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Global Health, Medical Education, Patient Care, Stanford Medicine Unplugged

From medicine to the mat: Learning self defense

From medicine to the mat: Learning self defense

Stanford Medicine Unplugged (formerly SMS Unplugged) is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the Stanford Medicine Unplugged category.

cute karate girl“You hit me!” My sparring partner accused me from behind his hands. We were in a self-defense studio practicing what to do in a mugging situation.

At first I was supposed to mug my six-foot tall, athletically built male partner. He had no problem fending me off safely.

The trouble started when it was his turn to mug me. He stepped past my socially acceptable 3-foot bubble. I panicked. My legs crouched and I lunged forward. My palm drove into his nose.

The mugger stumbled back and suddenly he was my partner again, holding his face.

“Sorry, sorry,” I didn’t know what else to say.

He squared his shoulders and offered to try again. As long as I didn’t hit him.

I nodded, trying to get focused. I was here for a reason. Many reasons actually. It had been a goal of mine to gain some level of proficiency in martial arts since I was little. When I grew up to be five feet three inches and too small to donate blood, I gave up on that particular goal.

Then this summer I spent a month volunteering in a hospital in Uganda. I saw more there than I have had time to process. There were real-life miracles, like when a patient survived after arriving with a blown pupil and an epidural hematoma. There were tragedies that I don’t know if I will ever shake off, such as the small child who died during rounds. There were also preventable snafus, like when one of my fellow volunteers was mugged walking home.

I had decided there were some tragedies I could protect myself from. Additionally, I had taken a year off from medical school to write a novel. The protagonist in my novel is highly trained in martial arts and I wanted to do some field research. When I returned from Uganda, I decided to throw my weight into self-defense classes every Monday and Wednesday evening.

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Cardiovascular Medicine, Patient Care, Surgery

61-year-old grandfather gets new heart valve at Lucile Packard Children’s Hospital Stanford

61-year-old grandfather gets new heart valve at Lucile Packard Children's Hospital Stanford

Dr. George Lui, M.D., Dr. Dan Murphy, M.D., Mr. Sang Hee Yoon, Mrs. Min Wha Yoon, and Dr. Katsuhide Maeda, M.D. at Stanford Children’s Health Care on Tuesday, October 6, 2015. ( Norbert von der Groeben/ Stanford School of Medicine )One little-known fact about children’s hospitals: A number of their patients are not children.

I wrote about one such patient recently, a 61-year-old San Jose grandfather who received a new heart valve at Lucile Packard Children’s Hospital Stanford in May. Sang Hee Yoon was born in South Korea at a time when many babies with heart defects died in infancy. He was one of the first people there to receive a surgical repair for his heart condition, called tetraology of Fallot. The repair worked well for many years, but eventually he needed a replacement for a malfunctioning heart valve.

When the time came, the doctors on our adult congenital heart disease team were here to help. My story explains the unusual challenges of their field, which is growing rapidly as 20,000 teenagers with congenital heart defects “graduate” to adult medical care each year:

“Patients come back at 40 or 50 years old, telling us, ‘My doctor said I was cured,’” said George Lui, MD, medical director of the Adult Congenital Heart Program at Stanford, a collaboration between the Heart Center at Lucile Packard Children’s Hospital and Stanford Health Care. Some patients’ childhood surgical repairs were initially judged so successful that they never expected to return to a cardiologist, said Lui… In other cases, the first surgery was so unusual and risky that the surgeon discouraged the patient from undergoing further operations.

But most adults with repaired congenital heart defects are not cured, doctors have learned. As the discipline has matured, cardiologists have honed their understanding of how to help patients like Yoon navigate the risks of living with lingering heart problems, as well as learning how congenital defects interact with cardiovascular problems people acquire with age.

Mr. Yoon’s new heart valve has made a big difference – he and his wife told me that his health is better than ever before. Prior to his surgery at Stanford, his malfunctioning heart valve meant that his body never quite got enough oxygen. He often felt achy or had tightness in his chest, especially at high altitudes. All that is resolved now. The couple’s four children and 10 grandchildren are thrilled:

“They are so happy about my condition,” [Yoon] said. “Not only family members but everybody I know is saying, ‘You look so healthy!’” The Yoons have already visited Kings Canyon National Park, a destination they chose for its mountainous scenery. “I feel such gratitude that now I can enjoy my new life,” Yoon said.

Previously: Patient is “living to live instead of living to survive” thanks to heart repair surgery, Little hearts, big tools and Surgeon building a heart valve that can grow and repair itself
Photo – of Mr. and Mrs. Yoon with his doctors (from left to right) George Lui, MD, Daniel Murphy, MD, and Katsuhide Maeda, MD – courtesy of Lucile Packard Children’s Hospital Stanford

Anesthesiology, Patient Care, Research, Stanford News

Study on training program for anesthesiologists shows challenges of changing doctor behavior

Study on training program for anesthesiologists shows challenges of changing doctor behavior

Simulation RAWith the problem of opioid addiction reaching epidemic proportions, anesthesiologists are pushing for greater use of non-narcotic methods of pain control, according to Edward Mariano, MD, an associate professor of anesthesiology, perioperative and pain medicine at Stanford.

One of those methods is ultrasound-guided nerve blocks, which involves using ultrasound to guide a small catheter next to a nerve to deliver pain relieving anesthesia directly to the site of the injury. The method is particularly effective in procedures like the 700,000 knee replacements that are done yearly, and its use has become somewhat commonplace over the past 10 years since it routinely began to be taught to anesthesiology residents, Mariano recently told me. But any anesthesiologist who entered practice prior to 10 years ago probably hasn’t received adequate training in the technique.

“I had to learn on my own,” said Mariano, which is what most established anesthesiologists end up doing if they use the procedure at all. Mariano set out to research whether teaching this method of pain control to anesthesiologists in a continuing medical education (CME) course using simulation training with mannequins might increase both the doctors’ ability to do the procedure and the use of the procedure when the physicians returned to their practice. Current CME courses are available to teach this procedure, but they don’t use simulation training with mannequins.

For the study, Mariano and colleagues recruited 32 anesthesiologists who had been in practice for 10 years or more to participate in the trial. During an eight-hour course, the physicians were taught how to use the procedure receiving both hands on training on mannequins and lectures by faculty.

What they found was that 12 of the participants used the method at least once after training – “however, there were no differences in the monthly average number of procedures or complications after the course when compared to baseline.”

In Mariano’s words: “Within eight hours we could take any anesthesiologist and train them to be proficient in very advanced ultrasound despite the technique being tough to learn. But sadly, even though we can train them in a day, they generally don’t change their practice when they go home.”

The researchers acknowledge that this was a small study, and the study sample was perhaps too small to draw firm conclusions. But they also point out that plenty of past research has shown just how difficult it can be to change physicians’ behavior in general.

“It’s very difficult to have an ongoing practice and to do something brand new,” Mariano told me. “Not only is there the pressure and time demands of taking care of patients, there is also a natural hesitancy to try new things.”

The results of the study appear in the print edition of the Journal of Ultrasound in Medicine this week.

Photo, of co-investigator T. Kyle Harrison, MD, working in simulation lab, by Edward Mariano

Events, Patient Care, Precision health, Stanford News

A conversation on the promises and challenges of precision health

A conversation on the promises and challenges of precision health

At a Town Hall event here on campus earlier this week, three faculty members explored the prospects for precision health — health care whose goal is to anticipate and prevent disease in the healthy and precisely diagnose and treat disease in the ill. Among the speakers was Mary Hawn, MD, professor and chair of surgery; as my colleague Jennie Dusheck explained in an online article today:

[Hawn] discussed how precision health could help surgeons better understand their patients’ risk factors for surgery and mitigate those risks. “We know we aren’t going to get the same outcome from surgery for every single patient,” she said. Health-care providers have to know individual patients and what their individual risks might be. At the same time, providers need to be able to communicate that information to patients and their families, so they can make decisions that feel right to them. Ideally, Hawn said, “We can see what risks the patient is bringing to the table and mitigate those risks.”

“We surgeons have been humbled by biology. We think we can do a great operation, but in the end, the biology wins,” Hawn said. “So, knowing that upfront, we can have a much more frank conversation with a patient about how invasive, how radical an operation to have…”

In a panel discussion moderated by Lloyd Minor, MD, dean of the medical school, geneticist Michael Snyder, MD, and Mark Cullen, MD, a population-health scientist, also weighed in on how clinicians can take advantage of large health data sets and advances in genomics to benefit their patients.

Previously: How Stanford Medicine will “develop, define and lead the field of precision health”, At Big Data in Biomedicine, Stanford’s Lloyd Minor focuses on precision health, and Global health and precision medicine: Highlights from day two of Stanford’s Childx conference
Photo, of Mary Hawn and Mark Cullen (left), by Norbert von der Groeben

Emergency Medicine, Health Policy, Patient Care

Improving patient satisfaction and turn-around time in an emergency department

Improving patient satisfaction and turn-around time in an emergency department

Emergency Room SignWhat could a manufacturing philosophy concocted by a car maker have to offer a beleaguered emergency department staff? More than you would expect.

“Lean manufacturing” is a method used in the 1960s and 1970s by Toyota to improve quality on its assembly lines. The idea was to empower all the workers to have the authority and confidence to stop the line and address quality and efficiency issues. In the decades since, it’s made its way to other industries beyond manufacturing, including software development.

When Amir Dan Rubin, MHSA, MBA, came on board four years ago as president and CEO of Stanford Hospitals and Clinics, he brought the lean management mentality with him.

Marlena Kane, MPH, executive director for performance excellence & medicine services at Stanford Hospital described the process as “looking at things from the patient’s perspective and getting people to talk to each other.”

The hospital’s emergency department implemented the lean methodology, and a year later, wait times dropped dramatically and patient satisfaction shot up. Kane, along with David Pickham, PhD, director of research at Stanford Hospital, and their colleagues reported their experience in a paper in the Journal of Nursing Administration last month. And Rubin spoke about the changes they’ve implemented at this year’s Medicine X conference.

The median length of stay in the ED fell by 17 percent, despite a 7 percent increase in patients. And there was virtually no increase in the cost of running the department. “We all want the same thing, to take care of patients well,” Kane said.

The main change the department made was to teach front-line staff to solve problems as they cropped up. Those front-line staffers were able to have discussions with other groups when they noticed inefficiencies or slow-downs. This required several teams to work together to find solutions – from nurses and residents to transporters, housekeepers and translator services.

Training the teams on the new approach was no small feat. For the day-long trainings, additional staff had to be called in to back-fill staff members who would be away from the emergency department.

She pointed out that the lean approach has to have leadership buy-in and commitment to work. “You have to start with the executive team,” she said. “They have to be invested and give time to let staff do it. It can’t be grass roots.” When the lean approach fails at an organization, it’s often because the leadership team isn’t fully invested in the process.

Kane noted that handing the power to solve problems to front-liners frees up leadership staff to tackle long-term problems. “If we keep solving problems for our teams, they won’t be empowered,” she said. “We are always fire-fighting, not thinking strategically.”

Previously: Speed it up: Two programs help reduce length of stay for emergency-room visitorsStanford’s “time banking” program helps emergency room physicians avoid burnout, and An emergency medicine physician’s take on honoring your emotions
Photo by KOMUnews

Medical Education, Patient Care, Rural Health, Stanford Medicine Unplugged

Two weeks in Humboldt County, Calif.: Insight into rural medicine

Two weeks in Humboldt County, Calif.: Insight into rural medicine

Stanford Medicine Unplugged (formerly SMS Unplugged) is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week during the academic year; the entire blog series can be found in the Stanford Medicine Unplugged category.
Hamsika among trees

As part of the family medicine clinical rotation here at Stanford, students have the option of spending two weeks doing a “rural medicine” track in Humboldt, a small 150,000-person county that is about a 5- to 6-hour drive north of Palo Alto. Each month, up to two medical students can volunteer to be in Humboldt, and Stanford takes care of arranging for hosts, clinic preceptors, and pretty much everything else. I had heard from upperclassmen that this track was “amazing” and “unique” and that I should “do it!!!” And so, three weeks ago, I found myself downloading an audiobook version of Aziz Ansari’s Modern Romance to keep me company as I made the long drive to Fortuna, California.

I’m not sure what I expected to see when I got there. For some reason, I had this dramatic idea that I would be spending two weeks with no cell phone service, spotty access to Internet, no Starbucks visible in a 10-mile radius, and paper medical records instead of an EMR. The reality wasn’t quite so bleak (in fact, the very first sign I saw in Fortuna pointed toward a Starbucks, and I had zero trouble with cell phone service and Internet access), but it was still a jarringly different experience from my first three months of rotations, spent in Palo Alto and Santa Clara.

First and most noticeable was the shortage of physicians. Everyone talks about the physician shortage and the need for primary care physicians, but it wasn’t until I got to Humboldt that I first saw this need manifest. In the clinic where I was working, there was one family medicine physician – total. Each day, he saw 25 or more patients and did everything from diabetes care to trigger point injections to skin cancer. There were poignant moments in clinic, when it was clear that a patient needed specialist care, but there simply wasn’t anyone to refer the patient to. The nearest specialist care center was UCSF, five hours away. Moreover, it was sometimes difficult to access patients’ past medical records, or records from other clinics. The EMR in Fortuna was just a few years old, and in fact, there was one day of clinic when my preceptor and I explicitly dedicated time to transferring patients’ past medical history from paper records into the EMR.

Contrast this to the second half of my family medicine rotation, which I spent at a Stanford-affiliated clinic. Over the course of 1 week in this clinic, I worked with five different family medicine preceptors, and there were still more physicians at the clinic with whom I had not worked with directly. We saw between 12 and 15 patients a day and had the luxury of scheduling in 40-minute time blocks whenever a patient needed the extra time. I had no trouble accessing patient’s medical records, not only within Stanford but from outside institutions they had been seen in in the past. Test results popped up in Epic (Stanford’s EMR) in a timely manner, with lovely color-coded labels and notifications whenever a patient was due for a vaccine. And when we needed specialist care, it was just a click away.

If I’m honest with myself (and I hope I don’t regret saying this publicly), I felt much more at ease in the latter clinic environment, where I was able to pend orders for any test I thought a patient needed, trend patients’ lab values, and declare confidently that I thought a patient could benefit from such-and-such specialist care, knowing that it was a viable option rather than a hopeful suggestion. My first two years of medical school trained me to think about what diagnoses were possible, then immediately what labs and imaging studies were needed to work these diagnoses up. I was lost in the world of rural medicine when sometimes the test to work something up was not an option. My time in Humboldt gave me much-needed perspective – not only into how far medicine has come but also what medicine was once like, and where I stand in the middle of it all.

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

Photo of Hamsika Chandrasekar by John and Jean Montgomery

Events, Patient Care, Public Health

During Stanford talk, U.S. Surgeon General calls for creation of a “culture of prevention”

During Stanford talk, U.S. Surgeon General calls for creation of a "culture of prevention"

Dean’s Lecture with Dr. Vice Admiral Vivek Hallegere Murthy at Berg Hall, Li Ka Shing Center at the Stanford University Campus on Wednesday, October 7, 2015. ( Norbert von der Groeben/ Stanford School of Medicine )

Updated 10-23-15: Video of this talk is now available here.


10-13-15: “In few other places in the world would the son of a rural farmer from India be asked by the President to serve the health of an entire nation,” remarked U.S. Surgeon General and Vice Admiral Vivek Murthy, MD, MBA, as he opened the latest Dean’s Lecture here last Thursday.

In making the remark, Murthy recalled the words spoken to him by Vice President Joe Biden, when Murthy became the nation’s 19th Surgeon General and the first of Indian descent.

“My story is part of the immigrant story that makes up America,” he said, describing his childhood with highly supportive parents who emigrated from India and settled in Florida, where Murthy and his sister worked weekends in their parents’ primary care clinic.

The experience led Murthy to medical school at Harvard — “I tried to come to Stanford, but it was vetoed by my mother, who was afraid of earthquakes”—followed by an extraordinary list of pursuits that included founding the nonprofit Doctors for America and biotech startup TrialNetworks.

Murthy’s background is now helping to inform his work as surgeon general, which has brought him to places all across the country during his ten-month tenure. He said his travels have reinforced two main themes: America faces an overwhelming burden of disease that is largely preventable, yet many Americans are beginning to lose faith in their ability to improve their own health.

“We invest relatively little in prevention and pay for it much later, often in the form of chronic illness — but that is something we can change,” he noted.

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In the News, Medicine and Society, Palliative Care, Patient Care

In the wake of passage of new end-of-life law, a call to help those who don’t want to die

In the wake of passage of new end-of-life law, a call to help those who don't want to die

end-of-lifeAs discussed here and elsewhere, the big medical-related news last week was California’s new end-of-life law. After the law was signed, Karl Lorenz, MD, a professor of medicine at the Palo Alto Veterans Medical Center, and two of his Stanford colleagues wrote in the Sacramento Bee about an aspect of end-of-life care they say wasn’t addressed in the debate over the legislation: how to improve the situation for those very sick patients who don’t want assistance dying.

After writing that “most of us want an effective treatment for pain, not a life-ending prescription,” the authors ask:

Will our legislators advocate for better end-of-life care? Will they invest in quality measures and public reporting that help us choose a good and not just a shorter end? Will they fund an electronic registry so that patients’ decisions against life-sustaining treatment are readily available? Will they make transparent the financial incentives for more efficient end-of-life care or support training in palliative care for nurses, social workers and physicians?

Such solutions represent the investment that most of us need to avoid an end that we mostly don’t want…

Previously: Stanford bioethicist weighs in on California’s new end-of-life lawHow would you like to die? Tell your doctor in a letterStudy: Doctors would choose less aggressive end-of-life care for themselvesStanford experts weigh in on spate of “right to try” laws for the terminally illOn a mission to transform end-of-life care and The importance of patient/doctor end-of-life discussions
Photo by Shutterstock

Patient Care, Public Health

Survey of e-patients offers insights on patient engagement and access to health care

Survey of e-patients offers insights on patient engagement and access to health care

6842253071_a9b35831c0_zPeople who seek out medical information and want to have a more active role in their health care are increasingly becoming the norm. To learn more about this growing community of engaged patients, Inspire, the largest online community of e-patients in the United States, surveyed 13,633 of their members, representing 100 countries on six continents.

The results of the company’s survey were recently released in the online report “Insights from Engaged Patients: An analysis of the inaugural Inspire Survey” (link to .pdf). Among the key findings:

  • About 55 percent of patients are “well-prepared for their doctor’s visits” and bring a buddy to assist with their appointment. (As one survey participant reported, “The more I inform myself with accurate information on the medications taken, or the medications available, the more I am able to have meaningful conversations with the doctors concerning treatment.”)
  • 52 percent of patients are largely responsible for initiating conversation with their physicians about potential new treatments.
  • Two-thirds of patients use social networks as a source of information and support for their health conditions.
  • Half of all patients reported having difficulty with the affordability of their medications at some point in their life.
  • 72 percent of U.S.-based patients reported experiencing some increase in their healthcare costs.

You might think that since the people surveyed were members of an online health community, they’d all be savvy, avid users of every kind of heath app and gadget. Nope. Instead, 72 percent of survey-takers reported they’d never used a smartphone app for their health-care needs. Moreover, less than half of the people surveyed reported feeling that such an app would be useful to them.

The rest of the report, which illustrates there are clear barriers that prevent people from adopting health-care technology and from getting the care and medications they need, is worth a read. (And, as a reminder, we’ve partnered with Inspire on a patient-focused series that appears here once a month.)

Previously: Engaging and empowering patients to strive for better health“What might they be interested in learning from me?” Tips on medical advocacy and A wake-up call from a young e-patient: “I need to be heard”
Photo by UW Health

Ask Stanford Med, Patient Care

Diagnostic errors: “A complex problem that requires a many-pronged, multi-level attack”

Diagnostic errors: "A complex problem that requires a many-pronged, multi-level attack"

A landmark Institute of Medicine report released last last month showed that despite dramatic improvements in patient safety over the last 15 years, diagnostic errors have been the critical blind spot of health-care providers.

Kathryn McDonald, executive director of Stanford’s Center for Health Policy/Center for Primary Care and Outcomes Research, is a member of the committee that wrote the report, “Improving Diagnosis in Health Care.” I recently spoke with her about the report’s findings and also got her suggestions for limiting one of the most overlooked health-care dilemmas today. Among our Q&As:

Q: You outline eight goals that physicians and health-care providers should follow in their diagnostic practice. Which do you believe are the most significant?

McDonald: They are all important. I know that isn’t a satisfying answer, but this is a complex problem that requires a many-pronged, multi-level attack from education to payment system reforms. We tried to be bold and aspirational, while grounded in the existing evidence. I guess if I had to underscore a goal where I am most optimistic that it will make a difference in the short run, I’d point to the teamwork one. There is a growing evidence base that the benefits of teamwork accrue to all members of the team, so this recommendation has the potential to be a win-win for all involved. Improving diagnosis is quite challenging, partly because making a diagnosis is a collaborative effort and involves many, often iterative, steps — few simple ones. These steps can unfold over time, across different health-care settings, and usually involve diagnostic uncertainty. All the moving parts, all the different types of expertise, all the people involved, well that’s a call for teamwork. This IOM report and the challenge of improving diagnosis puts health-care organizations on the hook for ensuring that health-care professionals have knowledge and skills to engage in effective teamwork — both interprofessionally and intraprofessionally. And the goal doesn’t stop there. We also recommended, as part of this first goal, that health-care professionals and organizations should partner with patients and their families as diagnostic team members, and facilitate patient and family engagement in the diagnostic process, aligned with their needs, values and preferences.

Beth Duff-Brown is communications manager for the Center for Health Policy and Center for Primary and Outcomes Research (CHP/PCOR).

Previously: Better communication between caregivers reduces medical errors, study finds

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