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Medical Education, Medicine and Literature, Patient Care

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

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

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

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

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

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

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

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

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

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

Neuroscience, Podcasts, Science, Stanford News

Stanford neurobiologist Bill Newsome: Seeking gains for the brain

Stanford neurobiologist Bill Newsome: Seeking gains for the brain

14601014695_30cfe1972d_zBill Newsome, PhD, knows the brain perhaps as well as the back of his hand. The Stanford neurobiologist was vice chair of the federal BRAIN Initiative launched by President Obama, and he directs the Stanford Neurosciences Institute. From that spot, he’s just funded a first round of interdisciplinary grants to Stanford faculty that he calls “risk taking.”  The need, he told me in this just-published 1:2:1 podcast, is critical:

When biomedical research money gets tight, as it now is, the funding agencies tend to get conservative. Right now we have these talented faculty at Stanford, many of them young faculty. They’re at the most creative parts of their career.  They’re at a place where they’re thinking big and dreaming big. We wanted to create this mechanism to allow them to do that.

I asked Newsome about the greatest challenges for neuroscience in the next few years. He had one word: technology. “If we were to improve the technology… If we could read out signals from the human brain and read in signals, actually do the circuit-tuning in the human brain non-invasively, at a spatial scale on the order of a millimeter or less and with fairly rapid time, it would revolutionize neuroscience,” he said.

So paint the picture, I asked, and  look ten years out. What would you like to see as far as progress? He told me:

I would like to see fundamental, substantive change on at least one devastating neurological or psychiatric disease. I don’t really care which one. Give me Alzheimer’s. Give me autism. Give me depression. Give me Parkinson’s disease. At the end of 10 years, if we can really have a breakthrough in the understanding of what causes one of those diseases mechanistically and have a therapy that dramatically improves people’s lives… I would say, ‘It’s worth it. We’ve done our job.’

Any worries or words of caution? He laments the current state of federal funding for science and worries that fiscal constraints will squeeze out young star scientists. “How do you keep convincing talented people to come into the field?” he said. “We’re deprioritizing science… How do we convince our brightest, our best, that this is a field with a really bright future?”

Previously: Deciphering “three pounds of goo” with Stanford neurobiologist Bill Newsome, Neuroscientists dream big, come up with ideas for prosthetics, mental health, stroke and more, BRAIN Initiative and the Human Brain Project: Aiming to understand how the brain works, Brain’s gain: Stanford neuroscientist discusses two major new initiatives and Co-leader of Obama’s BRAIN Initiative to direct Stanford’s interdisciplinary neuroscience institute
Photo by Allan Ajifo

Nutrition, Pediatrics, Research, Stanford News

Taking a bite out of food allergies: Stanford doctors exploring new way to help sufferers

Taking a bite out of food allergies: Stanford doctors exploring new way to help sufferers

allergen powdersPeople with food allergies and their families live lives of unremitting worry.  They are perfectly healthy unless they eat an allergen and then suddenly they are at death’s door.

When 9-year-old Maya Bodnick went on a skiing trip with her cousin, her aunt let her pick out some malt balls from a candy bin.  Within minutes her face began to swell, her throat hurt, and she vomited. When Tessa Yates Grosso was eight, she ate some spring rolls that turned out to contain wheat, which was one of her allergies – soon she began to lose consciousness. Her mother watched, terrified, as a medical team struggled to revive her by injecting two syringes of epinephrine and an array of other drugs. When my son Kieran was a toddler, he got hold of a cookie that contained eggs and nuts – both of which he was allergic to – and although I got the cookie out of his mouth before he bit down, and I rinsed his mouth out with water, he stopped breathing on the way to the hospital.

But for all three kids and their families, that life is now over after participating in a trial of a radical treatment for food allergies, headed by Kari Nadeau, MD, PhD. The treatment, known as oral immunotherapy, retrains the immune system by giving the patients micro-doses of the allergen and gradually working up – over months or years – to a full serving.  Nadeau has recently discovered that oral immunotherapy actually causes epigenetic changes – physical changes in patients’ genes that affect the way they are expressed.

Food allergic people are initially astonished – and terrified – by the suggestion they should eat the foods that had once poisoned them. But it turns out that – no matter how severe the allergy – everyone’s immune system can be retrained. Moreover, Nadeau discovered, the treatment works equally well for children and adults. At the newly created Food Allergy Center, Nadeau and her team will continue to research not only oral immunotherapy, but treatments for food allergies that do not involve eating the food. The center will also treat food sensitivities and intolerances, which patients frequently confuse with food allergies.

Read more about Maya, Tessa and Kieran’s treatment – and their new lives – here.

Melanie Thernstrom is a freelance writer.

Previously: Stanford Medicine magazine traverses the immune system, Simultaneous treatment for several food allergies passes safety hurdle, Stanford team shows, Researchers show how DNA-based test could keep peanut allergy at bay, A mom’s perspective on a food allergy trial and Searching for a cure for pediatric food allergies
Photo of allergen powders by Art Streiber

Grand Roundup

Grand Roundup: Top posts for week of Nov. 16

The five most-read stories this week on Scope were:

My last promises to her: Advocate for lung cancer awareness and live life to the fullest: In the latest installment of our patient-penned Inspire series, a California man talks about becoming a patient advocate after a lung-cancer diagnosis.

Stanford anesthesiologist explores consciousness – and unconsciousness: Anesthesiologist Divya Chander, MD, PhD, is one of a leading group of neuroscientists and anesthesiologists who are using high-tech monitoring equipment in the operating room to explore the nature of consciousness. She discusses her work in this Q&A.

Learning the pelvic exam with Project Prepare: In this piece, part of the SMS Unplugged series, Hamsika Chandrasekar discusses how a group of patient/educators is teaching medical students the art of performing a delicate exam.

Tackling the stigma of lung cancer – and showing the real faces of the disease: After learning that the first question typically asked of lung cancer patients is “Did you smoke?” Janet Freeman-Daily set out to help change public perception of her disease.

Big data approach identifies new stent drug that could help prevent heart attacks: By using a “big data” computational approach, learning about the genetic pathways involved in coronary artery disease, then testing the new theories on mice models in the lab, researchers at Stanford and Columbia were able to pinpoint a potential new treatment for patients who need stents.

And still going strong – the most popular post from the past:

What are the consequences of sleep deprivation?: Brandon Peters, MD, an adjunct clinical faculty member at the Stanford Center for Sleep Sciences and Medicine, explains how lack of sleep can negatively affect a person’s well-being in this Huffington Post piece.

Neuroscience, Research, Stanford News

Building a bridge between education and neuroscience

Building a bridge between education and neuroscience

3537327425_d0c519ed1e_zIt wasn’t long ago that my kids could barely identify all the letters in the alphabet and now I have to yell at them to put down books and eat dinner. That transition, from identifying symbols to learning how to interpret them in math and reading, is something that involves creating new pathways in the brain.

Neuroscientists have long known that those changes must be taking place in the brain, but only recently has brain imaging been good enough to reveal where and how those changes are taking place. With that advance, neuroscientists and faculty in the School of Education are now starting to work together to better understand the changes and also come up with ways of using what’s learned in neuroscience to develop ways of helping kids who fall behind.

I recently wrote about a new education professor, Bruce McCandliss, PhD, who is pulling together the interdisciplinary team of faculty from across Stanford to build the educational neuroscience program here. From my story:

In one set of experiments, McCandliss used a type of brain imaging that reveals connections or tracts of neurons to look at the brains of kids who were good readers and others who showed signs of dyslexia. He found that the kids who were better readers had stronger brain connections in that region.

“There is a profound relationship between the way a person’s brain is organized and how well that person masters abstract intellectual skills, such as reading or mathematics,” he said.

In a follow-up study, he and a team that included Allan Reiss, the Howard C. Robbins Professor of Psychiatry and Behavioral Sciences and professor of radiology, found that kids with dyslexia who activate a particular brain region when trying to read went on to make much greater improvements in their reading ability. Kids who did not activate that region made very little reading gain after the age of 14.

“The hope is that by understanding the nature of these differences we might be able to tailor interventions for those individuals,” McCandliss said.

The people I talked with for my story all said that we have many years to go before discoveries made in the lab start showing up as personalized learning in the classroom. Still, it’s nice to think that some of the kids who are struggling with reading or math might one day be able to get help that’s based on what’s actually known about learning in the brain.

Previously: Learning how we learn to read, Study shows brain scans could help identify dyslexia in children before they start to read and Stanford study furthers understanding of reading disorders
Photo by John Morgan

Emergency Medicine, Global Health, Stanford News, Videos

Improving global emergency medicine to save lives

Improving global emergency medicine to save lives

In July 2013, Stanford physician S. V. Mahadevan, MD, and colleagues conducted a study at the largest children’s hospital in Karachi, Pakistan to understand the kinds of medical emergencies that doctors treated at the facility. “What we found was astonishing,” he says in this Stanford+Connect video. “By fourteen days 10 percent of [the 1266 children enrolled in the study] were dead.” Mahadevan saw more children die during the one week he spent in the Pakistan hospital than in his entire 22-year-career in the United States.

Despite such dire statistics, there is hope. Mahadevan, founder of Stanford Emergency Medicine International, explains in the video how important early interventions can be made in the chain of survival to save thousands of lives in low-resource countries. Watch the full lecture to learn more about his efforts to establish Nepal’s first ambulance service, India’s first paramedic training program and his ongoing work to improve emergency care in Cambodia.

Previously: Stanford undergrad uncovers importance of traditional midwives in India, Providing medical, educational and technological tools in Zimbabwe and Saving lives with low-cost, global health solutions

Medicine and Society, Patient Care, Technology

Advice for young doctors: Embrace Twitter

Advice for young doctors: Embrace Twitter

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

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

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

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

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

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

Aging, History, Medicine and Literature, Medicine and Society, Stanford News

Stanford humanities scholar examines “the youngest society on Earth”

Stanford humanities scholar examines "the youngest society on Earth"

Young and old faces Over the past decades, our society has undergone a process of “juvenescence” that, according to Stanford professor Robert Harrison, PhD, makes it the “youngest on Earth.” For the first time in human history, he says, “the young have become a model of emulation for the older population, rather than the other way around” (as quoted in Stanford Report). The post-war period “has unleashed extraordinary youthful energies in our species and represents one of the momentous revolutions in human cultural history.”

Harrison is a professor of Italian literature whose new book Juvenescence: A Cultural History of Our Age examines the cultural forces that have brought about this development. The term “juvenescence” draws on the biological concept of neoteny, or the retention of juvenile characteristics through adulthood. Harrison’s research spans literature, philosophy, and evolutionary science.

His basic argument is that “juvenescence” can refer to either a positive or a negative change, and it isn’t clear which more accurately describes our current situation. The positive sense is one of cultural rejuvenation, while the negative one denotes juvenilization. Harrison explains, citing examples from his book:

Rejuvenation is about recognizing heritage and legacy, and incorporating and re-appropriating historical perspective in the present – like the Founding Fathers did when they created a new nation by drawing on ancient models of republicanism and creatively retrieving many legacies of the past… Unlike rejuvenation, juvenilization is characterized by the loss of cultural memory and a shallowing of our historical age.

…I feel ambivalent about where we are culturally in this age of ours.  It is hard to say whether we are on the cusp of a wholesale rejuvenation of human culture or whether we are tumbling into a dangerous and irresponsible juvenility.

Several aspects of our society suggest juvenilization. Most citizens of the developed world today enjoy the luxury of remaining childishly innocent about what they operate, consume, and depend on in daily life, while “in terms of dress codes, mentality, lifestyles and marketing, the world that we live in is astonishingly youthful and in many respects infantile.” Our culture’s emphasis on innovation and change honors the youthful drive that brings renewal and progress, but, without firm roots in the stability and wisdom of older generations and longstanding institutions, this risks being a meaningless chase after novelty. Youth’s genius is a luxury that requires solid foundations.

Continue Reading »

Autism, Behavioral Science, Events, Stanford News

Thinking in pictures: Stanford hosts Temple Grandin

Thinking in pictures: Stanford hosts Temple Grandin

Grandin Temple - smallEarlier this week, I got to hear a presentation by Colorado State University animal behavior expert Temple Grandin, PhD, who is widely known not just for her extensive work to enhance animal welfare, but also because she is one of the world’s most prominent individuals with autism. Like many others, I first became familiar with Grandin’s work through Oliver Sacks’ 1995 book, An Anthropologist on Mars. (The title came from Grandin’s description of how she feels when trying to decode the subtleties of social interactions.) Since I first read Sacks’ book, I’ve written frequently about autism research and treatment, and I’ve gotten some sense of how phenomenally important Grandin is to the autism community. So it was quite a thrill to be sitting just a few feet from her as she spoke to an overflow crowd at the School of Medicine.

Grandin’s talk focused on understanding animal behavior and reducing animals’ stress, but she interwove descriptions of her research with comments on how living with autism has influenced her work – and, indeed, how it influences the world around us. “A little bit of autism gives you Silicon Valley,” she quipped in the introduction to her talk. Although her subject was animals’ stress, at the heart, she was explaining different ways of thinking: in words or in pictures.

Animals think in pictures, especially when it comes to determining which elements of their environment are stressful or frightening, Grandin said: “Animals are all about sensory detail, little bits of detail we tend not to notice.” At one point in the talk, she showed a photo of a cow bending forward to investigate a spot of sunlight on the floor of the room where it was about to have a veterinary exam. To a human, this spot would likely seem insignificant, but to the cow, it is a foreign object that needs to be approached with caution.

“Novelty is a strong stressor for animals,” Grandin said, adding that if something visually new is forced in an animal’s face, it’s scary. The cow in the photo needs a few minutes to sniff the sun spot and figure out that it’s harmless; a human trying to force the situation will soon have a frightened, resistant animal to handle. Humans also have to keep in mind that our word-oriented brains may not categorize “novelty” in the same way that an animal does. For instance, an animal that has become accustomed to the sight of a blue-and-white umbrella may still be frightened by an orange tarp, Grandin said. To people, they’re both rain protection, but to a horse or cow, “It’s a different picture!”

Like many children with autism, Grandin began speaking later than most kids, and she still thinks in images more intuitively than words. “I see movies in my imagination, and this helped me understand animals,” she said. She likened her memory to Google Images, explaining that for her, a particular word will pull up many associated images, categorized by type. Her designs for meat-processing plants, now in use in half of the meat-processing facilities in North America, rely on her ability to mentally take a “cattle’s-eye view” of each step in the animal’s journey before slaughter, playing out a movie in her head that shows her where animals could be forced to encounter new things that might frighten them.

As well as describing her own work, Grandin advocated for broader acceptance of different kinds of thinkers, both with and without autism. People may think predominantly in pictures, or in patterns (that’s the math whizzes among us), or in words, she said, and we need educational and employment systems that can nurture and benefit from each of these ways of thinking. “There is too much emphasis on deficits [of children with autism], and not enough on building their strengths,” she said.

Grandin’s complete talk, which was hosted by the Department of Comparative Medicine, will soon be available on the department’s news website.

Previously: A conversation with autism activist and animal behavior expert Temple Grandin, Growing up with an autistic sibling: “My sister has a little cup” and Finding of reduced brain flexibility adds to Stanford research on how the autistic brain is organized
Photo by Rosalie Winard

History, Neuroscience, Research, Science, Stanford News

Illustration from 1881 resolves century-old brain controversy

Illustration from 1881 resolves century-old brain controversy

Figure2_WernickeThese days, a person can get through graduate school in the sciences practically without touching a physical publication. Most journals are available online going back decades. So it was a bit unusual when graduate student Jason Yeatman and postdoctoral scholar Kevin Weiner found themselves in the basement of Lane Medical Library trying to get to the bottom of a medical mystery.

It all started when Yeatman found a nerve pathway in brain images he’d taken as part of his work studying brain changes as kids learn to read.  This pathway didn’t appear anywhere in the available literature. He and Weiner became curious how this pathway – which clearly showed up in their work – could have escaped the notice of previous neuroscientists.

Their curiosity eventually led them back to an 1881 publication, still available in the basement of Lane Medical Library, where Carl Wernicke, MD, described identifying this brain pathway. Weier said, “That was a really cool experience that most people don’t have anymore, when you have to check your belongings at the door because the book you are about to look at is worth thousands of dollars per page. You are literally smelling 100 year-old ink as you find the images you have been searching for.”

Wernicke’s discovery contradicted theories by the eminent neuroanatomist at the time, Theodor Meynert, MD. I describe the controversy that led to this pathway expulsion from the literature in this Stanford News story:

Meynert strongly believed that all of the brain’s association pathways run from front to back – horizontal. This pathway, which Wernicke had called the vertical occipital fasciculus, or VOF, ran vertically. Although Yeatman and Weiner found references to the VOF under a variety of different names in texts published for about 30 years after Wernicke’s original discovery, Meynert never accepted the VOF and references to it became contentious before eventually disappearing entirely from the literature.

The group, whose work was published this week in the Proceedings of the National Academy of Sciences, says this was all more than just an exercise in curiosity. Psychologist Brian Wandell, PhD, in whose lab Yeatman was working, says it also shows the value of modern publishing methods, where making data available means scientists worldwide can try to reproduce results. He says it’s now less likely that a dispute could lead to a discovery being lost to history.

Image courtesy of PNAS

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