Stanford News

The Stanford University Medical Center Alumni Association (SUMCAA) is partnering with Doximity, a social networking service for physicians and health-care professionals, to test a new application for iPhone and Android devices.

The app, which the parties say is the first of its kind for any U.S. medical school, is built on Doximity’s network of over 50,000 physicians. Using the app, alumni can quickly access a searchable directory of published articles, lectures, clinical trials and curriculum vitae, and converse in an alumni-only forum.

The app is being made available starting today to a limited population of medical school alumni. To request access to the test group, please e-mail Doximity’s Taylor Carrol. All SUMCAA members will be able to download the app for free at the end of the month.

Stanford medical student Matt Goldstein, PhD, who is a research fellow with Doximity, commented on the app’s potential to foster collaboration, saying, “Research has shown better communication leads to better care. But like many of my classmates, I’ve had to stop using Facebook. It will be interesting to see what impact this app has on sharing clinical expertise and improving patient care.”

Previously: Stanford-developed iPARS app available for download, Mercury News looks at how clinicians are using medical apps and Study finds more doctors are using smartphones
Photo courtesy of Doximity

Physicians in rural areas in California are in short supply, and some fear the scarcity could grow more severe. But telemedicine might prove beneficial in these parts: Research has shown increased use could help reduce health disparities between rural and non-rural areas.

David J. Wong, MD, PhD, a Stanford dermatologist and cofounder and CEO of Direct Dermatology, stands among health-care providers working to increase the reach of telemedicine. His company brings medical dermatology expertise to poor and underserved populations in California to treat serious and even life-threatening conditions including melanoma, psoriasis and problems of the skin, hair, and nails.

A panelist at last week’s Healthcare Innovation Summit at Stanford, Wong believes a social mission driving a for-profit company can deliver healthy results. He discusses his company’s work and how it fits into broader efforts to improve rural medicine in a Stanford Graduate School of Business Q&A.

On explaining how Direct Dermatology visits work, he says:

The interaction is asynchronous. It’s not a live interactive visit over Web cams. A patient takes a picture of their skin problem, then sends in that picture along with their medical history. And then a dermatologist will review it, and send back a report and any prescriptions that are needed. We have a two-day turnaround. Dermatology is such a visually based specialty that dermatology consultation works well through images.

Later in the interview, he talks about how his work is relevant to other medical specialties:

While some specialties will always require some live interaction, nearly every specialty can provide better access, higher quality care and lower cost by integrating telemedicine in some fashion. Dermatology is a great one to start with as a proof of concept, because it is so visually based. But we believe similar concepts can be spread to other specialties.

In ophthalmology, for example, much of the exam is based on images of the retina. Cardiologists are looking at EKGs and echocardiograms. A lot of those types of images you’d have to first acquire at a lab or clinic, and then send them in. That being said, there is a growing number of home consumer appliances that will take your EKG, for example. And consumers will be soon able to send those in directly to their physicians.

A 2010 study showed that online dermatology visits, similar to those described by Wong, can be as effective as office visits and can save patients time.

Previously: Ask Stanford Med: Stefanos Zenios taking questions on health-care innovation and entrepreneurship, Phoning in your specialized medical tests and Can telemedicine work for dermatology patients?
Photo by mysiana

In a story online today, I describe how a team led by Stanford’s Carlos Bustamante, PhD, and Sean Myles, PhD, discovered that the gene for blond hair arose independently in the South Pacific nation of the Solomon Islands. The researchers identified the islanders’ “blond” gene and discovered it’s not the same gene that causes blond hair in Europeans.

Reporting the story was so much fun. I learned from Myles, who spent a month there gathering the data, how important it is to get the village chief on board when doing genetic research in the Solomon Islands, that Solomon Islanders’ saliva (which he collected for the study) is often bright red from chewing betel nut, and that on one of the islands (with an active volcano) you can cook by simply burying the food in the hot ground for a while. “The beaches are pristine, water super blue. You can hear the fish jumping in the water. It’s what a lot of people would think of as paradise,” he told me. Wow, what a trip.

The genetic finding, published in the May 4 issue of  Science, has a certain “wow” appeal too, and the researchers say there’s a serious message that comes along with it. As Bustamante told me, the finding underscores the importance of genetic studies on isolated populations like the Solomon Islanders:

If we’re going to be designing the next generation of medical treatments using genetic information and we don’t have a really broad spectrum of populations included, you could disproportionately benefit some populations and harm others.

Myles, now an assistant professor at Nova Scotia Agricultural College, expands on this on his lab’s website:

Our result is therefore a call for action. We must take steps now to ensure that the benefits of current genomics research extend beyond privileged populations and provide an increase in well-being for people everywhere. Humanity’s natural genetic diversity is vast and fascinating – we should be measuring and assessing it all! The same applies for genomics research in agriculture. A continued focus on a small number of elite individuals in plant and animal breeding is myopic and dangerous. An immense amount of existing genetic diversity that is essential to our future well-being is being ignored. Whether it’s us or our food that we research, our aim is to cultivate an appreciation for natural genetic diversity. Our future depends on it.

Photo of a child from the Solomon Islands by Sean Myles

To make better use of the fixed amount of educational time available to train doctors, dramatic changes are needed in medical education including re-imagining the traditional lecture format, according to a perspective piece to be published tomorrow in the New England Journal of Medicine by two Stanford professors.

In a piece, titled “Lecture Halls without Lectures–A Proposal for Medical Education,” Charles Prober, MD, senior associate dean for medical education at the School of Medicine, teamed with Chip Heath, PhD, a professor of organizational behavior at the Stanford Graduate School of Business, to look toward optimizing medical education.

Teaching practices haven’t innovated in step with the rapidly expanding body of medical knowledge, they say, noting that the last major reform occurred in 1910. From the perspective piece:

It’s time to change the way we educate doctors. Since the hours available in a day have not increased to accommodate the expanded medical canon, we have only one realistic alternative: make better use of our students’ time.

The authors draw from a new educational model that reverses the traditional teaching method of classroom time being reserved for lectures and problem-solving exercises being completed outside of school as “homework.” Known as the “flipped-classroom” model, the approach was popularized by institutions including the nonprofit Khan Academy.

We propose embracing a flipped-classroom model, in which students absorb an instructor’s lecture in a digital format as homework, freeing up class time for a focus on applications, including emotion-provoking simulation exercises. Students would welcome more opportunities for case-based, problem-based, and team-based exercises–strategies that activate prior knowledge. Teachers would be able to actually teach, rather than merely make speeches.

This year, the core biochemistry class at Stanford’s medical school was redesigned to follow this model. The lecture-based format was replaced with short, online videos that students watched on their own time. During class time, instructor facilitated interactive discussions of clinical vignettes that highlighted the biochemical bases of various diseases.

Early experimentation with this model has been extremely positive with substantial increases in student reviews of the course and gains class attendance from 30 to 80 percent, despite attendance being optional, according to a release.

Previously: Stanford dean discusses changing expectations for medical students, Think medical education takes too long? So does Victor Fuchs and A quick primer on getting into medical school
Photo by Stanford EdTech

On Thursday evening, Rep. Tim Ryan (D-OH) will visit Stanford to participate in Conversations on Compassion, a talk series sponsored by The Center for Compassion and Altruism Research and Education (CCARE).

During the event, CCARE director James Doty, MD, will talk with Ryan about how meditation-based practices can be used to address societal difficulties facing America, as described in his book A Mindful Nation. Currently serving his fifth term in the U.S. House of Representatives, Ryan began incorporating meditation techniques into his daily life after attending a retreat in 2008 conducted by Jon Kabat-Zinn, PhD, at the University of Massachusetts Medical School. In his book, he details scientific findings that support meditation’s beneficial effects and explores examples of how meditation programs have been implemented in a variety of settings, including boardrooms, research labs, and military bases, across the country.

The hour-long talk begins at 5:30 p.m. in McCaw Hall at the Frances C. Arrillaga Alumni Center. The event is free and open to the public.

Previously: Neurotheology: Investigating the relationship between the brain and spirituality and Dalai Lama and Stanford researchers explore science of compassion and altruism
Photo by Anne Wu

The U.S. Food and Drug Administration sometimes finds out that a drug it has approved for the market has dire and unanticipated side effects. A report released today by the Institute of Medicine suggests steps to help the agency catch such problems earlier in the process.

A key point is for the FDA to use more vigorously its authority to order additional studies after a drug is on the market. “Right now many studies are commissioned mainly when there’s a fire,” said Stanford Professor Steven Goodman, MD, PhD, a co-chairman of the Institute of Medicine (IOM) committee that produced the report, in an interview with me last week. “We think it’s better to initiate them when there’s just smoke.” Goodman is the medical school’s associate dean for clinical and translational research and a professor of medicine and of health research and policy.

The report comes as Congress is considering legislation reauthorizing the user fees that help to fund the FDA and is weighing ways to improve the agency’s drug-approval and tracking systems. Recent situations with the antidiabetes drug Avandia, the pain-reliever Vioxx and the cholesterol-reducing drug Crestor underscore the need to adopt new safety measures. The report proposes some factors that could indicate the need for a post-approval study. According to a release from the IOM:

[The report] identified some circumstances in which a product’s benefits or risks are particularly uncertain, including “first in class” drugs that have been approved based on surrogate endpoints used previously for other drug classes, and drugs for which several endpoints provide conflicting evidence about risk, such as an anti-hypertensive drug that lowers blood pressure but increases weight. In such cases, the committee recommended that FDA require safety research after approval or provide a public rationale for why it is not necessary. Early initiation of such studies could limit the harm done by drugs with risks that are later found to be unacceptable and avoid crises in which the agency is faced with few good options, the committee said.

It’s not every healthcare innovation summit keynote address that can make a person cry–twice, in my case. But then, not every organizing committee brings Anna Deavere Smith to campus for the occasion.

“Shifting Paradigms in Healthcare,” as the 2012 GSB Healthcare Innovation Summit was titled, took a turn from talking technology to looking realities of health care straight in the human face. Smith, an actress, playwright and professor (formerly at Stanford), joined Paul Costello, the medical school’s chief communications officer, in a conversation about current health disparities. The speakers examined issues addressed in Smith’s one-woman show Let Me Down Easy, which premiered in 2009, and Smith brought some of the characters in her play to the attention of the summit attendees through performance.

During the keynote, Smith portrayed an optimistic cowboy, a cynical doctor, a distrustful patient, a wise South African orphanage director, and Philip Pizzo, MD, dean of Stanford’s medical school, to tell their health-care stories as she interpreted them. Drawing from the 320 interviews she conducted while developing her script, Smith detailed instances in which people who sought care instead found abuse or abandonment, and others that showed that the most comforting care for the dying might not be the most scientific.

The presentation balanced the summit’s focus on industry and government innovation by bringing to light aspects of health care that aren’t measured in studies or promised to be reformed by a congressional act. Smith’s straightforward delivery let the characters’ words speak for themselves, communicating personal experiences of hardship instead of pointing fingers of blame.

Smith said, “When you have a crisis, you create narratives to tell someone what this means to you.” Though case-specific, the narratives speak to larger truths. Smith finished her series of characterizations as Trudy Howell, director of Chance Orphanage, who explains death to terminally ill children and sits with them until they depart. The Howell character comments about her approach to working with sick people this way: “In any case, don’t leave them in the dark. Don’t leave them in the dark.”

Previously: Anna of 1,000 Faces: Let Me Down Easy on PBS’ Great Performances, Dean Pizzo’s concerns about healthcare featured in solo show by Anna Deavere Smith and Let Me Down Easy

U.S. Chief Technology Officer Todd Park kicked off the 2012 GSB Healthcare Innovation Summit at Stanford yesterday with a fast-paced talk about how the implementation of the Affordable Care Act (ACA) may affect health policy, business and technology.

Addressing attendees via Skype from Washington D.C., Park spoke excitedly about the challenges and opportunities facing entrepreneurs as provisions in the health law are rolled out. He cited the Harvard paper “Where are the Health Care Entrepreneurs? The Failure of Organizational Innovation in Health Care” in explaining why the pace of  health-care innovation has lagged behind other sectors, and he singled out two roadblocks standing in the way of innovation: economic incentives are wrong and patient data and other medical information is locked away. If the path to reform is unblocked, Park told the crowd, more entrepreneurs will invade health care, to the benefit of both entrepreneurs and health-care consumers. “This invasion is happening as we speak,” he said. “It’s still underground, but it’s happening.”

During his talk, Park touched on ways that the health law’s implementation (which, it should be noted, hinges on the Supreme Court’s forthcoming decision about its constitutionality) and efforts by the U.S. Department of Health and Human Services can dismantle such roadblocks and, potentially, catalyze a technological revolution in the health-care industry. These include:

• Improving transparency: A trust problem prevents more health information sharing from occurring, Park said. Services on HealthCare.gov let consumers compare insurance coverage and pricing options. (See also: ACA Title VI: Transparency and Program Integrity.)
• Making more data available but ensuring privacy: Giving patients access to and control of their own data can empower patients and eliminate inefficiencies. One solution Park called attention to was BlueButtonData.org, which provides patients with a clickable button that allows them to download  their personal medical records from a secure website offered by their doctors, insurers, pharmacies and other health service providers. The technology was implemented earlier this year by the Department of Veterans Affairs, the Department of Defense, and the Centers for Medicare & Medicaid Services.
• Encouraging innovators to use data made available by HHS: Park mentioned Health Data Palooza, the annual forum of the Health Data Initiative,  as an example of how the federal government is fostering public-private collaboration in using HHS data to develop products and applications to improve health.

“I’ve never been more optimistic about the future of our health-care system,” Park said in his concluding remarks.

Previously: Live tweeting Healthcare Innovation Summit and Ask Stanford Med: Stefanos Zenios taking questions on health-care innovation and entrepeneurship

In a Stanford study appearing today in PLoS ONE, researchers show that anxiety-prone mice develop more severe cancer then their calm counterparts. The work, which is detailed in a release, is “the first to biologically connect the personality trait of high anxiety to greater cancer threats.”

Saying that studies in humans are now needed, stress expert and study author Firdaus Dhabhar, PhD, notes:

It’s bad enough that cancer diagnosis and treatment generates stress and anxiety, but this study shows that anxiety and stress can accelerate cancer progression, thus perpetuating a vicious cycle. The goal is to ameliorate or eliminate the effects of anxiety and chronic stress, at least at the time of cancer diagnosis and during treatment.

Leukemia, the most common form of childhood cancer, affects the blood-forming cells in the bone marrow. It is often treated with stem cell transplants that replace the patient’s bone marrow cells with stem cells donated by a healthy individual. Successful transplant depends on finding a donor who is a close genetic match to the patient. That’s a particular challenge for patients from racial and ethnic minority groups, who may die while waiting for a matching donor.

But a mostly-untapped source of genetically diverse stem cells is right under our noses: Blood left in the umbilical cord after a baby is born. Though it has typically been discarded as medical waste, this blood has real value, as a Packard Children’s press release explains:

With the right system in place, cord blood can be collected at no risk to a new mother and baby, and given to unrelated patients who need the stem cells. This public system is distinct from private cord blood banks, which charge families fees to collect cord blood and store it for their own possible use.

“The chance of needing banked cord blood for your own child is very remote,” said Maurice Druzin, MD, division chief of Maternal-Fetal Medicine at Packard Children’s. Because blood cancers are so rare, very few families who privately bank cord blood use the cells, Druzin explained. “But these cells are potentially lifesaving for someone else.”

The more than 4,000 babies born at Packard Children’s each year reflect the diversity of the Bay Area’s population. And the hospital’s new cord blood donation program will give all its new moms the option to donate their baby’s cord blood to an international stem cell registry that can be searched by hematologists and oncologists whose patients need stem cell transplants.

Meanwhile, Packard Children’s has already established a track record of using cord blood donated elsewhere to treat blood cancers and rare inherited blood diseases, explained Rajni Agarwal, MD, the clinical director for pediatric stem cell transplantation at Packard Children’s:

Agarwal is excited that Packard Children’s is coming full circle by collecting cord blood donations as well as using them. “Using cord blood for stem cell transplant is the biggest advance in this field in the past 20 years,” she concluded. “Establishing our new cord blood collection program is a very big deal.”

Photo by Norbert von der Groeben shows Stanford law Professor Amalia Kessler, JD, and her family. During Kessler’s first pregnancy (with Stella, at right) in 2009, she and her husband Adam Talcott were surprised that they could not find a Bay Area hospital that accepted cord blood donations. Baby Ari, at left, became the first to have his cord blood donated through the new Packard Children’s collection program when he was born in 2011.

Updated 12 PM: Due to technical issues we are unable to live tweet the summit keynote address, “Humanizing Healthcare: Why Reform Is So Essential.” We apologize for the inconvenience.

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Today we’ll be live tweeting the 2012 GSB Healthcare Innovation Summit at the Stanford Graduate School of Business. This year’s focus, “Shifting Paradigms in Healthcare,” draws on expertise from business, government and academic leaders to discuss solutions to current U.S. healthcare industry problems in a time of uncertainty and change.

Highlights include a talk by Todd Park, chief technology officer of the U.S. Department of Health and Human Services, titled, “Disrupting the Status Quo: An Update on Healthcare Reform and Its Effect on Innovation.” Park’s talk kicks off the day’s events at 8:30 a.m. Pacific.

The summit’s keynote address, “Humanizing Healthcare: Why Reform Is So Essential,” features Anna Deavere Smith in conversation with Paul Costello, the School of Medicine’s chief communications officer. The two will discuss Smith’s one-woman play Let Me Down Easy, which takes a personal look at the institution of healthcare.

You can follow our tweets on the @SUMedicine feed.

The third leading cause of death in the United States, stroke is also the number one cause of severe neurological disability, accounting for more than $50 billion annually in related costs. Now, research from Stanford neuroscientists and colleagues offers hope of a potential drug treatment to increase the number of new nerve cells in areas of the brain damaged during stroke and enhance patients’ recovery.

In the animal study (subscription required), researchers focused on a compound called LM22A-4, a small molecule whose bulk is less than one-seventieth that of the brain protein it mimics: brain-derived neurotrophic factor (BDNF), a powerful and long-studied nerve growth factor. Critical during the development of the nervous system, BDNF is known to be involved in important brain functions including memory and learning. As my colleague describes in a release:

[The research] team induced severe strokes on one side of the brain in adult laboratory mice that had been previously trained in several distinct athletic tasks. Three days afterward, the researchers administered once-daily intranasal doses of LM22A-4 in a solution to one group of the mice, while giving another group (who had suffered strokes as severe as those in the first group) a similar dose of the same solution without any LM22A-4 in it. Delaying the first dose for three days better tests the ability of this treatment to help stroke patients in the real world, [senior author, Marion Buckwalter, MD, PhD,] said.

Dosing proceeded for 10 weeks, while the scientists monitored both the animals’ recovery of their motor skills and the numbers of new nerve cells in areas of the mice’s brains that had been damaged by strokes.

Mice receiving LM22A-4 regained their athletic prowess considerably more quickly than those given the dummy solution: both the accuracy of their foot placement and the swing speed of the limb on the side of their bodies affected by the stroke improved more rapidly. Moreover, analysis revealed twice as many new nerve cells in these mice’s stroke-affected brain areas, at six and 10 weeks after the event, than in those of their LM22A-4-denied counterparts.

For recovering patients, walking speed is critical, said Buckwalter. “A major factor in their ability to retain their independence and regain their self-confidence lies in their recovering the ability to get around on their feet,” she said.

The results are promising because the compound wasn’t administered to the animals until a full three days after they had suffered strokes, noted Buckwalter. As such, the treatment – if proven effective in humans – could be particularly useful for patients who suffer strokes while sleeping or don’t readily recognize the symptoms and don’t get to the hospital fast enough for existing therapeutic agents to be administered.

Previously: Brain sponge: Stroke treatment may extend time to prevent brain damage, Every second matters for stroke survival, recovery and Newly approved drug appears to provide more cost-effective stroke prevention than warfarin

More than a century ago, Carnegie Foundation research scholar Abraham Flexner completed an assessment (.pdf) of medical schools’ curriculum in North America that acted to reform medical education. While the academic environment is greatly changed since Flexner’s day, the transformation is not as significant as some may think. As Dean Philip Pizzo, MD, writes in the latest issue of his newsletter, these changes have been “more evolutionary than revolutionary:”

It is true that medical schools, including Stanford, have sought ways of better integrating clinical and preclinical education and training – but, for the most part, these remain discrete and even separate experiences.

In a similar vein, the “premedical education requirements” have also changed relatively little – even from the time when I applied to medical school some decades ago.

Central to the discussion of how to improve medical education is the importance of students studying the humanities or the social sciences to develop a “broad educational experience.” Pizzo points out that some institutions are experimenting with formats that encourage such learning, but that students may be reluctant to take courses that seem insignificant in the pre-med path. He writes:

Some schools, the University or Pennsylvania being an excellent example, offer suggested areas for undergraduate study as an alternative to “requirements” (see: http://www.med.upenn.edu/). I believe this is an area needing further discussion and we will be examining whether we should move to a similar “recommendation” model at Stanford. As someone who concentrated in philosophy as an undergraduate (like a number of my colleagues who have spent their subsequent careers steeped in science) I do believe that students should have an opportunity to explore broadly and deeply in many different disciplines before entering medical school. But this will require some further discussion — since many students are still concerned about deviating from the tried and true path to medical school, which remains traditional and somewhat limiting if not inflexible.

Pizzo goes on to explore other potential changes in undergraduate education and medical school requirements, including recently approved changes to the Medical College Admission Test (MCAT). His full thoughts are worth a read.

Previously: A quick primer on getting into medical school, Discussing a new way to choose medical students and Changes ahead for the MCAT

Disease activists come in all shapes, sizes… and temperaments. There are genial fund-raising walkers, chained-to-the-courthouse protestors and every passion in between. The Spring 2012 edition (.pdf) of the Stanford Cancer Institute News features an interview with two activists: breast cancer survivors whose brand of advocacy is helping shape the search for a cure.

Susie Brain and Joan Venticinque are trained research advocates who partner with – and occasionally prod – the scientists and physicians developing new breast cancer treatments. Among the thoughts they shared during our Q&A:

Q: In what ways can advocates influence research?

Susie: Simply stated, we help provide a “face” to the disease and remind researchers of the human element. We provide input and strengthen research projects, assist in clinical trial design – including development of patient materials – and we facilitate community outreach and education.

Joan: As patient advocates we bring a sense of urgency and context to the work of the researchers. We are the voice of the patient in studies and in clinical trial design. We have firsthand experience living with cancer and its treatments, so we are able to offer them perspectives they may not otherwise hear.

My surgical scars remind me everyday why I am an advocate and why working in research is important.

Previously: Surviving is just half the battle: More on Stanford’s new survivorship clinic and Wellness after cancer: Stanford opens clinic to address survivors’ needs
Photo by Steve Gladfelter

If you found yourself biting your nails while following the news on recent shortages in cancer-drug supply, you may have been bandaging your fingers after a February announcement that the United States was close to running out of a critical component of chemotherapy treatment for children. Now Stanford’s Michael Link, MD, professor of pediatrics and current president of the American Society for Clinical Oncology, provides some insight on the topic for an Inside Stanford Medicine Q&A.

An excerpt from Link’s interview with science writer Erin Digitale, PhD:

Q: How is the so-called “gray market” involved in drug shortages?

Link: The shortages have created an opportunity for secondary drug distributors to make additional profits. With early knowledge of potential drug shortages, they have hoarded chemotherapy drugs in anticipation and sold them at amounts that are 650 percent to 3,000 percent of the original prices. This activity, referred to as a gray market, is actually a form of price gouging. The gray market has raised additional concerns about the reliability of drugs being sold to practices, because the pedigree of the drugs is uncertain. There is limited to no ability to trace their chain of custody, nor can we be sure they have been handled, stored and transported as required. It is estimated that the gray market accounts for up to 50 percent of drug sales during a drug shortage.

Previously: An in-depth look at the even-deeper problem of drug supply and Childhood leukemia patient on methotrexate shortage