disease and gee, I guess my front porch isn’t looking so bad after all.

Previously: As summer heats up, take steps to protect your skin, This summer’s Stanford Medicine magazine shows some skin and Stanford nutrition expert offers tips for a healthy and happy Fourth of July
Photo by Jordan Richmond

Medicine and Society, Stanford News

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

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

ADS - smallThe “skin” issue of Stanford Medicine magazine is out and online. In it, I have a Q&A with actor and playwright Anna Deavere Smith. TV audiences came to know Anna through her work as Nancy McNally, the White House national security advisor on the famed series “The West Wing.” And now, after seven seasons, she’s ending another acclaimed role, hospital administrator Gloria Akalitus on Showtime’s “Nurse Jackie.” Bur her seminal work has been in the theater, in two groundbreaking plays early in her career: “Twilight Los Angeles” and “Fires in the Mirror.” Her last theatrical piece, “Let Me Down Easy,” was a paean to the human body in its strength and fragility.

There are few actors who get into and under the skin of their characters more acutely than Anna. We thought it would be interesting (and different) for this issue of the magazine, which focuses on skin diseases, to talk with Anna and get another sort of take on skin. “In the early part of my career [my skin color] was a big stumbling block,” she told me. “There were stereotypes. As a woman, if you didn’t fit into the idea of a tragic mulatto or mammy it was really hard to situate yourself.”

Read on in the Q&A.

Previously: This summer’s Stanford Medicine magazine shows some skin and Let me down easy: A conversation with Anna Deavere Smith
Illustration by Tina Berning

Emergency Medicine, Ethics, Global Health, Medicine and Society, Patient Care

After Haiyan: Stanford med student makes film about post-typhoon Philippines

After Haiyan: Stanford med student makes film about post-typhoon Philippines

Multi-talented Stanford Medicine student Michael Nedelman has been featured on Scope before for his filmmaking and storytelling abilities. His new film, “After Haiyan: Health narratives in the aftermath of the typhoon,” is a series of vignettes about the November 2013 disaster in the Philippines. The film, which will be released soon, connects socioeconomic and structural issues of access to health in times of crisis.

It was filmed primarily in Tacloban, Leyte, in July and August of 2014, and Nedelman made a follow-up visit in November and December to premiere and promote the project. Despite his busy end-of-school-year schedule, Nedelman answered some questions for me about his work in a recent email exchange.

What was it like filming in the wake of a tragedy? 

Phil Delrosario said it best. He’s the cinematographer and editor I met here at Stanford. Knowing when to turn on the camera was a “huge balancing act” between our drive to document the truth, and our obligation to be compassionate storytellers. We couldn’t ignore the emotional weight of Typhoon Haiyan, and we couldn’t ignore the fact that we weren’t part of the communities we were documenting. So we sought out people who not only wanted to share their stories with us, but who could also provide some insight as to how they wanted those stories to be seen… For one of the videos, Deaf advocates like Noemi Pamintuan-Jara reached out to us first, not the other way around… That was really special for us, to be able to work alongside a community that has been promoting Deaf accessibility and culture long before we ever arrived on the scene. And we had these new partners who could give meaningful feedback on our filmmaking decisions.

Filming in the wake of a tragedy doesn’t mean everything is tragic. The shadow of Haiyan is still there, but there’s also a sense of living in the moment and moving forward. All over the city, you’ll see posters and graffiti that say, “Tindog Tacloban!” (“Rise Tacloban!”) That’s something that really resonated with our team and the ethos of our project. You can’t tell the full story of Tacloban without optimism and resilience.

How does this film link storytelling and health, and what is special about that for you?

When I was first discussing the project with one of the producers, Roxanne Paredes, we asked ourselves a similar question: How would our project add to or nuance the coverage of the typhoon? Right after the storm, Haiyan was all over the news. Tacloban was in survival mode. But months later, after many of those cameras had left, there was a different set of long-term challenges and a focus on recovery. Those were the issues we wanted to explore, which tend to be less covered by the media but still have profound implications for community health and future disaster preparedness. In short, just because the cameras stopped rolling doesn’t mean there weren’t more stories to tell. That really broadened the way in which I think of health stories.

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Health Policy, In the News, Medicine and Society, Public Health

On King v. Burwell and the survival of the Affordable Care Act (and an unexpected birthday present)

On King v. Burwell and the survival of the Affordable Care Act (and an unexpected birthday present)

5362318849_dd1527d632_zToday is my birthday – and the Supreme Court (or, at least, two-thirds of it) just gave me, most people who follow health policy, and millions of now still-insured Americans a present: King v. Burwell.

There’s a lot to say about this decision, but I want to focus on three things: the strength of the conflicting substantive arguments, the possible internal Court dynamics that resulted in the majority and dissenting opinion, and a guess at some deeper meanings of the case for the future of health care in America.

On the substance, this is a case that really could have gone either way. The idea that the Court should apply the words as written, no matter how silly, has precedent in the Court’s history; so does the idea that the Court should try to interpret laws in ways that make them work as intended. The majority — at the end, Chief Justice John Roberts’s opinion — does recognize this conflict; the dissent, from the more textualist end of the Court, rejects the idea of a tension. The majority has it right in the sense that sometimes the Court applies the words as written, sometimes it requires interpretation, and that both are legitimate responses to cases – both are within the culture of legal interpretation that the Court has included over the last two-and-a-quarter centuries.

I do think the Court could have legitimately gone the other way, though I think it would have been foolish and harmful, to the country and even to the conservatives who will now bemoan this outcome. I am glad they did not. I prefer judges who try, when the law – or more accurately its interpretative culture – will allow them to, to make things work in a sensible way. The dissent’s position would have upended a major government program and harmed millions of people for a technicality – like a ticky-tack penalty or foul call deciding the Super Bowl or the World Cup. The Court could have done that, but it would have been wrong.

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Health Policy, In the News, Medicine and Society, Public Health

Supreme Court upholds Affordable Care Act with a 6-3 vote

Supreme Court upholds Affordable Care Act with a 6-3 vote

Supreme Court picUpdated 4:07 PM: “Obamacare lives to fight another day,” writes David Studdert, ScD, a core faculty member at CHP/PCOR and an expert in health law, in a Stanford Law School blog post. In his piece, he offers more legal details of the ruling.

***

Updated 1:51 PM: Stanford law professor Hank Greely, JD, has this to say:

Today is my birthday – and the Supreme Court (or, at least, two-thirds of it) just gave me, most people who follow health policy, and millions of now still-insured Americans a present: King v. Burwell

I do think the Court could have legitimately gone the other way, though I think it would have been foolish and harmful to the country and even to the conservatives who will now bemoan this outcome. I am glad they did not. I prefer judges who try, when the law – or more accurately its interpretative culture – will allow them to, to make things work in a sensible way. The dissent’s position would have upended a major government program and harmed millions of people for a technicality – like a… foul call deciding the Super Bowl or the World Cup.  The Court could have done that, but it would have been wrong…

What does it mean about the future of Obamacare? Well, I think it means the Supreme Court is done with it, at least with its fundamental, life or death issues.

Greely will expand on these thoughts in a longer piece on Scope later today.

***

Updated 12:45: Mello goes into detail on the ruling in a just-published Stanford Law School blog post.

***

Updated 11:51 AM: Stanford’s Laurence Baker, PhD, who has done extensive research on the economic performance of the U.S. health-care system, has also weighed in, saying, “This ruling, affirming the intent of the Affordable Care Act, is a relief for millions of Americans who have gained coverage under the law. It also provides important stability for insurers and the health-care system more broadly, avoiding what would have been tumultuous disruption in health-insurance markets in many states. We can now turn full attention back to the important work of improving health-insurance markets and expanding coverage, from which this court case was such a distraction.”

***

Updated 11:04 AM: Some thoughts now from Stanford health economist Jay Bhattacharya, MD, PhD, a core faculty member at the Center for Health Policy and the Center for Primary Care and Outcomes Research (CHP/PCOR):

Today’s Supreme Court ruling preserves the Obama administration’s implementation of the ACA’s subsidy scheme to all qualified people (between 133 and 400 percent of the poverty line). The Supreme Court essentially ruled for the status quo.

Had the plaintiffs won the case, such subsidies would only have been legal in states, like California, that have established their own insurance exchange (or marketplace). The immediate effect of the ruling, then, would have been to eliminate federal subsidies for the people living in states without a state-established insurance exchange. Families with income between 133 and 400 percentof the poverty line in such states who purchased their insurance through a federally-established exchange would have had to pay the full costs of their insurance premiums. This would have made insurance unaffordable for many of these families.

The ruling would not have directly affected people who get insurance through their employers or through the government in some other way, such as through Medicare (health insurance for the elderly and disabled) or through Medicaid (health insurance for the poor).

It is difficult to imagine, had the ruling gone the other way, that it would be a stable political equilibrium for people in one state to be eligible for federal subsidies, while similar people in another state to be not eligible. There would have been a lot of pressure on Democrats and Republicans at both state and federal levels to reform Obamacare, and either reestablish the subsidies or make some other arrangement to make insurance affordable. With the Supreme Court ruling the way it did, there will be substantially less impetus or desire for the reform of Obamacare, especially on the Democratic side.

***

Updated 10:45 AM: Stanford’s Michelle Mello, JD, PhD, professor of law and of health research and policy, has just provided her insight on the ruling, which she said offered strong claims by both sides:

The Court was profoundly influenced by its desire to avoid an interpretation of the law that would defeat Congress’s purpose in passing it. That purpose was to create a functional market through which individuals could buy insurance… The Court found it “implausible” that Congress intended for States that opted not to set up their own Exchanges to suffer the foreseeable, well-understood consequence of a “death spiral.”

The spiral occurs because without the tax credits, a very large proportion of the people who would otherwise be required to buy insurance get exempted from the individual mandate because the insurance cost exceeds a set amount of their income. That means too few people — and in particular, too few healthy people — buying insurance now… People know they can buy insurance later when they get sick. Their decisions to do so push premiums up for everyone, and the adverse selection makes the market unsustainable…

The trio writing in dissent could hardly have shown greater disgust with the majority’s approach. They disputed the majority’s threshold claim that the four little words were ambiguous — and everything that followed from it. The length and complexity of the majority’s justification for its holding, they claimed, is just proof that (once again) the justices are contorting the law in order to achieve a political objective — upholding the Affordable Care Act…

But on balance, I think the majority got it right in pointing to the well-understood consequences of withholding tax credits as evidence that Congress didn’t intend the reading the challengers urged. The decision is on firm legal ground, and to public-health advocates, is an enormous relief.

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Medical Education, Medical Schools, Medicine and Society, Stanford News, Surgery

How two women from different worlds are changing the face of surgery

How two women from different worlds are changing the face of surgery

IMG_1038“I hope you’re not serious about doing something in medicine.”

These words are all too familiar to Annete Bongiwe Moyo, a senior medical student at the University of Zimbabwe College of Health Sciences in Harare, Zimbabwe, and a former Stanford visiting scholar. In Zimbabwe, where the proportion of men to women in medical school is roughly 3:1, women are encouraged to take up professions as teachers, artists, caregivers – not doctors. And for a woman thinking about becoming a surgeon, well, she might as well keep dreaming.

Though the odds were stacked against her, Moyo made the decision to become a doctor at a very young age. But it wasn’t until she met Stanford surgeon Sherry Wren, MD, that she started to believe that becoming a surgeon was a realistic goal.

The outlook for women in surgery in Zimbabwe is not terribly unlike that in the U.S. when Wren began her residency at Yale University almost 30 years ago. After receiving her medical degree from Loyola University, Wren became the first woman from the university to specialize in surgery. At that time, only 12 percent of surgical residents were women, and the number of women surgeons in the workforce was far less.

But Wren has never let her womanhood hold her back. In fact, her powerhouse personality, fearlessness and passion for her work are the very traits that define her. She has worked all over the world, applying her skill and resourcefulness to provide the best possible care, often with extremely limited resources in remote locations. In many of these places, Wren is often the first woman surgeon anyone has ever seen.

Shocked too was Moyo when Wren appeared on her surgery rotation at the University of Zimbabwe two years ago. Here’s how Moyo recalls their first encounter – one that would have a lasting impact:

[Wren] was a visiting professor in a grand rounds. Medical students are not usually invited to grand rounds, but that day, we were permitted to attend. When the presentation was done, she asked a question, and when she looked my way, she could tell I knew the answer. She called on me, but one of my professors said ‘Wait, she’s a third year student, she may not know what you’re talking about.’ But Prof. Wren insisted, and I answered correctly. So she asked another question, and I got it right. And then another, and I got it right again.

The mood had shifted in the room. No one expected a junior female medical student could be capable of such an eloquent response. No one had ever given her the chance.

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Medical Education, Medical Schools, Medicine and Society, Research, SMS Unplugged

Research in medical school: The need to align incentives with value (part 3)

Research in medical school: The need to align incentives with value (part 3)

SMS (“Stanford Medical School”) 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 SMS Unplugged category.

This is the final post in a three-part series on research in medical school. Parts one and two are available here.

confusion-311388_1280In my last two posts, I explored the research paradigm of American medical training. The takeaway was that research requirements may create inefficiencies that have a host of consequences, including an unnecessarily long training process, a potential physician shortage, and an underutilization of talent.

In this post, I’ll lay out a vision for a training process that can produce a more effective physician workforce. The role of a physician has changed over time, and the education system must evolve to keep up. I’ll consider three topics: what students should get out of medical training, how schools and residency programs can help them do it, and how the system at large can enable schools to make changes.

What should students get out of medical training?

First and foremost, medical training should produce doctors who have a strong understanding of human health and disease and have the clinical skills to translate that understanding into patient care. The goal should be to produce good clinicians – that’s what the vast majority of doctors will focus on in their careers.

With that said, I accept the premise that medical training is not exclusively about clinical skills. Physicians are bright, capable individuals, and are uniquely positioned to improve the health status of their patients by other means. Schools should empower their students to pursue those opportunities. For the reasons I discussed in my last post, medical schools have decided that the primary way to do that is through research.

Research is one way to push extraordinarily important advances in medicine, but it isn’t the only way. Doctors can also improve their patients’ health by taking on roles in community health, policy, entrepreneurship or management, among others. These involve many of the same skills and techniques as research, but medical trainees don’t get exposed to these opportunities. We should.

How can schools fulfill this mission?

So how can the education system make this happen? At some point, whether it is in college or medical school, students should be given the flexibility to explore multiple domains of medicine and health care. They should then be able to pick the one or two that fit their interests and pursue them in more depth. Many students will choose to do research, while others will select other specialties. If students explore these opportunities and decide that they would rather focus on being an excellent clinician, that should also be doable.

This would allow physicians to become more effective leaders and decision-makers in the health care system. The traditional training process treats medicine as a universe of clinical practice and research, but the physician workforce has unfulfilled potential across a spectrum of other fields.

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