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Imaging, Patient Care, Stanford News, Technology

Every foot has a story: Why communication is key in radiology

Every foot has a story: Why communication is key in radiology

11739904364_92e702bc65_zBack in the day, radiology departments were simpler. After obtaining an x-ray, the technologist would hand off the images to the radiologist. In the process, the radiologist might ask about the technologist’s family, how Aunt Lucy was faring or how that day’s commute had been. Maybe a senior technologist would walk by, glance at the pinned up images and offer the junior technologist some advice on how to improve the positioning of the patient. The primary care doctor and the junior radiologist might chat about the patient over their lunchtime tennis game.

Not to say it wasn’t busy — it was. But in a smaller, simpler environment, informal relationships were easier to maintain. Despite their informality, these relationships, and the communication that went with them, served as a powerful means to improve patient care, according to Stanford radiologist David Larson, MD.

Fast forward to today. At a busy, top-tier hospital, radiologists might not know their colleagues, much less the technologists or referring physicians. All images remain on computers — no need to pin anything up for public viewing, or to receive unsolicited comments, or advice.

The many technological improvements, as well as the scale and speed of modern radiology, have inadvertently thwarted communication, Larson and colleagues write in a paper recently published in the American Journal of Roentgenology. Here’s Larson:

In radiology, we’re in the business of information. Everything we do from the time that somebody even thinks of a question, to the time they ask for an imaging study, to when we then interpret the images, is really all about information.

So we need to be really good at moving that information efficiently and effectively, which means we need to be good at communicating… But in many ways, we’re thinking as if we still operate in a small, simple environment, even though we’re operating in a large, complex environment.

For example, Larson said, in addition to having the images, it’s also important for radiologists to know about a patient’s history. He said information that someone runs 20 miles a week, for example, makes a big difference when interpreting an image of a foot. “I have been in the situation where I looked at the study and was about to call it normal. Then I looked at the history, looked back at the study, and found the very subtle stress fracture,” Larson said. “A good history makes that possible.”

Larson pointed out that Stanford is continuously improving its own communication processes. For example, the hospital recently hired a reading room assistant, what Larson referred to as an “air traffic controller,” to direct queries and facilitate communication among physicians.

Previously: Despite genetic advances, detection still key in breast cancer, Using 3-D technology to screen for breast cancer and Better communication between caregivers reduces medical errors, study finds
Photo by Jill Carlson

Medical Education, Medicine and Literature, Patient Care

Prescribing a story? Medicine meets literature in “narrative medicine”

Prescribing a story? Medicine meets literature in "narrative medicine"

woman reading bookIn the November issue of The Lancet, Chris Adrian, MD, postulates about what might be called “narrative medicine.” How do stories and poems alter our experience of caregiving, illness, and suffering? Does literature “help”?

Adrian, who is trained in both creative writing and medicine, thinks that artistic expressions of experience do bring something to clinical care, whether care is experienced on the giving or the receiving end. He also finds these benefits ineffable, impossible to quantify, study, or prove, and all the more powerful for it. He writes:

Lately I feel a strong, anxious conviction that writing and reading fiction and poetry might in fact execute some kind of alleviating change upon our suffering, even in the world of the hospital, upon that portion of our suffering related to illness and death. I can’t begin to argue logically or systematically how it actually does this. Accidentally or miraculously is about as far as I get when I try.

The reason literature, or perhaps art more generally, complements clinical practice is because it communicates in an entirely different language that speaks to different aspects of the human experience. Adrian ponders a line from W.H. Auden’s  “In Memory of W.B. Yeats,” which reads, “For poetry makes nothing happen…” and speculates:

…which is not by any means actually nothing, but instead a domain of activity so estranged from our degraded understanding of what human beings can do in the world that [Auden] had to call it Nothing to say what he meant.

Adrian, who is on faculty at the Columbia University Medical Center and an accomplished author, feels that medicine doesn’t train doctors how to interact with the less-scientific aspects of humans experiencing illness, injury, and suffering. There’s a gap or an absence in most medical care, and that’s where storytelling can step in. Columbia’s Program in Narrative Medicine, which originated in 2000, is dedicated to this idea. It draws participants from a vast array of fields, and inspired the International Network of Narrative Medicine. As its website states, “The care of the sick unfolds in stories. The effective practice of healthcare requires the ability to recognize, absorb, interpret, and act on the stories and plights of others. Medicine practiced with narrative competence is a model for humane and effective medical practice.”

Storytelling in medicine isn’t just for medical practitioners to engage in. Adrian’s musing was inspired by a new book by Carol Levine, Living in the Land of Limbo: Fiction and Poetry about Family Caregiving, which collects the stories of family members who dedicate uncountable resources to caring for sick loved ones. Consider also the longstanding role of the hospital chaplain, and the recent proliferation of doulas, both of whom are specialized professionals who work “next-to” medicine, absorbing emotions, anxieties, and fears, and providing nurturance. And then, of course, there are the patients themselves, who in Adrian’s words might benefit from “art as a considered clinical intervention… very nearly like prescribing a story.”

Previously: Intersection of arts and medicine a benefit to both, report finds, Literature and medicine at life’s end, Thoughts on the arts and humanities in shaping a medical career and Physicians turn to books to better understand patients, selves
Photo by Alex

Medicine and Society, Patient Care, Technology

Advice for young doctors: Embrace Twitter

Advice for young doctors: Embrace Twitter

9093733888_79ccacf171_zYoung doctors have to juggle a huge workload, so it’s not surprising that many don’t use Twitter or other social media. But Brian Secemsky, MD, an internal medicine resident at the University of California, San Francisco recently wrote a story on Huffington Post outlining the benefits of the twitter-verse for young physicians. He notes that Twitter can serve as a good source of medical knowledge and writes:

By choosing a good mix of these medical profiles, especially those that tweet links to high-yield content, you are able to create an individually tailored and constantly updated curated source of medical information, freely available at any time.

(@StanfordMed is one of those profiles, in our humble opinion)

He also points out that Twitter is a good way for up-and-coming physicians to interact with others in their specialty and a place to for them to voice opinions about topics important to them. Also, these days, doctors have a presence online whether they plan to or not, so it’s best to take control of that image. Secemsky writes:

Whether you like it or not, your professional image will likely end up on the Internet. It may be through the increasing patient use of physician rating websites or your own institution displaying your professional profile and accomplishments. It will be difficult to avoid the impact of the online community in your medical career.

Previously: How can health-care providers better leverage social media to improve patient care?More reasons for doctors and researchers to take the social-media plungeSubjects for doctors to avoid when using social media, How, exactly, can Twitter benefit physicians? and How can physicians manage their online persona? KevinMD offers guidance
Photo by Kooroshication

Patient Care, Pediatrics, Stanford News

Eightysomething “neonatology superhero” still at it

Eightysomething "neonatology superhero" still at it

archive Sunshine pic

Several years ago, as I’ve recalled here before, I was assigned a story for Stanford Medicine magazine on the evolution and importance of children’s hospitals – and there was one interview I was particularly excited to score. It was with neonatologist Philip Sunshine, MD, a physician I wanted to talk with in part because of how long he had been here and how much he knew about children’s hospitals and the field of pediatrics, and in part because he had what I considered one of the most amazing last names for a doctor ever. (Dr. Sunshine? How cool is that?)

Fast forward to earlier this week, when I came across a Healthier, Happier Lives blog post noting that Sunshine has been caring for preemies for more than five decades now. Has been – as in, still is! At the age of 84, he’s still at it, as I learned from the piece:

Sunshine started at Stanford in the 1950s, back when the Stanford University School of Medicine was located in San Francisco. What this gentle giant has accomplished since then not only forms a narrative of modern-day neonatal care, but also provides a legacy for modern medicine to follow.

Sunshine is the discoverer of a rare and deadly metabolic disorder, a member of the team that first implemented mechanical ventilation at Stanford, and originator of a scoring system for selecting infants needing assisted ventilation. He has authored several groundbreaking research papers and has received countless awards, including the prestigious Virginia Apgar Award in Perinatal Pediatrics from the American Academy of Pediatrics. The list of his accomplishments continues — all very deep, all very scientific and all very lifesaving.

Burned out from glory? Nope. This pioneer is still excited to come to work — even on days he isn’t on duty — to check in on his patients in the Packard Intermediate Care Nursery and keep in touch with colleagues.

Oh, and as for my interview with Sunshine back in 2006: He was knowledgeable, helpful (he plucked an out-of-print book on a Canadian hospital from his bookshelf and let me take and read it for background), easy to talk to, and clearly a kind man. Just what you would expect with someone in his line of work. Or with that last name.

Previously: A pioneer of modern-day neonatology and Neonatologist celebrates 50 years of preemie care
Photo courtesy of Lucile Packard Children’s Hospital

In the News, Mental Health, Patient Care

Imagining voices: A new movement is using drug-free ways to treat auditory hallucinations

Imagining voices: A new movement is using drug-free ways to treat auditory hallucinations

Artistic_view_of_how_the_world_feels_like_with_schizophrenia_-_journal.pmed.0020146.g001The idea of hearing voices, or auditory hallucinations, is an experience that frightens many of us. It can be seen as a sign that you are no longer in control of your mind. Auditory hallucinations are also a symptom of schizophrenia, and those with the disease often hear voices which are hostile, mean and disturbing. But in Europe, a small band of clinicians, led by the Dutch psychiatrist and president of Intervoice, Marius Romme, MD, PhD, is exploring new ways to treat the problem of hearing distressing voices. A recent interview with one of Romme’s colleagues, Dirk Corstens, MD, and two of his patients, was featured in The Atlantic.

Stanford anthropologist Tanya Luhrmann, PhD, has worked extensively with people who hear voices, and a recent study she conducted compared the experiences of psychotic patients with auditory hallucinations living in three very different locales – San Mateo, California; Chennai India; and Accra, Ghana. Her team found that the voices of Indian and Ghanaian patients were more likely to be playful and benign, whereas those of U.S. patients were on average more threatening.

When Luhrmann took time to talk with me to discuss the implications of her research and the new approach, which calls itself the Hearing Voices movement, she noted early on that although the treatments espoused by the new movement won’t work for everyone, “The Hearing Voices approach is very important and has an important kernel to it.”

Some of what the group advocates is controversial. “They often reject the idea of schizophrenia, are hesitant about medication, and have a model of hearing voices that identifies sexual trauma as the most important cause of hearing voices,” she says. But a growing body of scientific evidence shows that it may be useful to teach people to interact with their voices.

The Hearing Voices movement, says Luhrmann, advocates seeing the voices as meaningful, treats them as people, respects the voices and encourages patients to interact with them with the help of a trained clinician. One of the patients featured in The Atlantic piece described how he learned to work with the voices he heard:

[Dr. Corstens and I] started to work with each other five years ago, or more. I was around 20 years old. It took about two years of work to actually figure out what the relationships were, what the triggers for the voices were, and what feelings are coupled to these voices. Once you start to learn to express yourself and work out these problems on your own, the voices don’t have to act out their part. Now, when I hear voices, I know what triggered them. I ask, “What is happening with me? What am I neglecting in my own emotions?” Does that make sense?

Luhrmann says that while more research needs to be done, it seems that some patients appear to benefit and the voices they hear diminish, or at least become less aggressive and intrusive. But she cautions that the method may not be appropriate for all patients. “I think it’s important to remember that schizophrenia is a difficult heterogeneous experience,” she says. “It’s pretty clear, even at this early point, that these new techniques don’t work for everyone.” At the same time, she points out, research on related practices like cognitive behavioral therapy has been shown to ease the severity of the voice-hearing experience.

The new movement is mostly centered in European countries at the moment, but Luhrmann notes that it’s growing fast in a grassroots kind of way, somewhat in the way Alcoholics Anonymous grew in the last century. She predicts that some of the approaches used by the group will probably be used among patients with schizophrenia here in the U.S. in the next decade.

Previously: The link between mental-health conditions and cardiovascular diseaseNew thinking on schizophrenia, it’s the mind, body and social experience and Study shows meditation may alter areas of the brain associated with psychiatric disorders
Image by Craig Finn

Medical Education, Patient Care, SMS Unplugged

Dreaming vs. doing: How my definition of compassion changed during medical school

Dreaming vs. doing: How my definition of compassion changed during medical school

SMS (“Stanford Medical School”) Unplugged was recently launched as 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.

dreamingI woke up gasping for breath. My patients had died, and I was dying with them. Gradually, my mind unclouded and I realized that it had been a dream, but that realization didn’t soothe my worries. I lay in bed wide awake, anxious. I was picturing the woman who couldn’t speak due to a stroke, who squeezed my hand and raised her eyebrows urgently, asking me for something I couldn’t identify. Then I was remembering the very sick elderly man whose wife brought homemade soup to the hospital every day, and who always had a warm smile and a flurry of gratitude in Mandarin for anyone who entered his room. Their faces swam through my mind for a long time before I returned to sleep.

I was in the midst of my first clinical rotation. After two years focusing on the basic science of medicine, finally caring for actual patients was exhilarating and all-consuming. Even after long days in the hospital obsessing over what else I could do for my patients, I would talk about my clinical experiences on the phone with my mom, on runs with my friends, and over dinner with my husband. I lived and breathed my new role so completely that in my dreams, my patients’ deaths were synonymous with my own.

Now, two years later, I still love my days spent caring for patients in the hospital and clinic, but I don’t dream about my patients anymore. I rarely talk about my work over dinner. This wasn’t a purposeful change, and sometimes I wonder if it means I care less than I once did. I worry that I am Exhibit A for the predictable erosion of empathy that we’re all told to expect by the time we graduate from medical school.

In my more self-forgiving moments, I tell myself this change in how I experience patient care means that I’m learning to compartmentalize my experiences to survive the many emotionally demanding years ahead of me in the medical profession. Based on what I hear in the periodic group reflection sessions that we have in medical school, many students, as well as senior physicians,  agree that this kind of compartmentalizing is the key to avoiding burnout. After all, being completely present for the patient sitting in the room with me means learning to put aside other concerns – including thoughts about my other patients. The same goes for my ability to be present in the rest of my life as a wife, mother, or friend. However, in spite of all this, there is still a part of me that wonders if my growing ability to mentally put my patients’ problems aside will translate into a decline in empathy and passion for my work. After all, I didn’t come to medical school just to survive it – I came to medical school because I believed caring for patients was my calling. What does it say about me that I can so easily leave that passion at the door of the hospital?

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Patient Care, Pediatrics, Research, Stanford News

Better communication between caregivers reduces medical errors, study finds

Better communication between caregivers reduces medical errors, study finds

Miscommunication between caregivers is one of the largest causes of medical errors, but a new study published this week in the New England Journal of Medicine suggests that the problem is at least partly preventable.

The study at nine children’s hospitals, led by Boston Children’s Hospital and including our own Lucile Packard Children’s Hospital Stanford, tested the effects of a standardized method for medical residents to hand off information about their patients at shift changes. Shorter shifts for residents have increased the number of such hand-offs, putting the hand-offs themselves under more scrutiny in recent years.

At each participating hospital, medical residents were trained to use an acronym that reminded them what information to share about each patient, and in what order. The hand-off process included both oral and written communication, and ended with the person who was receiving the information repeating back a summary of what was shared with the person who gave it. The program also included other supports to ensure that the hand-off procedure was embedded in the hospital’s culture and did not have a negative effect on the doctors’ overall workflow.

The participating hospitals reduced their rate of medical errors by 23 percent, and preventable adverse events dropped by 30 percent. From a Boston Children’s press release about the research:

“Because we know that miscommunications so commonly lead to serious medical errors, and because the frequency of handoffs in the hospital is increasing, there is no question that high-quality handoff improvement programs need to be a top priority for hospitals,” says [lead study author Amy] Starmer. “It’s tremendously exciting to finally have a comprehensive and rigorously tested training program that has been proven to be associated with safer care and that meets this need for our patients.”

The program tested in the new research is available for free to any hospital that wants to implement it.

Previously: New study shows standardization makes hospital hand-offs safer, Less burnout, better safety culture in hospitals with hands-on executives, new study shows and Automated safety checklists prevent hospital-acquired infections, Stanford team finds

Aging, Imaging, Ophthalmology, Patient Care, Research, Stanford News

New way to predict advance of age-related macular degeneration

New way to predict advance of age-related macular degeneration

eyeballAge-related macular degeneration, in which the macula – the key area of the retina responsible for vision – begins to degenerate, is the leading cause of blindness and central vision loss among adults older than 65. Some 10-15 million Americans suffer from the disease.

If those numbers don’t scare you, try these: “It affects 14%-24% of the U.S. population aged 65-74 years and 35 -40% of people aged 74 years or more have the disease.” Yow!

Most cases of AMD don’t lead to blindness. But if the disorder progresses to an advanced stage where abnormal blood vessels accumulate underneath the macula and leak blood and fluid, irreversible damage to the macula can quickly ensue if treatment doesn’t arrive right on time.

Timing that treatment just right is a real issue. As I wrote in my recent release about a promising development in this field:

[U]ntil now, there has been no effective way to tell which individuals with AMD are likely to progress to the wet stage. Current treatments are costly and invasive – they typically involve injections of medicines directly into the eyeball – making the notion of treating people with early or intermediate stages of AMD a non-starter. Doctors and patients have to hope the next office visit will be early enough to catch wet AMD at its onset, before it takes too great a toll.

Here’s the good news: A team led by Stanford radiologist and biomedical informatician Daniel Rubin, MD, has found a new way to forecast which patients with age-related macular degeneration are likely to progress to the most debilitating form of the disease – and when.

The advance, chronicled in a study in Investigative Ophthalmology & Visual Science, is a formula – derived from extensive computer analysis of thousands of retinal scans of hundreds of patients’ eyes – that recommends, on a personalized basis,  when to schedule an individual patient’s next office visit in order to optimize the prospect of catching AMD progression before it causes blindness.

The formula predicts, with high accuracy, whether and when a patient with mild or intermediate AMD will progress to the dangerous advanced stage. And it does so simply by crunching imaging data that is already commonly collected in eye doctors’ offices anyway.

“Our technique involves no new procedures in the doctor’s office – patients get the same care they’ve been getting anyway,” Rubin told me. His team just tacked on a sophisticated, computerized image-processing step.

Previously: Treating common forms of blindness using tissue generated with ink-jet printing technology, To maintain good eyesight, make healthy vision a priority and Stanford researchers develop web-based tool to streamline interpretation of medical images
Image courtesy of Daniel Rubin

Cardiovascular Medicine, Medicine X, Patient Care, Surgery

Operation Heart: Engaging patients in caring for patients

Operation Heart: Engaging patients in caring for patients

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. Our inaugural post comes from Sarah E. Kucharski.

mended heartRivulets of deep brown iodine trickled across the patient’s body as nurses swabbed with sponges and unfurled blue surgical drapes. I contemplated his bare feet. I wondered if they were cold. I wondered if he wore no socks so that the nurses might palpitate for his dorsalis pedis and posterior tibial pulses. And I thought about how many times the patient on the operating table had been me.

When given the opportunity to observe surgery, I had accepted eagerly. One hardly could have called it an exercise in learning self-care techniques — no matter how empowered I am as a patient, even I draw a line at doing by own arterial bypass. Rather I wanted to see how the other half lived. For once I entered the operating room wearing scrubs and surgical mask instead of an open-backed gown and an IV line pushing Versed through my veins.

My conscious presence meant I represented not just myself but my fellow patients who clamored for meaningful engagement. There is much talk about being able to view health care and the medical establishment from another perspective, but few truly have an opportunity to do so. It has been pointed out that doctors attend school to learn how to be doctors, yet patients do not attend school to learn how to be patients. More importantly there is no school to teach doctors how to be patients and, save for those patients whose condition manifests early enough to motivate medical school, no method of teaching patients how to be doctors. Collaborations to re-imagine health care for our joint benefit will be ineffective unless we expand medical education to regularly include the patient, which will facilitate empathy and improved health literacy through shared experiences.

As surgery preparations continued, the operating room nurses appeared apprehensive they were going to share an experience with me. I had signed on with a go big or go home philosophy — the aortic root and mitral valve replacement would be my first surgery. Each nurse’s eyes widened for two tell-tale seconds when I told them my novice status, and their voices caught as they tried to mitigate surprise, “Ooh.” Their apprehension meant I had something to prove. There would be no circumstance under which I would faint.

And with the loud whine of the sternum saw, we were underway.

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Health Costs, Health Policy, Patient Care, Stanford News

A call for medical malpractice reform

Golden Lady Justice, Bruges, BelgiumA new report in the Journal of the American Medical Association offers a look at the current decline in medical malpractice suits and makes some predictions about their future. The authors include two Stanford faculty, Michelle Mello, JD, PhD, and David Studdert, LLB, ScD, who both have joint appointments at the School of Medicine and the School of Law.

Using national databases, the researchers found that the paid claims against doctors decreased between 2002 and 2013. Rates decreased by an average of 6.3 percent for medical doctors (MDs) and 5.3 percent for doctors of osteopathy (DOs). The amount of an average paid claim peaked in 2007 at $218,400, but had gone down a bit as of 2013. A post on the Stanford Law School’s blog explains why this may be a good time for policy-makers to consider reforms in the medical liability system:

“After years of turbulence, the medical liability environment has calmed,” said Mello. “Although many aspects of the malpractice system are dysfunctional, causing angst for physicians, the cost of malpractice claims and insurance have been stable for the last few years and the number of claims has been declining.”

She added, “Usually, attention is only focused on reform during ‘malpractice crises,’ but highly charged political environments are not conducive to cool-headed policy decisions. This current period of calm is a good time to be thinking about reforms that could improve our medical liability system.”

In their piece, the authors describe seven different novel approaches to medical malpractice reform, including one that encourages medical institutions and providers to communicate with complaining patients and find resolutions that might include payouts to patients before they file suit.

The paper also includes some predictions about the trends that will be important for medical liability policy in the coming decade. The authors assert that traditional tort reforms “will never deliver,” but the previously mentioned communication-and-resolution programs are likely to expand, as will “safe harbor” laws that protect clinicians and their institutions if they can show they are following a prescribed course of clinical treatment. Other trends include the increasing consolidation of health care within hospitals and large health systems. These large entities are likely to use their growing size to influence the liability system.

More ominously, authors note that liability insurance crises have happened in regular cycles since the system was expanded in the 1960s, and warn that another is imminent. They conclude their report by saying:

Action now to reduce the amplitude of the next medical liability cycle is both prudent and feasible. Further testing of nontraditional reforms, followed by wider implementation of those that work, holds the most promise. Prospects for permanent improvement in the medical liability climate depend on it.

Photo by Emmanuel Hybrechts

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