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CDC, Complementary Medicine, Medicine and Society, NIH, Podcasts

Podcast explores Americans’ use of complementary medicine

Podcast explores Americans' use of complementary medicine

5007651053_935ec0fd58_zDo you do yoga, take probiotics, see a chiropractor, or follow a special diet? If so, you’re not alone; roughly 34 percent of Americans make use of complementary therapies, and these are among the most popular ways to do so.

You may have read about the CDC report (.pdf) that came out last month and showed the prevalence of complementary medical approaches among American adults. For more, check out this podcast from The Lancet, during which Josephine Briggs, MD, director of the National Center for Complementary and Integrative Health (NCCIH), and Richard Nahin, PhD, MPH, NCCIH’s lead epidemiologist, discuss the major findings of the report and some of the potential implications for public policy.

Previously: Study shows complementary medicine use high among children with chronic health conditions, More hospitals offering complementary medicine, Older adults increasingly turning to complementary medicine and Americans’ use of complementary medicine on the rise
Photo by lyn tally

Events, Medicine and Society, Patient Care, Stanford News

Author-physician Atul Gawande on dying and end-of-life care

Author-physician Atul Gawande on dying and end-of-life care

Dr Atul Gawande, MD, MPH, Professor, Department of Health Policy and Management Harvard School of Public Health Harvard Medical School, gives a lecture ?Being Mortal: Medicine and What Matters in the End? on Monday, March 2, 2015, at Cynthia and Alexander Tseng, Jr., MD, Memorial Lectureship at Berg Hall Li Ka Shing Learning and Knowledge Center at Stanford School of Medicine . ( Norbert von der Groeben/ Stanford School of Medicine )When Atul Gawande, MD, MPH, witnessed the untimely and inevitable passing of patients, friends and his father, the shortcomings of our medical system’s approach to dying were revealed to him. As the noted author and surgeon told an overflow crowd at Stanford’s medical school earlier this week, he became inspired to “pick up my journalist’s pen” and explore questions about life and mortality that his elite medical education hadn’t equipped him to remedy.

Headlining the eighth annual Cynthia and Alexander Tseng, Jr., MD, Memorial Lecture, the former Stanford undergrad introduced his talk on end-of-life issues with the observation that begins his New York Times #1 book, Being Mortal: “I learned about a lot of things in medical school, but mortality wasn’t one of them.”

In a highly personal, and at times moving, talk, Gawande went on to discuss how decades of modern medical advances have changed our attitudes about dying and death. As fewer diseases and injuries pose life-threatening risks due to vastly improved medications and therapies, people simply expect to live longer. Well-being has become synonymous with longer and more robust life, supported at every stage by effective medical interventions, including a growing market of “lifestyle” rather than life-saving treatments.

Gawande argued that while health and medicine advances are of course positive, one consequence is that we have “medicalized our mortality” to the point where even terminally ill patients and their families look to their doctors for life-saving answers.

“Well, I didn’t [have the answers],” Gawande said.

Gawande said that medicine’s typical approach is to trade time and quality of life in the short term for longer life in the future, but the trade-off isn’t always a good one. For example, aggressive cancer treatment can be debilitating and painful, and often fails to prolong life, merely making the end of life miserable for patients.

In contrast, the goal of palliative care is to create the best possible day for patients today, regardless of what it means for the future. Studies show that for terminally ill patients palliative care improves quality of life, including people’s sense of control and empowerment over their lives. While these positive attitudes may be expected, palliative care practices reduce unwanted medical procedures (as well as costs) and have been shown to actually increase life span – by 25 percent in one study of late-stage lung cancer patients.

“If palliative doctors were a drug, the FDA would approve them,” Gawande told the audience.

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

Engaging with art to improve clinical skills

Engaging with art to improve clinical skills

med students looking at paintingThe scene: A group of medical students huddled around the iconic Robert Frank photograph Car Accident – U.S. 66, Between Winslow and Flagstaff, Arizona in the Cantor Center for the Visual Arts. They’re being led through an observation exercise by Sarah Naftalis, a doctoral student in art and art history at Stanford, as part of an innovative new medical school course supported by the Bioethics and Medical Humanities Scholarly Concentration.

Naftalis asks students what they see as she gestures to the photograph, which appears to have as its focal point four people standing out in a field, looking at something under a blanket on the ground. Several students note the people, the odd lumpiness of the blanket and the reduced horizon. Second year medical student Sam Cartmell says, “Well there may be more than four people,” and points to an odd contour at the shoulder of the lone female in the photograph. Cartmell’s observation sparks a lively debate, as his fellow students take turns looking closely at the work, seeking to discern what Cartmell has seen.

The concept behind this class is so important. If medical students can grasp these observation skills, it will really serve them well in their residencies and beyond.

That moment, explains Naftalis, illustrates the “productive ambiguities of art,” as well as the benefit of engaged close looking without “rushing to assign meaning to what we see.”

The practice of engaged close looking as a means to improve observational skills is a key goal of the course, which includes gallery sessions facilitated by doctoral students from the Department of Art and Art History at Stanford paired with a clinical correlate hour where School of Medicine faculty members applied the lessons of the art gallery portion to the clinical setting. Physicians from family medicine, orthopedics, dermatology, pathology and anesthesiology led discussions on a range of topics including narrative, body in motion, skin and tone, and death.

“The thematic organization was meant to inspire conversation across disciplines, by putting two takes on a similar theme in proximity to each other for two hours,” explains art history doctoral student Yinshi Lerman-Tan, who helped develop the course. “Bringing medicine into the space of the museum was a great aspect of the course – simply allowing different bodies of knowledge to exist under one roof. The medical students would sometimes use clinical vocabulary or concepts to describe works in the gallery, making for an interesting range of language in our discussions.”

Cartmell said one important take away for him from the course, which is called “The Art of Observation: Enhancing Clinical Skills Through Visual Analysis,” was learning to observe without jumping to interpretation. “I was surprised at how strong the impulse was to interpret the work, before I had actually observed the entire piece,” he says. The exercises the instructors led us through, describing what we saw objectively without commentary, really forced me to slow down and really see what was in front of me, without jumping to conclusions or interpretation.”

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Emergency Medicine, Medicine and Society, Patient Care, Public Safety, Stanford News

A young child, a falling cabinet, and a Life Flight rescue

A young child, a falling cabinet, and a Life Flight rescue

ticktockLife in the air rescue business is highly unpredictable. You can spend many hours idling away the time in an obscure, basement office. But when an emergency call comes, you literally don’t have a second to grab a pen on the way out the door.

So it was on one November day, when I did a ride-along with Stanford’s illustrious Life Flight air ambulance service, the oldest in California. The team graciously agreed to let me accompany them on a flight for a story for Stanford Medicine magazine, whose current issue is focused on the role of time in medicine. Life Flight, I figured, would give me a sense of the split-second timing that can sometimes make a difference between life and death in an emergency situation. I was scheduled to fly with the crew in late October, but instead I spent that day learning about the service in what proved to be a leisurely day with no calls.

On my second ride-along day, it appeared that history was about to repeat itself when, just as my shift was about to end, the emergency call came in at 3:39 p.m. I became an eye witness to the rescue of a toddler who suffered a serious head injury when a heavy, ill-secured cabinet at her preschool crashed down on her head during naptime. The story was so dramatic that it made the local news. The school was shut down several days later by local officials because of code violations.

Things could have gone poorly for little Aeshna, the 3-year-old victim of the accident, who was left dazed, not fully conscious and vomiting as a result of her injury – clear signs of head trauma. She could have suffered significant bleeding in the brain and permanent brain damage – a prospect that was a major concern for her parents and caregivers.

The two Life Flight nurses, who have a breathtaking array of skills, and their veteran U.S. Navy pilot made it to the scene at the Fremont, Ca. preschool across the bay within 23 minutes of the call and were able to bring Aeshna back to Stanford for quick assessment and treatment.

You can read the minute-by-minute scenario of Aeshna’s rescue in the the magazine, which came out last week.

Previously: Stanford Medicine magazine reports on time’s intersection with health, Comparing the cost-effectiveness of helicopter transport and ambulances for trauma victims, Stanford Life Flight celebrates 30 years and Ask Stanford Med: Answers to your questions about wildnerness medicine
Illustration by Lincoln Agnew

Genetics, In the News, LGBT, Medicine and Society, Research, Sexual Health

Sex biology redefined: Genes don’t indicate binary sexes

Sex biology redefined: Genes don't indicate binary sexes

14614853884_3d6d1d662a_zImagine being a forty-six-year-old woman pregnant with her third child, whose amniocentesis follow-up shows that half her cells carry male chromosomes. Or a seventy-year-old father of three who learns during a hernia repair that he has a uterus. A recent news feature in Nature mentioned these cases as it elaborated on the spectrum of sex biology. People can be sexed in a non-straightforward way and not even be aware of it; in fact, most probably aren’t. As many as 1 person in 100 has some form of “DSD,” a difference/disorder of sex development.

The simple scenario many of us learned in school is that two X chromosomes make someone female, and an X and a Y chromosome make someone male. These are simplistic ways of thinking about what is scientifically very complex. Anatomy, hormones, cells, and chromosomes (not to mention personal identity convictions) are actually not usually aligned with one binary classification.

The Nature feature collects research that has changed the way biologists understand sex. New technologies in DNA sequencing and cell biology are revealing that chromosomal sex is a process, not an assignation.

As quoted in the article, Eric Vilain, MD, PhD, director of the Center for Gender-Based Biology at UCLA, explains that sex determination is a contest between two opposing networks of gene activity. Changes in the activity or amounts of molecules in the networks can sway the embryo towards or away from the sex seemingly spelled out by the chromosomes. “It has been, in a sense, a philosophical change in our way of looking at sex; that it’s a balance.”

What’s more, studies in mice are showing that the balance of sex manifestation can be shifted even after birth; in fact, it is something actively maintained during the mouse’s whole life.

According to the Nature feature, true intersex disorders, such as those from divergent genes or the inability of cellular receptors to respond to hormones, yield conflicting chromosomal and anatomical sex. But these are rare, about 1 in 4,500. For the 1/100 figure, they used a more inclusive definition of DSDs. More than 25 genes that affect sex development have now been identified, and they have a wide range of variations that affect people in subtle ways. Many differences aren’t even noticed until incidental medical encounters, such as in the opening scenarios (the first was probably caused by twin embryos fusing in the woman’s mother’s womb; the second by a hormonal disorder).

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Genetics, In the News, Medicine and Society, Research, Science, Technology

A leader in the Human Genome Project shares tale of personalized medicine, from 1980 until today

A leader in the Human Genome Project shares tale of personalized medicine, from 1980 until today

2559447601_005b33ae7d_zEric Lander, PhD, warned the several hundred people who came to hear him speak on the Stanford campus earlier this week that he wasn’t giving a traditional data-packed scientific presentation.

Instead, the founding director of the Broad Institute and veteran of the Human Genome Project — who Google’s Eric Schmidt introduced — promised to tell a story, a yarn about, as he put, the biomedicine of the East Coast meeting the technological innovation of the West Coast. (He couched the statement and admitted that yes, the West Coast does have a bit of biomedicine.)

So here goes:

Once upon a time, 35 years ago, in a land ruled by punk rock and big hair, scientists worked hard to pinpoint the genetic cause of cystic fibrosis, a disease caused by a single mutation. It was slow, hard work, but they persevered and found the gene.

Wouldn’t it be wonderful to know all the human genes, some scientists speculated, buoyed by their preliminary success. Cancer could be vanquished. Genetic disorders a thing of the past. But getting to that point might take as long as 2,000 years.

Enter the Human Genome Project (HGP) in 1990. A collaborative effort of 16 research centers in six countries, the team “industrialized biology,” cranking out a code for the 3 billion base pairs that make up the human genome.

Of equal importance, the HGP was advocating the importance of public access to genetic material. It faced a challenge from a rival private company, Celera, who proposed creating a subscription database with the genetic information.

The HGP also had to contend with hype, Lander said: With a banner-headline, the New York Times had proclaimed in 2000 “Genetic code of human life is cracked by scientists.”

But really, the scientists had little more than a gigantic text — ATCGGCTATATAATCG — that Lander likened to the Rosetta Stone. By comparing it with the genomes of mice, dogs, rats, cats, dolphins and many other critters, scientists worldwide were able to decipher it piece by piece.

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Events, In the News, Medicine and Society, Stanford News

Panel on diversity calls for transformative change in society, courageous leadership from individuals

Panel on diversity calls for transformative change in society, courageous leadership from individuals

diversity-33606_1280The School of Medicine’s quest to boost all forms diversity stems from two distinct, yet related, imperatives, Dean Lloyd B. Minor, MD, told the 100-or-so students and faculty members at the second Town Hall on Diversity last evening.

First, it’s part of the school’s mission, Minor said. “We have an obligation, a responsibility to ensuring we’re promoting diversity in our society,” Minor said. “We do that through the students we admit, the faculty we hire, to the way we speak.”

But of equal importance: Without diversity, Stanford Medicine just wouldn’t be Stanford Medicine, Minor said.

“Imagine what we would be like if we had a group of monolithically thinking people,” he said. From a melting pot of backgrounds and opinions and personalities comes innovation, challenges and excellence.

To ensure this melting pot, Stanford Medicine must stand strong against a society that is perhaps even regressing in its views on race and bias, said sociologist Doug McAdam, PhD, one of two panelists who fielded questions from the audience and moderators Malcolm Pyles, president of Student University Minority Medical Alliance, and Julie Huang, president Biomedical Association for the Interest of Minority Students.

Everyone who hopes to make a change must leave their comfort zone, McAdam said. “These are not normal times,” McAdam  told the audience. “I think they call for us to step outside our [normal] roles.”

That means everyone must consider how they support — even through unconscious biases — the current system and take steps to counter it, he said.

Paula Moya, PhD, an associate professor of English, emphasized that the role of the university is different from the job of a budding researchers or doctor.

“The university has the obligation to make these topics of conversation,” she said. “Students have the responsibility to learn about history and how what you do on a daily basis affects the maintenance of pernicious ideas like race.”

Both panelists recently published books on race. McAdam is a co-author of Deeply Divided: Social Movements and Racial Politics in Post-War America, while Moya penned Doing Race: 21 Essays for the 21st Century and has another book coming out this year.

Previously: Intel’s Rosalind Hudnell kicks off Dean’s Lecture Series on diversity, The medical community and complicity: Our role in the Eric Garner case, Diversity is initial focus of new Stanford lecture seriesLloyd B. Minor, Stanford medical school’s dean, shares five principles of leadership and NIH selects Hannah Valantine as first chief officer for scientific workforce diversity
Photo by Nemo

Immunology, In the News, Medicine and Society, Pediatrics, Public Health, Stanford News

A discussion of vaccines, “the single most life-saving innovation ever in the history of medicine”

A discussion of vaccines, "the single most life-saving innovation ever in the history of medicine”

vaccine and syringeIn a recent, in-depth interview with KCBS Radio, now available online, Stanford immunologist Mark Davis, PhD, called vaccines “the single most life-saving medical innovation ever in the history of medicine” and called not vaccinating children a real danger.

Davis was interviewed on air for 30 minutes following the announcement that he’ll direct a new, $50-million initiative at Stanford, funded by the Bill & Melinda Gates Foundation, which aims to speed discovery of vaccines for some of the world’s deadliest infectious diseases, such as malaria, tuberculosis and HIV.

Davis, who directs the Stanford Institute for Immunity, Transplantation and Infection, harked back to the time when cemeteries were filled with the graves of young children who fell victim to diseases such as measles and mumps that were virtually wiped out with the advent of vaccines. In the pre-vaccine era, about half of all children died of infectious diseases that are readily preventable today, he noted.

“One day I wandered through Union Cemetery in Redwood City, which started around 1850,” he said. “What was telling about the earlier graves is how many graves you have where they are two large headstones for the mother and father and a lot of little headstones for the children who died in infancy from measles and mumps and all these diseases that had also vanished with childhood vaccination but that are now coming back because people say, ‘I’ve heard something bad about these vaccines. So we are not going to give them to our kid.’”

Parents who chose not to vaccinate their children “are putting your kid at risk and also putting other young children at risk, as children don’t get vaccinated for measles until they are one year old. So kids die. Older people – a population we study here at Stanford – don’t respond very well. Their immune system often deteriorates with age… So even if they had a measles shot in their youth, they might still be vulnerable. So if you don’t vaccinate your child, you are putting your kid at risk, anyone with an immune deficiency at risk, little babies at risk, old people at risk. It just shouldn’t be permitted.”

Measles, he noted, is a “very ambitious” virus that spreads through the air, surviving on droplets of water vapor, so coughing can readily spread the disease. As a matter of public health, the disease can be controlled through the principle of “herd immunity” – the idea that if most people are vaccinated, a disease will be less likely to move through the population, he said.

“So it’s not just about you and your child. It’s about society… If more and more people are not vaccinated, it gives a virus, like the measles virus, an opportunity to run through the population very quickly, which it does, and endanger many more people,” he told listeners.

As to whether California should require parents to vaccinate their children, Davis was adamant on the subject:

I wouldn’t want unvaccinated kids in a classroom with my kids. I think it’s a danger. These are decisions made by parents that could affect the health of their children for the rest of their lives… The government is totally correct to say you should not kill your child, you should not starve your child, you should not beat your child, and you should not deprive your child of vaccines.

Previously: With a Gates Foundation grant, Stanford launches major effort to expedite vaccine discovery, Infectious disease expert discusses concerns about undervaccination and California’s measles outbreak and Side effects of childhood vaccines are extremely rare, new study finds
Photo by NIH

Aging, Health Costs, Medicine and Society, Ophthalmology, Research, Stanford News

Factors driving prescription decisions for macular degeneration complex – and costly

Factors driving prescription decisions for macular degeneration complex - and costly

5197694152_fbbfe73c21_zFor the last decade or so of her life, my grandma was basically blind. Her eyes, like those of many seniors, suffered from macular degeneration, a progressive disorder that affects the macula, a small spot near center of the retina critical for clear vision.

She lived her last years in a nursing home in Iowa and I honestly don’t know what drugs, if any, she took for this condition, much less how much they cost.

But multiplied by millions (macular degeneration is the most common cause of visual impairment in older adults), the costs are a big deal. That’s why Stanford researchers set out to understand why doctors would prescribe one drug, ranibizumab (let’s call it r) at a cost of $2,000 a dose over bevacizumab (b), which runs $50 a dose.

They published their findings in Health Affairs today.

Both drugs are equally effective and have similarly severe side effects. And, according to a 2011 report, if all Medicare doctors had prescribed b rather than r in 2011, the system would have saved $1.1 billion.

Stanford researchers hypothesized that Medicare physicians — who face a financial incentive to prescribe more expensive drugs — would be more inclined to prescribe r than Veterans Affairs physicians, who don’t have the same incentive.

Instead, as health economist Kate Bundorf, PhD, told me, it’s much more complex.

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Health Costs, Medicine and Society, Medicine X, Technology

The power of social media: How one man uses it to help amputees get prosthetics

The power of social media: How one man uses it to help amputees get prosthetics

Stanford’s Medicine X is a catalyst for new ideas about the future of medicine and health care. This new series, called The Engaged Patient, provides a forum for some of the patients who have participated in or are affiliated with the program. The latest installment comes from Medicine X ePatient Joe Riffe.

Allie - smallWe’re all familiar with social media. We spend our days updating our Facebook statuses, tweeting our latest attempt at being funny, or using Instagram to show off our last meal. Social media is an excellent way to connect with friends and family; some people have even gained celebrity status all through the social-media movement. Social media has sparked revolutions as well. The Occupy Wall Street Movement, for example, was largely driven by the power of a hashtag.

This power is also accessible to patients to start a David versus Goliath type war. I use the power of social media to help amputees get prosthetics, and in this piece I’ll tell you two of these stories. The first is about Allie; the second is a recent story about my own battle to get a prosthetic.

I met Allie in the hospital after a mutual friend asked me to meet her and her family to show them that being an amputee doesn’t mean you can’t live the life you want to live. I immediately connected with Allie. I wanted to be her mentor; she the Luke to my Obi Wan. Allie didn’t have insurance at that time, and I couldn’t stand the thought of this young girl, just starting her life, not having access to the best prosthetics available. I explained to her that with the right prosthetic, anything is possible.

A local prosthetic company had gotten to Allie before the prosthetist I use was able to meet with her and her family. They convinced the family that due to Allie’s lack of insurance she would have to settle for the best prosthetic she could afford – and not the best available like she deserved. Allie suffered on this prosthetic for months. The ill-fitting socket and knee didn’t suit the lifestyle of an active 20-year old.

After nearly a year of suffering, Allie found herself with insurance and made her way to the prosthetist I use. He quickly saw the need for her to have access to the best technology available and had his team start creating a prosthetic for her.

There are many hoops to jump through when trying to get a prosthetic leg. The biggest obstacle is that advanced technology comes with a hefty price tag. Luckily, the office she goes to now knows how to get through these hoops fairly quickly.

Allie made it though this process fairly quickly and received a letter from her insurance company promising to pay for the advanced prosthetic. Then, they began the stall tactic. They waited months, delaying the payment required to order the prosthetic that Allie so desperately needed.

That was when I came in. With one tweet – just one tweet – I was able to expedite the payment for her prosthetic limb. Why does this company prevent amputees from returning to their lives by approving high-quality prosthetics then not paying for them, I wrote to my hundreds of followers. A few days later I was greeted on Facebook by the photo above: Allie with her new leg.

Unadulterated joy!

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