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SMS Unplugged

Medical Education, SMS Unplugged

When the white coat comes off: Is “medical student” a full-time profession?

When the white coat comes off: Is “medical student” a full-time profession?

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.

P1000878In our transition to medical school as first-year medical students, one significant part of our learning has been adopting the dress of the medical profession. Twice a week, in our first year Practice of Medicine course, we wear professional attire and don our white coats, the famous symbol of the medical profession. As we learn how to interview and interact with patients, the white coats encourage us to fully embrace our new professional roles as physicians in training.

At first, the strong symbolism of the white coat made me highly aware of the different roles and personas that we occupy as medical students. If the white coat symbolized my role as a professional, wearing a T-shirt and shorts to my developmental biology class symbolized something decidedly more student-like. In many ways, being able to take off the white coat and hang it up for the day was a convenient way to demarcate our different selves: our professional persona on the one hand, and our “normal” (and more familiar) role as students on the other.

Over time, however, I began to feel a shift in terms of what that my “normal” self was. As I spent more and more time practicing clinical skills that involved helping people to feel comfortable, respected, and cared for, it felt only natural to adopt these qualities in my daily life. After all, after devoting a great deal of effort doing the little things to help make the lives of our patients better, did it really make sense to stop putting in the same effort when interacting with the rest of the world, just because the white coat and badge came off? Is our role as physicians only to help the patients who are sitting in front of us, or should we be thinking about our impact on the well-being of everybody we interact with, from our faculty and staff to the person answering the customer service complaint line?

In some ways, this idea of adopting the professional persona full-time is a scary one. Work-life balance is one of the most discussed concerns among medical students, and many (if not all) of us have fears of our work dominating our lives and keeping us from important things in our lives such as family and friends. Because of this, I have a feeling that the separation that the symbolic white coat offers will become more and more important for us as our careers progress and we become more immersed in our work lives.

That being said, I also acknowledge that, as medical students, the professional persona can help us to consider our daily impact on the world around us, which just might influence the health and happiness of a few extra people each day. For now, then, I’m willing to admit that perhaps there is a little more value to taking our professional mindset home with us than I first realized.

Nathaniel Fleming is a first-year medical student and a native Oregonian. His interests include health policy and clinical research. 

Photo courtesy of Nathaniel Fleming

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

 

Medicine and Society, SMS Unplugged

Why I screamed when my boyfriend hugged me

Why I screamed when my boyfriend hugged me

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.

black and white rocksI was checking my email when it happened. My boyfriend had texted me saying that he was late arriving to the airport. So I stood outside with my suitcase behind me and clicked to an email from my mother.

I didn’t notice until too late that someone had approached me, and I screamed when I saw a black man reach out to grab me from the corner of my eye. Before the sound reached my ears, I realized it was my boyfriend, excited to have surprised me. I unfroze my arms as quickly as possible and embraced him.

We never talked about it. In the car ride back to Stanford, where we were both seniors, we talked about our upcoming spring break. I wondered if he had noticed other people on the sidewalk turn to stare at us. I wondered if he would ever surprise me at the airport again.

Mostly though, I chewed on the newfound knowledge that I had prejudices. Would I have screamed if a white man had grabbed me? An Indian man? A Hispanic man? Probably. I knew girlfriends who had been assaulted by all of the above during our time in college.

Regardless though, the thought in my mind when I screamed was not fear of being assaulted, it was fear of a black man. And I’m so ashamed to put this to words. I am half white, half Hispanic and grew up with a family that values diversity. I have been blessed with friends of all different backgrounds. So if I, with a liberal, multicultural upbringing had a prejudiced reaction in a moment of stress, I shudder to imagine what lies dormant and unrecognized in other people’s minds.

The question is not whether we are prejudiced. We are. Every single one of us in some way or other categorizes people by how they look and assign a danger factor to them. It’s how we are biologically wired to survive in nature.

The question is what we are going to do about it. In the quiet of our own home when no one is watching, are we going to unpack our assumptions and examine how we can improve ourselves? Are we going to encourage each other to go out of our comfort zone, to open ourselves to ridicule for admitting that we are imperfect, to challenge ourselves to be better?

My boyfriend and I are no longer together. We are at separate medical schools and I know that one day, when we are doctors in our respective specialties, I may call him for advice on the health of a loved one. I know that I will trust him more than I trust many of my peers who happen to be white.

And it hurts me to know that sometimes, it won’t matter that he has a gentle soul. Sometimes, the world will see him as dangerous before even looking.

Ferguson has hit our nation, our people, hard because it lives in every home – black, white, yellow, red or brown. It’s not a controversy over hyper-reactive policemen or a history of slavery. It’s a slap in the face that every single one of us has to own up to our discriminatory thoughts and grow. Americans need to grow as people and as a people. We the people need to become a we, not an us and a them.

Natalia Birgisson is a second-year student at Stanford’s medical school. She is half Icelandic, half Venezuelan and grew up moving internationally before coming to Stanford for college. She is interested in neurosurgery, global health, and ethics. Natalia loves running and baking; when she’s lucky the two activities even out.

Photo by Chris_J

Medical Education, SMS Unplugged

My couple's match: Applying for medical residency as a duo

My couple's match: Applying for medical residency as a duo

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.

Moises and fianceIn my last post, I wrote about the pressure that comes with the scrutiny of residency applications and the interview process. Adding to this, many applicants apply alongside their significant other, making use of the “couple’s match” option. Let’s think about that: No longer do you have to stress for yourself, but now you worry for your partner too. And while your primary concern is for them to do well in the match for their own success, it’s hard to overlook the fact that their outcome directly impacts your own.

This spring I’ll be couple’s matching with my fiancé, also a Stanford medical student. We both recently took part in our first interviews, and I’m not sure whether I was more nervous for mine or for hers. While she was at hers I was wishing and hoping for the best; while I was at mine, I was thinking about how my interview reflected on her as well. The topic of applying as a couple has come up many times during medical school, and I expect I’ll be asked it during future interviews.

When I talk to other students who are in relationships with fellow med students, I typically hear two things. Some people say it’s ideal to have a partner outside of medicine, so as to have an escape in their personal life. Others believe that a real benefit of having a partner in the same profession is the understanding that comes with it. I’d say they’re both right. My fiancé and I had to deal with the normal challenges of growing as a couple, but we’ve had to do it in front of shared friends, professors, and clinical teams – which was less than ideal at times. Ultimately (and fortunately), though, these challenges have only contributed positively to our development as future physicians.

Also lucky for us, Stanford’s pass/fail grading scheme during pre-clinical years helped reduce tensions when studying together. In a productive learning manner, it didn’t matter who did better, simply that we were able to help each other pass. Step 1 challenged this a bit: The score mattered. I have to admit getting sucked back into a competitive persona more than I would have wanted – something that didn’t make life much fun for my fiancé at times. Still, those long days of reviewing First Aid and USMLE World were made more tolerable by having her by my side.

We didn’t plan it this way, but our clerkships never overlapped – and the benefit was that we could fill the other in on the quirks of each service. I sure appreciated the heads-up and tips on how to fit into the ob/gyn team. And it was nice to see us each develop our special interests – hers in pediatrics and me in emergency medicine. We’ve started turning to each other with respective questions, making the learning stick better.

The National Resident Matching Program has a different process for matching couples than they do for those going solo; it’s not just about her top choice or my top choice, it’s about the best choice for us as a couple. That could mean an option that places me at my fourth-choice program while she’s at her first, but that’s a win in my book.

As geared as we are in our type-A personalities for personal success, working next to my fiancé in medical school has taught me how to enjoy selfless happiness. I have two envelopes to open come Match Day: twice the pressure, but twice the fun.

Moises Gallegos is a fourth-year medical student. He’ll be going into emergency medicine, and he’s interested in public-health topics such as health education, health promotion and global health.

Previously: “It’s tough feeling like you’re always in a position to be judged” and other thoughts on medical school
Photo courtesy of Moises Gallegos

Medical Education, SMS Unplugged, Women's Health

Learning the pelvic exam with Project Prepare

Learning the pelvic exam with Project Prepare

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.

This past Friday, half my class crowded into a small room in the basement of the Li Ka Shing Center. When we walked in, we saw our names written on the board, under one of the following headings: “Male Pelvic Exam,” “Female Pelvic Exam,” and “Female Breast Exam.”

It felt like a safe space to make mistakes, ask questions, and fumble a little bit – without feeling like I was in over my head

For many of us, this was our first session of Project Prepare – a 3-session, 8-hour course designed to teach medical students how to provide supportive care for patients in the area of sexual health. (The history of the program is included in this article.) The teachers in Project Prepare take the dual role of patient and educator, using their own bodies to help students learn how to perform pelvic and breast exams.

This was my first day of the course, and I was scheduled to do the female pelvic exam session with a patient-educator whom I’ll call Stacie. I had heard from other classmates who had already done this session that it was “intense” and that it took some time to emotionally recover afterwards. I’d heard from others that it was “incredible;” one classmate even said it made her to want to be a Project Prepare patient-educator herself. The many mixed messages rolled together in my mind and distilled into a single overwhelming sense of anxiety.

But Stacie made everything so easy. She didn’t beat around the bush about how awkward or uncomfortable the experience could be. The first thing she asked us was, “What have you heard about Project Prepare?” and when I said I’d heard it was “intense,” she responded, “Why do you think that is?” In doing so, she set the tone for the rest of the afternoon: gentle, filled with open-ended questions and non-judgmental responses.

Over the next three hours, Stacie guided a fellow classmate and me through the exam techniques and word choice that accompany the 5-part female pelvic exam. She pointed out nuances that would never have otherwise crossed my mind, like how saying “that’s perfect” and “great” are fine in other parts of a medical interview or exam but painfully awkward and even inappropriate in the context of a pelvic exam.

After the session, I looked up Project Prepare, curious as to how many medical schools invite the team to their campuses. I was surprised to see that only Stanford, Touro University College of Osteopathic Medicine (both in CA and NV), Kaiser, and UCSF are on Project Prepare’s list of clientele. Though I still have two sessions left, it is so clear to me that Project Prepare is a unique, effective way of teaching students the pelvic and breast exams. As a medical student, the idea of doing these delicate exams for the first time on a real patient (one who is not simultaneously a trained educator) is terrifying. I had this experience last year, at Stanford’s Arbor Free Clinic, where I performed my first pap smear, with the guidance of an attending physician. I recall how scared I felt that I might hurt my patient and somehow “mess up.” In contrast, my experience with Project Prepare felt like a safe space to make mistakes, ask questions, and fumble a little bit – without feeling like I was in over my head.

This week, I have two more sessions with the Project Prepare teaching team, and this time, my feelings leading up to the sessions are colored with excitement rather than anxiety. To the Project Prepare patient-educators: Thank you so much for sharing your time, your knowledge, and most of all, your bodies, with us, as we take this journey from classroom to clinic. Our medical school experience feels more complete because of you.

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

Previously: Reality Check: When it stopped feeling like just another day in medical school

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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Medical Education, SMS Unplugged, Surgery

Rituals of the body – honoring the loss of bodily wholeness in medicine

Rituals of the body - honoring the loss of bodily wholeness in medicine

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.

footWatching my first below-the-knee amputation on my surgery rotation, I felt a curious mix of revulsion and detachment. The woman on the operating table had a gangrenous infection that had spread across her foot. Her long history of smoking and her delay in seeking medical care meant that she had stiff, black toes by the time a surgeon first saw her. The only treatment was amputation.

In the operating room, the patient was draped such that only the leg was visible and exposed. The first incision was easy, a semicircle around the calf, and then the surgeons dissected down further until they hit bone. A bone saw sliced its way through the tibia, while the slimmer fibula was taken apart in chunks with a bone cutter. The skin and muscle were cut in a flap; the flaps were brought around over the bone and sewn together to create the stump.

The amputated leg sat on the scrub nurse’s table, next to a tray of retractors. The foot was balanced upright. The skin was smooth until the edge, where it gave way to jagged edges of flesh, remnants of blood vessels, and two cross-sections of bone. I felt unsettled with the amputated portion of the leg so close to me, a graphic reminder of what was lost.

What was it that troubled me? Maybe it had been the ordinariness of the moment when the body was divided up, its fibers severed with precision and focus, but no surprise, no significance. This patient would wake up some hours later, still groggy from the haze of anesthesia. Though she had signed a consent form, though this surgery had saved her, I wondered how she would she feel when she looked down at her leg.

Even in the absence of phantom pains or other sensory reminders of the missing part, dealing with an amputation is hard. It breaks the taken-for-grantedness of the body. It forces people to move through the world in new ways. These experiences made me think, can we imagine any ritual to mark a loss of bodily integrity? A pause to appreciate the work the body has done, and to prepare ourselves for its new form?

I witnessed many bodily transformations on my surgery rotation, as we do in medicine every day. But in our increasingly technical engagement with patients, do we forget the many social and cultural meanings of the body and its parts? Like why a patient may ask for his rib back after it is excised from his chest well to relieve obstruction, or why grieving parents of a stillborn child may want to bury the baby with her placenta? Perhaps a ritual could help physicians recover the awe and the empathy toward bodies we care for, and further connect to how our patients make sense of these changes.

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Medical Education, SMS Unplugged

"It’s tough feeling like you're always in a position to be judged" and other thoughts on medical school

"It’s tough feeling like you're always in a position to be judged" and other thoughts on 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.

One of the hardest parts about medical school for me has been the constant pursuit of approval. Having a pass/fail system during pre-clinical years helped ease things some, but there remains a personal desire to prove myself. In front of attendings, all I can focus on is performing my physical exam just right, presenting in the perfect manner, and nailing the assessment and plan. Unfortunately, my strong desire to look good in my evaluators’ eyes has led to missing learning opportunities at times. For example, I often passed up offers to do a procedure I really wanted to do, for fear that I would look bad if I messed up.

It’s tough feeling like you’re always in a position to be judged.

As I find myself in the middle of residency applications, I realize that this feeling of scrutiny has been elevated to a whole new level. And from this point, I’ll be judged on what is already done and how I’ve been evaluated on my rotations over the last few years. I can’t do anything more to change the “me” that those who review my application see. Part of the process is an interview, but it seems as if the interview has been taking place since I began medical school.

I’m extremely grateful for the training and preparation that Stanford has provided me, and I’m confident in my application – but the uncertainty is real. And the way I see it, my success with residency applications isn’t just reflective of me: I want to make my family and the Stanford faculty and mentors who have supported me along the journey proud.

As stressful as this process and the worry about judgment are, though, I’ve been trying to re-focus myself and “check my privilege.” To even be in the position of applying and interviewing for residency is huge. I’m months away from being able to put MD behind my name. As much as I could complain about how hard medical school has been, I’ve been blessed with a wonderful opportunity to be in a position to care for people when they most need it. And, in fact, of all the evaluations that we’re required to seek during a rotation, the ones I value most are from patients and their families.

For me, medicine comes easiest when my patients and their health outcomes are front and center in my mind –  not whether I stand out to my team or answer a tough question correctly. And so with my future patients in mind, it’s time to suit up (tie-clip and all). The work’s been done.

Moises Gallegos is a fourth-year medical student. He’ll be going into emergency medicine, and he’s interested in public-health topics such as health education, health promotion and global health.

Photo in featured-entry box by Yuya Tamai

Medical Education, SMS Unplugged

Why “looking dumb” in medical school isn’t such a bad thing

Why “looking dumb” in medical school isn’t such a bad thing

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.

hands in air - longerIf I had to choose one theme that has stood out in the first weeks of medical school, it would be this: questions, questions, and more questions. In the first class on our first day of medical school, our professor set the tone by laying down the requirement that we ask a minimum of ten questions before the lecture was over. Based on my experience in large undergraduate lectures, where questions were as rare as rain in Palo Alto, I naively thought this would be a challenge for us. To my surprise, we met the challenge and probably asked at least twenty questions in that first class alone.

This first day set the tone for the rest of our time together so far, and my class has quickly gained a reputation among the faculty for the volume of questions that we ask. It’s a common occurrence for a lecturer to be moving along smoothly, only to look up and see four or five hands in the air, of people waiting patiently to ask for clarifications, pose hypothetical situations, or simply admit that the last lecture slide was way too confusing. More than one class session has been derailed and run out of time because of our frequent interruptions. One of our professors memorably poked fun at us by hinting – not very subtly – that our class had no problem with “looking dumb” in front of our peers.

Given the amount of important information and interesting ideas that I’ve learned through my classmates’ questions, I’ve quickly come to feel that learning how to ask questions is an important part of my early medical training. However, this can be a difficult thing. By asking a question in public, you’re more or less admitting to everybody in the room that you didn’t know the answer; that you needed help from somebody else to get the information. Only certain learning environments – namely, with a close group of non-judgmental peers and willing professors – are conducive to this.

With that in mind, what will happen with our class as we move through our medical training? I’m hopeful that our willingness to ask questions will continue, along with the receptiveness of our teachers and mentors. As first-year medical students, we’re not expected to have a vast medical knowledge yet, so admitting “I don’t know” is relatively easy. But what will happen in a few years, when we reach the clinics and are expected to be able to put the knowledge from our first two years to use? Or more importantly, what will happen when we are fully trained physicians, and our patients expect us to have all the answers? When we don’t have the answers, will we be as willing to ask for help as we are now? As a patient, I would certainly hope that my physician would be willing to ask the right questions when needed. Because of this, I think our class can and should aspire to keeping the flood of questions coming.

Nathaniel Fleming is a first-year medical student and a native Oregonian. His interests include health policy and clinical research.

Image by Kaz

Obesity, Pediatrics, Public Health, SMS Unplugged

When the wheels on the bus (don't) go round: Driving the spread of local health programs

When the wheels on the bus (don't) go round: Driving the spread of local health programs

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.

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A few years ago, I was doing a summer internship in which I looked at health outcomes for hospitalized patients. I sat in an office and read about patients with issues like high blood pressure and cholesterol. At a certain point, I realized that the reports on their outcomes were interesting, but the real solution to the problems I was studying was happening outside my window. My window overlooked a park, where kids would run around all day until they were exhausted. And it got me thinking that if all kids were as active as those ones, there would a lot fewer reports for me to read.

So last year, I worked with several medical and law students to design a county-level childhood obesity prevention policy. The need for such programs is self-explanatory: More than one third of children in the U.S. are overweight or obese. By the time people reach adulthood, that proportion goes up to two thirds. By creating a team of both medical and law students, we hoped to come up with approaches that achieved the goal of improving health, and did so in a practical and implementable way.

Over the course of several months, we analyzed dozens of programs that have been used to bring down childhood obesity rates in various communities across the country. The programs ranged from well-known approaches (e.g. a soda tax or menu calorie counts) to some more obscure ones. My personal favorite was the “Walking School Bus” (WSB). Think about how your parents used to tell you that things were tougher in their day when they had to walk to school (in the snow, going uphill, barefoot, etc.). The goal of a WSB is to bring that world back. The catch is that parents/adults walk along a predetermined “bus” route, pick up kids along the way, and then walk them to school. Kids get a supervised walk that allows them to get some exercise every day.

Case studies, and one meta-analysis, suggest that WSBs are an effective way to increase the amount of exercise kids get. But odds are, you’ve never heard about them before. Neither have most school officials, local politicians, and others in a position to take action on childhood obesity. That’s because WSBs are not widely used. This realization led me to an interesting question: Which factors make a local program or intervention spread to other communities? What does it take to turn a single success story into a widespread strategy?

These are hardly new questions. Every business or non-profit that plans to scale up considers it. Atul Gawande, MD, attempted to figure out why certain medical interventions spread in a New Yorker article last year. Whether you’re talking about social programs, technology, or just an idea, the question remains. I don’t pretend to have the answer, but my work reviewing obesity prevention policies did lead me to a few conclusions about the spread of local programs.

First, success is necessary but not sufficient for a program’s spread. Just because it proves to be successful does not mean anyone else will adopt it. WSBs were one example. Granted, WSBs are not adaptable to every community – they require schools to be within walking distance and rely on good weather. But the same story is true for other approaches. For instance, joint-use agreements are a strategy where schools open up their facilities (e.g. outdoor fields, basketball courts, etc.) after school hours to give children and families access to recreational space. Despite a correlation between these agreements and better health outcomes, they remain in limited use in many of the communities where recreational space is most lacking.

So if success doesn’t lead to a program’s spread, what does? I believe one factor is the involvement and enthusiasm of multiple stakeholders, potentially including local government, businesses, school administrators, and involved community members. A second factor is the development of measurable and achievable goals. It is nearly impossible to see incremental changes in health outcomes, so programs designed to change health must establish metrics that can demonstrate progress.

The list of lessons from our survey of local programs goes on, but the biggest takeaway is clear. Problems in health care require not only a solution, but successful execution.

Akhilesh Pathipati is a second-year medical student at Stanford. He is interested in issues in health-care delivery.

Image by EME

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