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Humor, In the News, Medical Education, Medicine and Literature, Medicine and Society, Patient Care

Graphic medicine takes flight

Empathy-Ian-Williams-510x438A recent blog post on Somatosphere sparked my interest in the role that comics can play in the study and delivery of healthcare, an emerging field called “graphic medicine.” The term was coined by UK-based Ian Williams, MD, who is an artist and independent humanities scholar as well as a physician. He recently launched a website of the same name.

The post introduces a few new books that just came out on the subject: Graphic Medicine Manifesto, a collaborative work by six healthcare professionals and humanities scholars, and Ian Williams’ The Bad Doctor. It also describes how comics can open us up to new ways of seeing in ways that text alone cannot:

Comics allow us to ask how we can “orient” ourselves… toward the potentiality of images and away from the systematizing effects of text alone… [Comics use] images and imagistic thinking as a way to see a different mode of existence.

Since it is an anthropology blog, it suggests that a “graphic medical anthropology” would be a great way to accomplish the anthropologist’s goal of “seeing structure, complexity, nuance, emergence, and multiplicity simultaneously.” We anthropologists often try to achieve this goal with complicated metaphors and theories, but perhaps the old adage about a picture being worth a thousand words holds true in this case.

The post notes that drawings can provide an experience of self-reflection for the artist, and can inspire readers to readily and easily respond with their own experience, making the work more of a dialog. They can introduce “theoretical orientations” in ways that are more accessible, and can expose power relations in ordinary lived experience. Ordinary lived experience is particularly well conveyed by comics; they showcase the mundane and make it meaningful. They can take those “ordinary, chronic and cruddy moments” and convey what it’s like to be part of our society.

Previously: Cancer Ninja fights patient misinformation, one cartoon at a time, Using graphic art to understand the emotional aspects of disease, A comic look at 12 medical specialties, Economist to explain health reform through graphic novel, and Webcomic xkcd gets medical
Illustration by Ian Williams, “Autography as Auto-Therapy: Psychic Pain and the Graphic Memoir.” Journal of Medical Humanities 2011, reposted from Somatosphere

Addiction, Emergency Medicine, Health Costs, Patient Care, Research

Questionnaire bests blood test at identifying patients with risky drinking behaviors

Questionnaire bests blood test at identifying patients with risky drinking behaviors

3144132736_9de39a590d_zAs many as half of the patients who visit the emergency room with traumatic injuries have alcohol in their bloodstream, and roughly 10 percent of these patients will return to the ER within a year. Today, many emergency rooms use blood alcohol tests to screen for patients with risky drinking behaviors. Yet a new study by researchers from Loyola University Medical Center suggests that a questionnaire may be a better way to identify at-risk patients.

In the study, researchers reviewed 222 records from patients 18 years of age and older that were admitted to Loyola University Medical Center’s level I trauma center between May 2013 and June 2014. Each of the patients in the study had a blood alcohol test and had answered the World Health Organization‘s 10-point questionnaire, called the Alcohol Use Disorders Identification Test (AUDIT). The research team compared the results of the blood test to that of the AUDIT test and found that the questionnaire was 20 percent more effective at identifying at-risk patients with dangerous drinking habits than the blood test.

As the researchers explain in their study, blood alcohol tests only provide “a snapshot of the patient’s recent drinking behaviors” by measuring of the amount of alcohol in the patient’s system at the instant the test is taken. In contrast, the questionnaire assesses the patient’s overall drinking behaviors by asking questions such as, how often they drink, how much they drink per day and if they have feelings of guilt or remorse after drinking.

These findings are significant because blood alcohol tests are often the only tool used to assess at-risk drinking behavior in ER patients. Their findings call this common practice into question and suggest that the AUDIT questionnaire may be a better way to identify, and ultimately prevent, potentially dangerous drinking behaviors.

Previously: Alcohol-use disorder can be inherited: But why?Could better alcohol screening during doctor visits reduce underage drinking? and How to make alcoholics in recovery feel welcome this holiday season
Via: Business Wire
Photo by: Julie °_°

Patient Care, Pregnancy, Women's Health

“The Mama Sherpas”: Exploring the work of nurse-midwives and their collaborations with doctors

"The Mama Sherpas": Exploring the work of nurse-midwives and their collaborations with doctors

baby feetAs a doula, I’m pretty tapped into the birth community, and I’ve definitely noticed a trend toward midwifery care and low-intervention births. Indeed, a 2012 study showed that more babies than ever before are being delivered by midwives.

Now, a new film is documenting how midwives and obstetricians are increasingly teaming up to offer great maternity care. “The Mama Sherpas,” directed by Brigid Maher and produced by Ricki Lake and Abby Epstein (the same people behind the well-known “The Business of Being Born“), showcases the growing popularity of Certified Nurse Midwives (CNMs) in hospital births.

CNMs are registered nurses who have a master’s degree in midwifery and who adhere to the “woman-centered” Midwives Model of Care. According to the film, collaborative care between CNMs and obstetricians can lead to decreased C-section rates, increased VBAC rates (vaginal birth after cesarean), far lower health-care costs, and mothers who are more satisfied with their birth experience.

I had the chance to attend an advance screening, sponsored by the Nurse-Midwives of Monterey Bay, last week, and I was particularly impressed by the footage of the births of the women chronicled. While highly graphic, it provided beautiful portraits of calm and powerful vaginal births, a life-saving caesarian, and even a vaginal breech birth – which I and many in the audience of birth workers had never seen before! Afterwards, the panel of CNMs and obstetricians from hospitals in Santa Cruz and Davis called for more obstetricians to be trained in vaginal delivery of breech births, and in turning breech babies by performing external versions, so that those options can be offered to women.

Previously: In poorest countries, increase in midwives could save lives of mothers and their babiesA reminder that prenatal care is key to a healthy pregnancyUnneeded cesareans are risky and expensive and Tensions high in debate over safety of home births
Photo by Bridget Colla

Patient Care, SMS Unplugged

An anthropologist on the wards

An anthropologist on the wards

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; the entire blog series can be found in the SMS Unplugged category.

As my third year of clinical rotations comes to an end, I’ve been reflecting on the ways in which I use my training as an anthropologist on the wards. One patient comes to mind, a recent immigrant from South Asia who came into the hospital after an accident where he was bicycling and got hit by a car. He was scanned from head to toe for any injuries, and though his bones were intact and organs whole, a few spots lit up on his chest imaging. Because he was uninsured and had a high risk of not following up, he was admitted for a few nights for a workup to rule out cancer.

His first night in the hospital, he lay in his bed, back aching where the blood had congealed, hunger gnawing at his belly. The nurse had handed him a meal card with the Stanford Hospital dining options — but he wouldn’t call to make his order. By the time I got to know him, he had already been in the hospital more than 24 hours without eating anything.

He felt that in being his advocate, I was an angel sent to take care of him. In reality I had played the role of the anthropologist…

I had the fortune of understanding one of the languages he spoke, and he started to tell me his story. Before me, various doctors had come and gone to ask him the details of the accident (How fast was he riding his bike? Was he wearing a helmet?), and he had answered them in broken English, anxiously. It was only by speaking with him in Hindi that I understood his deep financial fears. He was worried that he would be held at fault for the accident, although it was the automobile driver who had hit his bike. He didn’t understand why doctors were asking so many questions instead of examining and treating him. And, he refused to eat because he was terrified that he would be charged an exorbitant price for the food, when he could not afford to pay for this hospitalization at all.

I clarified that either way he would not be made to pay. Stanford Hospital had options in place for those who could not immediately cover their medical bills. And besides, the food came with the cost of admission — if he did get charged for his stay, the food would be included in that price whether he ate or not. He agreed to have a chicken and rice bowl with some fruit, and fell into a fitful sleep.

The next day we talked more. His back still emitted a dull throb, but otherwise he felt fine. “But what about those lesions they saw?” he asked me. “Am I going to die?” He put his rough hand on mine and started to cry. He explained that his wife and child were back home. He was a policeman in his home country. He had come here a few years ago to earn money, and worked long hours at a gas station — often through the night. He worried about his safety. Every screech, every car that slid up while he was on his shift, set his nerves alight.

I asked him if he had a chance to speak with his wife, and he said he was afraid because he didn’t know how to explain what was happening to him.

At rounds, we discussed this patient as our mystery case: mediastinal lymph nodes on chest CT in a previously healthy male who lived abroad. Could this be reactive tuberculosis? Lymphoma? We stood in a circle outside his room, throwing around diagnostic options, citing papers, making a list of tests to order and consultants with whom to confer. All of this without needing to see his face.

Another day passed. When I saw him again, he had moved to a positive pressure isolation room, behind two sets of doors, and nurses went in and out wearing thick blue masks. When I walked in to see him, also wearing the mask, he looked tense. “Why am I in here?” he asked.

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Events, Global Health, Haiti, Medicine and Literature, Patient Care, Stanford News

Physician writers share a “global perspective on healing”

Physician writers share a "global perspective on healing"

6319607736_156bcef31e_zWhen I saw that an event called “Medicine Around the World: Healing from a Global Perspective” was taking place on campus, I thought it would be right up my alley as a medical anthropologist.

The event, sponsored by Stanford’s Medicine and the Muse program and the Pegasus Physician Writers group, was a reading in which physicians shared some beautiful pieces they had written about their experiences providing medical services across the globe, including Haiti, Mexico, Austria, and Vietnam. The musings were less about culture than they were about poverty, conflict, disasters, and war, and what it’s like to seek health and healing in such overwhelming circumstances.

All five physicians’ writings brought to life a difficult scene. Julia Huemer, MD, a child and adolescent psychiatrist, wrote an aching piece about interviewing a young Somalian refugee in an Austrian winter just before Christmas. She conveys the utter incapacity of her survey to capture his experience, and an uneasy awareness that he is the one doing her a favor, indulging her intrusion. Here is a teenager too childlike to carry the weight of adulthood, yet who carries it with more grounded grace than many adults. Her holiday, once marked by stressful emptiness, is not transformed in any heartwarming sense, but at least becomes more heavy, more real.

Ali Tahvildari, MD, a radiologist, composed a “Ghazal for Global Health,” a poetic form used to convey love, loss, and longing, in this case pleading for the privileged to care about foreign suffering. Mali Mann, MD, a psychiatrist, chronicled her experience being one of “los medicos volodores” who fly to Mexico, where she works with orphaned children suffering severe emotional traumas. Henry Ward Trueblood, MD, a trauma surgeon, read an excerpt from his forthcoming book about being a surgeon in Vietnam during the war, where he worked in a tragically understaffed civilian hospital. The extreme environment pushed him to test the limits of his surgical competence, which both challenged him to grow and taught him to respect his own limits when he was way out of his league.

The piece that brought in the most “culture” in a classic anthropological sense was that of William Meffert, MD, a cardiovascular surgeon who read a fictional account of being trapped in a collapsed building in Haiti while on a medical mission after the earthquake. In it, he grappled with how religion – a Haitian mix of voodoo and Catholicism – played a vital role in the life of his assistant. As an atheist, the protagonist vacillated between being baffled, annoyed, and comforted in a way he couldn’t quite grasp; in a way that circled between dream and reality, the supernatural was a means toward healing.

Previously: Stanford doctor-author bring historic figure Jonas Salk to life, Stanford med student chronicles his experiences working in rural Kenya, Surgeon-author: “My intent is to let people know that the person next door could be intersex”, “Write what you know”: Anesthesiologist-author Rick Novak discusses his debut novel, For a group of Stanford doctors, writing helps them “make sense” of their experiences, and Exploring global health through historical literature
Photo by Hanna Sorensson

Chronic Disease, Patient Care, Pediatrics

On growing up with chronic illness: “I’ve never felt like I had ownership over my body”

We’ve partnered with Inspire, a company that builds and manages online support communities for patients and caregivers, to launch a patient-focused series here on Scope. Once a month, patients affected by serious and often rare diseases share their unique stories; this month’s column comes from a patient with Crohn’s disease.

woman-body-144220_1280

As a child who was diagnosed with Crohn’s disease at the age of nine, I learned to give my power over to my doctors and parents. I never questioned the constant prodding, the pain that I had to endure from different tests and exams, the dozen pills that I swallowed down each day, because after all, I was to trust doctors and adults. They knew what was best for me. They knew what was best for my body. And of course, this is true – but only to an extent. Please hear me out.

In no way am I undermining the miraculous work that medical professionals do each and every day. I am beyond grateful for the way that my disease was handled, I was given a fairly normal childhood because of the way my medical team was able to manage my disease. And on top of that, I have the most incredible parents who handled my disease beautifully; they allowed me to feel supported, loved and taken care of. Honestly, I just had to show up for doctor appointments, swallow pills, and be a kid. I left the details up to the adults.

But then I started growing up. High school, boys, and school dances became my new normal. I lost my power at the age of 17 when I was date raped. Although I attempted to say “no” and stick up for myself, I ultimately didn’t know how to confidently do this. I didn’t know how to command respect because I was so used to never being asked to say “yes.” Unfortunately, this situation snowballed into another date rape and ultimately a suicide attempt. I truly felt detached from my body. It wasn’t mine. I didn’t know how to handle it. I despised it. It was the source of so much pain. And so, I wanted to leave it.

I never connected my inability to stick up for myself with being a child of chronic disease until the last couple of years. As I reflect back, the correlation is so clear. I never was taught to question what my doctors did to my body. I cannot recall being asked if it was “okay” to be examined or to be touched. If I was in a doctor’s office, it was just assumed and expected. To be clear: There was absolutely never anything inappropriate that happened to me in my doctors’ care. I think the only reason that the perceived lack of power on my side affected me is because I was a child, and I didn’t have the capability to differentiate the way I handled my body in the care of a doctor versus the hands of a teenage boy.

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Behavioral Science, Men's Health, Patient Care, Public Health, Stanford News

How can we get men to take better care of themselves?

How can we get men to take better care of themselves?

7206160814_dca6203a04_zFirst, I tried asking. Sprinkling little reminders, jokingly throughout the day. Then I started lecturing. Now, more than a month into my get-my-husband-to-the-dentist campaign, I’ve moved on to heckling, grilling, guilt-tripping and bargaining. I’m not too proud to beg.

I’ll bet my efforts sound familiar to men’s health expert Donnovan Somera Yisrael, MA. He’s a wellness educator at Stanford’s Vaden Health Center and he manages sexual and emotional health programs, often focusing on preventing or curbing risky behavior. And not going to the dentist, when you have an obvious tooth problem, counts as risky in my book.

Yisrael recently sat down for a Q&A with BeWell@Stanford to discuss his work with men. And his first sentence solidly supports my case: “I believe that the phenomenon of men neglecting their health generally as compared with women has been solidly established.” Uh, huh! And he has a few ideas about why that is:

Over the years, as I’ve dug deeper into “why people do risky things,” it has become evident that culture (broadly defined) is a huge factor in these risky behaviors, and in turn gender roles/stereotypes play powerful roles in the culture that influences our behavior.  Whether we are talking about wearing sunscreen, body image/eating disorders, alcohol/drug abuse or sexual/relationship violence, gender “rules” play a major role.

I’m up against a tough foe and eager for tips. The BeWell interviewer read my mind by asking how we can encourage the men in our lives to take better care of themselves. Yisrael’s response:

Men need to be persuaded and educated that in order to best maintain health, they must find a healthy way of asking for help. They must pursue health maintenance and self-care without concern that doing so means they are weak or not “real men.”

We must work to challenge what it means to be a guy, boy, man, father, etc. in 2015 and beyond. This issue is dealt with so brilliantly in the film The Mask You Live In by Jennifer Siebel Newsom. I recommend it to everyone.

And, in the case of the dentist, I’ll keep cajoling and perhaps add a bit of gender messaging to my arsenal: Manly men visit the dentist regularly.

Previously: To live longer, men need to embrace their femininity, new research suggests, Sex matters: Why we shouldn’t conduct basic research without taking it into account and Examining how fathers’ postpartum depression affects toddlers 
Image by Christoph Weigel via Marcel Douwe Dekker

 

Health Policy, Mental Health, Patient Care, Pediatrics, Stanford News

Stanford expert on new treatment guidelines for teens’ eating disorders

Stanford expert on new treatment guidelines for teens' eating disorders

eatingdisorder-plateEating disorders often begin in the teenage years, but, surprisingly, the medical community long lacked a teen-specific set of guidelines for treating these serious illnesses.

That changed in May with the publication of a set of practice parameters co-authored by Stanford eating disorder expert James Lock, MD, PhD, who also directs the Comprehensive Eating Disorders Program at Lucile Packard Children’s Hospital Stanford. The parameters were based on an extensive review of the current scientific evidence around eating-disorder treatment, including recent studies by Lock and his colleagues that show that teens’ parents can play an active role in helping their children recover from anorexia nervosa. That’s a big shift from traditional thinking about eating disorders, which held that young patients’ families should be shut out of treatment.

In a new Q&A, I talked with Lock about why the parameters were needed. He told me:

There have never been practice parameters that address eating disorders in children and adolescents, and expertise in treating these disorders has been sort of sequestered. Yet eating disorders are so prevalent and are such a severe problem: Lifetime prevalence in adolescent girls is around 1 percent, and the disorders have among the highest fatality rates of all mental illnesses.

Teens need treatment approaches that account for their level of physical and emotional development, the fact that their parents generally want and need to be involved in their recovery, and the fact that they have not usually had eating disorders for as long as adult patients with the same diagnoses.

Lock also discusses how he hopes the new guidelines will improve training of psychiatrists, how recent changes to eating disorder diagnostic criteria are making it easier for doctors to get their patients the help they need, and why outpatient treatment is the new front line for young people with eating disorders.

Previously: Patient tells how social media helped her overcome the “shame” of her eating disorder, Incorporating family into helping teens overcome eating disorders and Story highlights need to change the way we view and diagnose eating disorders in men
Photo by Darren Tunnicliff

History, Patient Care, Stanford News, Transplants

A look back at one of Stanford’s first kidney donors

A look back at one of Stanford's first kidney donors

Inga GoodnightMuch of medical science writing involves reporting on the next potentially lifesaving treatment. But sometimes it’s rewarding to look back. The recent death of one of Stanford’s first kidney donors had me doing just that – and exploring a time when this now-common procedure was cutting edge.

Inga Goodnight, who died at the age of 99 in April, donated her kidney to her son Gary, who went on to live another 37 years.

As I wrote in a just-published article on their story:

Today, kidney transplants are established procedures; more than 17,000 were performed in the United States last year. Improvements in surgery and immunosuppressive drugs have increased the number of potential kidney matches. Studies have shown that donors have no increased health risks compared with the general public.

But in 1965, when Gary became the third patient to receive a kidney transplant at Stanford, many things were unknown. Doctors were still determining proper dosages for the immunosuppressive drugs, and they didn’t know if Gary’s body would reject the kidney or if he would even survive the first year.

While it was known that a person could live with one kidney, no one knew if there would be long-term health impacts for Inga. And unlike modern laparoscopic surgery, with its tiny incisions and short hospital stays, the surgery to remove the Inga’s kidney involved a large incision that cut through abdominal muscles and required a long recovery.

While these advancements in medicine were interesting, I found my conversation with Bill Goodnight (Inga’s son and Gary’s brother) about his memories from this time equally informative. In many ways their attitudes towards Gary’s condition and treatment seemed quite modern.

Gary Goodnight was aware that his kidneys weren’t going to last and actively followed the news about the emerging field of transplants. Both Bill and his mother had themselves tested to see which might make a good match. And, similar to today’s patients and families with life threatening conditions, the Goodnight family approached the procedure with hope.

Kim Smuga-Otto is a student in UC Santa Cruz’s science communication program and a writing intern in the medical school’s Office of Communication and Public Affairs.

Previously: Double kidney transplants leave Hawaii siblings raring to goKidney-transplant recipients party without drugs – immune suppressing anti-rejection drugs, that is and Well blog: Minnesota man denied insurance for donating kidney
Photo courtesy of Bill Goodnight

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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