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In the News, Patient Care, Pediatrics, Stanford News

Fifty-plus years of Sunshine: Long-time Stanford neonatologist discusses his career

Fifty-plus years of Sunshine: Long-time Stanford neonatologist discusses his career

sunshineWith a name like Dr. Sunshine, parents should know their premature babies are in good hands. On yesterday’s Forum, neonatologist Philip Sunshine, MD, discussed the fifty-plus years he’s been caring for preemies. At 84, he’s still at it, working 30 hours in a step-down nursery at Lucile Packard Children’s Hospital Stanford. (He jokingly told host Michael Krasny, “I do all the stuff the young people don’t want to do.”)

During the hour, Sunshine, a 2015 “Legends of Neonatology” honoree, talked about the changing field of neonatology, including his views on the ever-growing popularity of home births (“Home deliveries are for pizzas only,” he quipped, referencing a pin his former classmate always wore). He also read e-mails and took calls from listeners – many of whom thanked him for saving their children’s lives (30,000 and counting).

Previously: Eightysomething “neonatology superhero” still at itA pioneer of modern-day neonatology and Neonatologist celebrates 50 years of preemie care
Photo courtesy of Lucile Packard Children’s Hospital Stanford

Health Costs, Health Policy, Patient Care, Research

Medicare payment reform shown to cut costs and improve patient care

Medicare payment reform shown to cut costs and improve patient care

PT got Margie practicing on crutches, including going up and down a step.A few years back, the Centers for Medicare and Medicaid Services (CMS) made a straightforward change: No longer would it pay for easily preventable conditions that develop in the hospital. A care-team fails to help ambulate a patient following a hip or knee surgery and the patient develops deep-vein thrombosis? Unfortunate for the patient and unfortunate for the hospita, which now has to absorb the cost of that care.

It seems obvious, yet slightly disturbing, that this approach would be successful. In my idealized worldview, all patients are treated the same, regardless of who’s picking up the tab.

But when you change the financial incentives, change happens. Stanford health economist Jay Bhattacharya, MD, PhD, and health economist Risha Gidwani,DrPH, who is affiliated with the VA and Stanford, found the prevalence of two preventable conditions – deep-vein thrombosis and pulmonary embolisms – for patients with a recent hip or knee surgery dropped after Medicare stopped paying. The study was published today in the Journal of General Internal Medicine.

From our press release on the work:

When CMS stopped paying for treating deep-vein thromboses and pulmonary embolisms, the incidence of those conditions after hip or knee replacement surgery dropped 35 percent in the Medicare population, Gidwani said. In the younger, non-Medicare population, the incidence of these two conditions increased, although they also decreased in the patients over age 65 who had private insurers. There are more than 1 million hip or knee replacements performed in the United States each year, and over 60 percent of them are paid for by Medicare.

“We have a win-win,” Gidwani told me. “We have patients who are avoiding adverse events while Medicare saves money.”

Previously: Beyond Berwick brouhaha: Medicare chief another step to health-care reform, Experts discuss high costs of health-care — and what it will take to change the system and Competition keeps health-care costs low, Stanford study finds
Photo by Dave & Margie Hill

Patient Care, Public Health, Research, Science

Finding cures for the most challenging diseases

640px-Drawing_Test_tubes_different_colorsThe recent Ebola outbreak and the subsequent race to find a vaccine and other treatment options has brought the topic of drug development back in the public spotlight. But despite the millions of dollars spent on these efforts and the technological advances in biomedical sciences in the last 20 years or so, the process is still time-consuming and prone to failure. A recent feature story from National Journal (which also appears on The Atlantic’s website today) describes the work of several scientists trying to find cures or treatments for some of the most challenging diseases, from infectious diseases, like AIDS and Ebola, to chronic diseases such as Alzheimer’s.

The first disease the article highlights is a rare disorder called progeria, which causes young children to age prematurely. Recent breakthroughs in treatment have come from a team led by Francis Collins, MD, PhD, who is more famous for leading the Human Genome Project and now serves as director for the National Institutes of Health. Collins worked briefly on progeria early in his career and the combination of Collins’s work and genomics made it possible for his team to crack the genetic secret of the rare disease: that it was caused by a single genetic mutation. That finding led to a treatment that extended the lives of patients with progeria by several years. But it also points to some of the overwhelming challenges of chasing down cures and treatments:

The doctors and scientists hunting for new cures and treatments work in a constant state of tension. They operate in a tremendously high-stakes environment, pouring years of their lives into research as the people who inspire them continue to suffer and even die. Drug hunters face failure after failure, almost never followed by success. Decades of work flame out. Promising ideas turn into dead ends. For every 10,000 compounds they explore, scientists wind up with just one drug approved by the Food and Drug Administration. Even when medical science moves as fast as it can—and today, it’s moving faster than ever before—it’s still an agonizingly slow process.

“As much as we say that failure is part of what we do—if you’re not failing, you’re probably not doing science that’s very interesting—it still hurts,” Collins says. “It is frustrating, because you want to come up with the answer. You want to save lives. That’s what we all get into this medical research area to try to achieve, and yet the challenges are immense. And we make progress, oftentimes, in very small baby steps, even though what we’re hoping for are big leaps.”

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Emergency Medicine, Medical Education, Patient Care, SMS Unplugged

Role reversal: How I went from med student to ED patient in under two minutes

Role reversal: How I went from med student to ED patient in under two minutes

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.

emergency sign - smallAs part of the second-year clinical skills course, each member of my class is required to complete two 8-hour Emergency Department (ED) shifts. I had my first ED shift last week, and when I walked in, I introduced myself as a second-year medical student who needed to practice IV placements, EKGs, and any other procedures that happened to come my way. Three hours later, when I walked out of the ED, staff knew me not as a medical student, but as a recently discharged patient, grasping paperwork with my official diagnosis: “syncope and collapse.”

It was 30 minutes into my ED shift, while I was watching a pelvic exam (ironic, given my post a couple weeks ago), when I began to feel a little dizzy. I’ve fainted twice before – once in high school after getting my blood drawn, and once when watching a C-section at a clinic in India – so I recognized the signs: feeling a little hot, starting to see black dots, slightly swaying. I tried to fight off the sensation by breathing slowly, but I could tell it wasn’t working. At the earliest possible opportunity, I turned to the attending in the room, saying, “Is it okay if I leave? I’m feeling lightheaded.”

I barely waited to hear her response before I bolted out of the room and found the closest stool to sit on. Bad call. The stool had no back to it, and next thing I knew, I was on the ground. When I opened my eyes, there were at least five  nurses around me, one whom matter-of-factly said, “Honey, you just became a patient.” Another nurse quietly slipped my hospital badge off my jacket, returning two minutes later with a medical bracelet that she fastened around my wrist.

My memory of those early moments is a little shaky, but I do remember saying over and over again, “I’m so sorry, I’m so sorry.” I felt awful that I had come to the ED to learn from the patients, physicians, and staff – without being a burden – but had ended up being another patient for whom they had to provide care. The nurses and attendings immediately normalized the situation, telling me repeatedly that this is a common occurrence in the ED and that many of them had had this happen to them as well. Their assurances made me feel so much better.

The efficiency of the events that followed totally impressed me. The nurse helping me to the bed did the fastest history on me I’ve ever heard, all while hooking me up to a BP cuff and a pulse oximeter. Did I have allergies? (Nope.) Did I  have diabetes? (Nope.) When was the last time I ate? (That morning). Any other medical conditions that I’m being treated for? (Nope.) Any family history of cardiac conditions? (Nope.)

The attending who was with me when I initially felt lightheaded came in at that point and asked, “Has this happened to you before?” and when I told her about the C-section, joked, “ObGyn probably isn’t your favorite thing, huh?” She then laid out the plan for what would happen next: an EKG, a glucose stick, and a blood test, to check for cardiac abnormalities, low blood sugar, and anemia, respectively. Within 30 minutes, all three of these had been done, and I even got a bonus ultrasound thrown in by someone who was practicing recognizing cardiac pathology (not that I had any). Noticing my scrubs and med student badge, this person took the time to show me each ultrasound image, pointing out the various heart chambers, valves, and the location where my IVC entered my right atrium.

By 2 PM, my tests were all back, everything was normal, and I was able to laugh about the entire situation: Somehow, I had come into the ED hoping to practice blood draws and EKGs but came out having them done to me instead. Just another day in the life of a med student.

Hamsika Chandrasekar is a second-year student at Stanford’s medical school. She has an interest in medical education and pediatrics.

Photo by zoomar

 

Health Costs, Health Policy, Patient Care, Research

Spotting stellar primary care practices, Stanford study identifies 10 practices that lead to excellence

Spotting stellar primary care practices, Stanford study identifies 10 practices that lead to excellence

crutches-538883_1280Many of us know first-hand that expensive, substandard health care abounds in America. The problem has been analyzed and bemoaned, measured and critiqued. Solutions, bright spots and success stories are less abundant—in fact they are downright rare. That’s why recent findings from a partnership between Stanford’s Clinical Excellence Research Center and the Peterson Center on Healthcare, a new organization that aims to improve health care in the United States, are so exciting. Bucking current theories, researchers found that independent, primary care medical practices can provide superior care while saving money. And, they identified 10 principles these practices embrace, which distinguish them from their peers.

I had the chance to speak with CERC Director Arnold Milstein, MD, about the Stanford-based project:

What exactly did you do?

We examined the performance of more than 15,000 primary care practices looking for “positive outliers” or practices that provide excellent care at a lower cost. This is the first  systematic comparison of its kind and we weren’t sure we’d be able to discern any differences. But we did. We found a substantial difference in measures of quality and the total annual amount of health care spending between sites. Then, we arranged for  observers (independent physicians) to visit these offices to understand what was different about care delivery at sites associated with less spending and high quality scores.  They discovered 10 distinguishing features of successful health-care practices that were present much more frequently in these positive outlier practices than in other offices. There are some major differences in how they deliver care.

What were some these features? Did any surprise you?

About two-thirds align with current national initiatives such as Choosing Wisely and the Patient Centered Medical Home, but about one-third are new ideas.

The 10 features are not abstract ideas, they are tangible and therefore more easily transferable. For example, the higher-performing sites are ‘always on’ — patients can reach the care team quickly 24/7. I use the word ‘care teams’ because I’m not referring to physicians only. These teams include nurses, nurse practitioners, medical assistants and/or office managers, developed  to the highest of their abilities. These teams often treat conditions in a gray zone between primary care and specialist care. They follow up with their patients when a case is referred to a specialist. They check in with patients to ensure they are able to follow self-care recommendations.  Their work station is shared, so they can learn from each other. These teams adhere to systems to deliver care — choosing individual tests and treatments carefully. Distribution of revenues among physicians is not  solely based on service volume. Finally, these practices invest much less in office rent and costly testing hardware.

 

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In the News, Infectious Disease, Medical Education, Medicine and Society, Patient Care

A doctor’s attire – what works best?

A doctor’s attire – what works best?

Lab CoatsDoes what your doctor wear matter to you? You may simply want your doctor to be competent and compassionate, but a recent article in The Atlantic points out some subtle issues in the effects a doctor’s dress may have. Most people seem to prefer “formal” to “casual,” but the author recalls being put off by a well-coiffed female doctor dressed in a smart business suit. But if there’s such a thing as too formal, a doctor in cut-off shorts and a tee isn’t likely to get too many repeat patients either.

I’m pregnant and I have a toddler, so I’ve had more than the average number of visits to the doctor in the past couple of years. I also like clothes and notice what people are wearing, but even I had to stop and think about what, if anything, I remembered about what my OB/GYN or my daughter’s pediatrician (both women) wore during recent visits. Mostly I remember slacks and simple blouses, or in the unforgiving summer heat typical in this area, something a little lighter. My daughter’s pediatrician also has a couple of small Disney character toys attached to her name tag to entertain the youngest patients.

There’s a middle ground that doctors have to strike that may be tricky depending on their specialty, their hospital or clinic’s dress codes (Mayo Clinic requires all docs to dress in a business suit) among other things. And that’s not even considering the issue of how a doctor’s clothes can spread infectious disease. From the article:

The definition of what counts as professional clothing is also in flux, thanks to increasing knowledge of infectious risks. Earlier this year, the Society for Healthcare Epidemiology Association (SHEA) published new guidelines for healthcare-personnel attire in hospital settings. Their goal was to balance the need for professional appearance with the obligation to minimize potential germ transmission via clothing and other doodads like ID badges and jewelry and neckties that might touch body parts or bodily fluids. The SHEA investigators’ take-home points regarding infection: White coats should be washed weekly, at the minimum; neckties should be clipped in place (70 percent of doctors in two studies admitted to having never had a tie cleaned); and institutions should strongly consider a “bare below the elbow” (BBE) policy, meaning short sleeves and no wristwatches or jewelry. Although the impact on reducing the risk of infections remains to be determined, it’s considered potentially significant enough that a number of countries have adopted BBE requirements for all clinicians. (And it leaves me wondering: When will the Mayo clinic update its dress code to short-sleeved business suits?)

The other factor doctors have to consider is that the “business casual” that I’ve seen on most doctors may need to be upgraded for more formal meetings – something I’d never considered as a patient. Again from the article:

Last week, two days in a row, I ran into a colleague who’s a pediatrician. The first day, she wore a beige pantsuit (I’d label it formal, or business) and looked fairly corporate. I wondered to myself if she realized that her clothes were sending a message to her patients, a message that indicated that her medical practice was a business and that she wielded the power. The next day, she wore a loose-fitting knee-length navy dress (professional informal, perhaps, or smart casual). I asked her if she had seen patients the first day. She had not; it was a day of meetings, and when I told her I was writing about doctors’ clothing, she laughed. “When you’re seeing patients,” she said, “you have to look like you’re not afraid to get dirty.”

I’m not sure how I would have reacted if at our first appointment our pediatrician had worn a formal business suit. At the very least, I would have felt under-dressed (jeans and tees are my de facto uniform these days), but I would have likely judged her as cool or somehow distant, not suited to working with kids. Which may prove nothing, but only hint that that the best attire is the kind that your patients don’t notice.

Previously: NY bill proposes banning white coats, ties for doctors
Photo by Pi

Imaging, Neuroscience, Patient Care, Pediatrics, Research

Stanford-led study suggests changes to brain scanning guidelines for preemies

Stanford-led study suggests changes to brain scanning guidelines for preemies

preemieOne big challenge of having a premature baby: the uncertainty. With good medical care, a great many preemies do very well, but some face long-term disabilities, medical complications and developmental delays, and others, sadly, die in infancy. Unfortunately, doctors can’t always tell how a baby will fare in the long term.

A new study, led by a Stanford team and conducted at 16 sites around the country, is part of the ongoing effort to change that. The researchers examined what type and timing of brain scans give doctors the greatest ability to predict preemies’ neurodevelopmental outcomes in toddlerhood. The research, published online today in Pediatrics, found that for babies born more than 12 weeks early who survive to near their original due dates, brain scans performed near their due date are better predictors than scans done near birth.

Most preemies already get at least one brain scan. That’s because national guidelines recommend that preemies’ doctors perform a cranial ultrasound seven to 14 days after birth to look for immediate problems such as bleeding into the brain. (Ultrasound is a good fit for the needs of fragile infants: Babies’ fontanelles provide “acoustic windows” to the brain, and ultrasound is non-invasive, uses no radiation, requires no sedation, and can be performed with a portable scanner brought to the bedside.) Some prior research has shown that these early scans can also give information about an infant’s risk of cognitive, motor and behavioral deficits or delays in childhood, but the predictive value of these early scans can be fairly low.

The new study examined both cranial ultrasound and MRI performed close to the baby’s due date, which is also when most preemies are ready to go home from the hospital. A lot changes in the brain during those first few weeks, perhaps explaining why later scans did a significantly better job of predicting which children would have persistent neurodevelopmental problems when the doctors checked in with them at 18 to 22 months of age.

“Neuroimaging may help us understand what a child’s outcome may look like, and ultimately help us focus our attention in terms of the type of follow-up and specific interventions that could best support a child after discharge from the hospital,” said Susan Hintz, MD, the study’s lead author and a neonatologist at Lucile Packard Children’s Hospital Stanford.

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Chronic Disease, In the News, otolaryngology, Patient Care

A look at one woman's long journey to diagnosis and treatment of rare disorder

VertigoThis week’s Medical Mysteries column in The Washington Post tells the story of a woman who lived with debilitating vertigo and odd tinnitus. Baltimore’s Rachel Miller lived with dizziness, the exaggerated sound of her heart and breathing and even anomalies with her vision for five years before she was diagnosed and treated. Many of the doctors she saw dismissed her symptoms as psychosomatic and Miller even went through a period when she stopped seeing doctors for her condition. Miller described her travails this way:

“I had started to feel like a person in one of those stories where someone has been committed to a mental hospital by mistake or malice and they desperately try to appear sane,” recalled Miller, now 53. She began to wonder if she really was crazy; numerous tests had ruled out a host of possible causes, including a brain tumor. Continuing to look for answers seemed futile, since all the doctors she had seen had failed to come up with anything conclusive.

But then she went to see David Zee, MD, who diagnosed her strange symptoms as a rare disorder called superior canal dehiscence syndrome (SCDS), when a small hole or a thin area of the temporal bone allows the fluid of the inner ear to touch the brain, transmitting sounds from the rest of the body, like our heartbeat or breathing, or even the movement of our eyeballs. John Carey, MD, operated on Miller, filling the small hole with bone and other tissue from the skull. As the piece notes, both Carey and Zee trained with Lloyd Minor, MD, now dean of the Stanford School of Medicine, when he was at Johns Hopkins University. Minor discovered SCDS in 1995 and developed the surgical treatment that Miller subsequently received in 2012.

Miller has recovered now, with only occasional problems when she gets a cold. But her story points out how difficult it can be to diagnose rare medical problems.

Previously: NIH network designed to diagnose, develop possible treatments for rare, unidentified diseases and Using crowdsourcing to diagnose medical mysteries
Photo by Mikael Tigerström

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

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