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Behavioral Science, Neuroscience, Podcasts

Advice for changing health behavior: “Think like a designer”

Advice for changing health behavior: "Think like a designer"

When listening to our latest 1:2:1 podcast, featuring a conversation with Kyra Bobinet, MD, MPH, two things jumped out at me. First, Bobinet, an expert in design thinking and behavioral change who says she “leads by my curiosity,” has a very cool personal story, and second: We shouldn’t be so hard on ourselves when we struggle to make positive health changes. In short, it’s not us – it’s a design flaw.

The interests of Bobinet, CEO and founder of a design firm using neuroscience to change behavior, can be traced back to medical school, when she was exposed to a program that taught health education in juvenile hall. “I became fascinated by the behavioral patterns of gang members who had violent pasts and came in and out of the system,” she says. These gang members vowed to stay out of jail when they were released but yet “two days later they were immersed” in their old lives and back in trouble. “Why is that happening? And how is that different than me saying I don’t want to eat french fries during Lent but then doing so the second day?” she wonders aloud.

Not long after, an experience with a patient wound up changing the trajectory of her career. During residency she saw a man with gout who had taken meth just three days prior. Bobinet had only ten minutes in clinic with him, and he only mentioned the drug use during the tail end of their conversation, before she had a chance to probe into it. “He changed my life,” she says. “I was so interested in the behavior that led to the medical condition – I [realized I] didn’t want to write prescriptions for the condition anymore, I wanted to focus on the behavior.” She went on to public health school from there.

In the podcast, Bobinet, who also teaches courses on patient engagement and empowerment in the Stanford AIM Lab with Larry Chu, MD, goes on to talk a lot more about behavior and what she has learned through extensive research of patients and caregivers. She talks about her new book, Well Designed Life, which lays the groundwork for those looking to design the changes they want to see in their life, and she offers more advice and words of encouragement for people who are struggling to, say, stay on a diet or quit smoking. “Think like a designer,” she says. Your failed attempt at making positive change “was just a version, just a protoptype… That was something that didn’t work – but it’s not you, it’s the design… And you have to redesign what will grab your attention now.”

Previously: Designing behavior for better health

Cancer, Complementary Medicine, In the News, Research

“We need a breakthrough”: Cancer researchers call for more effective, lower cost therapies

"We need a breakthrough": Cancer researchers call for more effective, lower cost therapies

1024px-Tripterygium_regelii_1Cancer is wily. Although drug developers are continually crafting hard-hitting drugs, a variety of factors, such as a tumor’s genetic heterogeneity, mean that cancer usually comes out on top.

Something else is needed.

And that something, writes a panel of 180 researchers in a special issue of Seminars in Cancer Biology, is an array of treatments that bombard a series of targets. These treatments can be based on substances found in nature that are lower in cost and toxicity than many current treatments, the researchers write. Some of these compounds stem from plants, such as the Chinese herb Tripterygium wilfordii (although that herb, like many treatments is not without a downside: it also suppresses the immune system).

The team identified 74 molecular targets deserving of investigation and set up a framework for researchers to pitch in. And the time is now, researchers Anupam Bishayee, PhD, and Keith Block, MD, write in the introductory paper: “We have a long way to go before oncology can offer true comfort to most patients.”

Stanford oncologist Dean Felsher, MD, PhD, was part of the project. “This is an area that merits considerable attention and where interdisciplinary and international collaboration is needed,” he said in a statement.  “Our approaches to therapy are improving, but we need a breakthrough that can helps us address the problem of relapse.”

Previously: Researchers develop molecular target for brain cancer, Kidney cancer secrets revealed by Stanford researchers and Tool to identify the origin of certain types of cancer could be a “boon to doctors prescribing therapies”
Photo by Qwert1234

Anesthesiology, Medical Education, Sports

How to combine anesthesiology, internal medicine and rock climbing

How to combine anesthesiology, internal medicine and rock climbing

Michael Lin, M.D. at the Stanford Hospital and Clinics on Wednesday, September 23, 2015.

I’ll admit it: I’m in awe of, and a little intimidated by, medical residents. Between the early call times, long hours, and flurry of patients and cases, I often find myself wondering how these doctors-in-training manage to do it all.

So I was amazed to learn about Michael Lin, a fourth-year resident in Stanford’s combined internal medicine-anesthesia residency program. While most residents focus on just one field – like dermatology or surgery — Lin spends his time training in both anesthesia and internal medicine. He’s equally at home in the operating room prepping patients for surgery and in the internal medicine clinic treating outpatients.

But Lin also manages to squeeze in rock climbing outings to the gym and to meccas such as Yosemite National Park.

During a recent interview, I had the chance to speak with Lin about his dual interests, his experience at Stanford, and why doctors make great rock climbing partners. Here’s an excerpt from our Q&A:

What initially drew you to both fields?

When I was a medical student, I was interested in critical care and I was trying to decide which training route I wanted to take during my residency. I met with a lot of anesthesiologists and pulmonary critical care doctors who said that you get certain, specific skill sets from the medicine training and the anesthesia training. I realized that I didn’t want to choose. I wanted both skill sets.

One thing that has really drawn residents into this program is the critical care component. The ICU is really the intersection of medicine and anesthesia. You’re encountering critically ill patients with severe pathologies, so you need skills in acute resuscitation and advanced medical support that anesthesiologists are accustomed to providing in the OR, but you also need to treat the underlying pathology that landed them there in the first place, which is more aligned with the work of internal medicine physicians.

And as for why doctors make the best rock climbers? Lin has a simple response: “They’re detailed oriented and stay calm under stress, and you can trust them with your life.”

The only downside, he says, is that they always seem to be on call.

Previously: Stanford Internal Medicine Residency program to host Google+ Hangout, My couple’s match: Applying for medical residency as a duo and “We are a team”: Advice for new residents from chief residents, in their own words
Photo by Norbert von der Groeben

Cancer, Pediatrics, Research, Stanford News

A cure is not enough for young cancer survivors

flower-887443_1920I survived Hodgkin’s lymphoma as a young adult about twenty years ago, thanks to the chemotherapy and radiotherapy that I received at Stanford Hospital as part of a clinical trial.

Even back then, the focus of the research was on fine-tuning my cancer treatment to maintain an excellent likelihood of survival, while minimizing the long-term health problems due to therapy. I knew Hodgkin’s was unlikely to kill me, so I had to worry instead about future health issues caused by my radiation and chemotherapy.

People that survive cancer at a young age are expected to live many decades after diagnosis and treatment, so they are the most vulnerable population to long-term damaging effects from cancer therapy. Stanford’s Karen Effinger, MD, MS, and Michael Link, MD, explore this issue in an editorial published today in JAMA Oncology.

The editorial explains that it is critical to directly study the late effects in young adult cancer survivors, rather than the common practice of extrapolating from studies of children and middle-aged adults.

In particular, they discuss a new study by Katherine Rugbjerg, PhD, and Jorgen Olsen, MD, DMSc, from the Danish Cancer Society Research Center, which used the national Danish registries to compare the long-term risk of hospitalization in almost 34,000 5-year survivors of adolescent and young adult cancers with that of more than 228,000 age- and sex-matched population controls. Reported in the latest issue of JAMA Oncology, Rugbjerg and Olsen found that adolescent and young adult cancer survivors had significant health issues due to their treatment; however, these treatment effects were different than survivors of childhood cancers.

The editorial also discusses the late effects of pediatric cancer treatment on survivors’ neurocognitive development, which impacts education, employment and quality of life. Effinger and Link specifically describe a new study reported in JAMA Oncology by Kevin Krull, PhD, and colleagues from the St. Jude Children’s Research Hospital, which compared the neurocognitive outcomes in 80 adult 25-year survivors of a pediatric cancer with 39 controls. Krull concluded that the risk of neurocognitive impairment from cancer treatment was related to the development of chronic health conditions — rather than directly from exposure to high-doses of chemotherapy, as expected — but longitudinal studies are needed to sort out possible modifying factors.

The editorial authors conclude:

Going forward, we must apply our knowledge of late effects to improve monitoring and interventions for patients. While the progress made in the management of cancer in children and young adults has been gratifying, we must remember the words of Giulio D’Angio, who reminds us that “cure is not enough.”

Jennifer Huber, PhD, is a science writer with extensive technical communications experience as an academic research scientist, freelance science journalist, and writing instructor.

Previously: Study highlights childhood cancer survivors’ increased risk of future health problems, Questioning whether physicians are equipped to care for childhood cancer survivors and A cancer survivor discusses the importance of considering fertility preservation prior to treatment
Photo by klimkin

Big data, Biomed Bites, Research, Science

How one statistician is refining clinical trials

How one statistician is refining clinical trials

Biomed Bites is back. It’s a weekly feature that introduces readers to some of Stanford’s most innovative biomedical researchers. 

A love of mathematics propelled Ying Lu, PhD, to his current position as professor of health research and policy – with a specialty in biostatistics.

As the genomic revolution generates skyscrapers of data, biostatisticians like Lu are scrambling to develop more effective and efficient ways to design experiments and conduct clinical trials. Here’s Lu in the video above:

My research focuses on the development and application of novel, cutting-edge biostatistical methods in the evaluation, validation and comparison of new medical diagnoses as well as treatment interventions.

Lu also directs the nearby VA Cooperative Studies Program Coordinating Center, which conducts national clinical trials on topics such as stroke prevention, post-traumatic stress disorder and heart failure treatment.

Learn more about Stanford Medicine’s Biomedical Innovation Initiative and about other faculty leaders who are driving biomedical innovation here.

Previously: What I did this summer: Stanford medical student investigates health statistics and costs in Costa Rica, It all comes down to truth: Stanford med student digs in on public-health campaigns and How the FDA is promoting data sharing and transparency to support innovations in public health

Palliative Care, Patient Care, Research, Science, Stanford News

Desire for quality end-of-life care crosses ethnic groups

Desire for quality end-of-life care crosses ethnic groups

VJ in officeEthnic minorities want quality end-of-life care, including in-depth conversations with their physicians about how to achieve this, but they often face barriers to getting the care they desire. That’s according to a study published today in the Journal of Palliative Care.

In a press release I wrote about the study, lead author VJ Periyakoil, MD, a Stanford expert in end-of-life care, explained why she decided it was important to conduct a study with the goal of reaching out to traditionally hard-to-reach ethnic groups within the communities where they live:

There is so much generalization and stereotyping by physicians about how ethnic minorities want everything done, irrespective of how effective these treatments might be at the end of life. I decided that we needed to go into their communities and ask them what they want.

Periyakoil and her colleagues conducted a series of in-person interviews at a scattering of community-based senior centers around the San Francisco Bay Area accompanied by interpreters. The populations are particularly hard to reach because of a number of issues, including language barriers, immigration status, and poverty levels, Periyakoil said. In addition to English, interviews were conducted in Spanish and five Asian languages — Burmese, Hindi, Mandarin, Tagalog and Vietnamese. As I described in the release:

The researchers… found that all participants valued high-quality end-of-life care. A majority, 61 percent, said there were barriers to receiving high-quality care for members of their ethnic group.

The 191 participants who reported barriers to getting quality end-of-life care were asked to describe the biggest barriers, which were, in order of how often they were cited: finances and health insurance; physician behavior; communication problems with doctors; family beliefs; health system barriers; and cultural/religious barriers.

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Chronic Disease, Clinical Trials, Mental Health, Research, Stanford News

Treating insulin resistance may speed recovery from major depression

Treating insulin resistance may speed recovery from major depression

depressionIn a randomized, placebo-controlled clinical trial detailed in this study in Psychiatry Research, pioglitazone – a generically available drug that’s approved for type 2 diabetes – helped to relieve symptoms of major depression in patients whose blues had withstood an assault by standard therapeutic regimens for six months or longer.

But this beneficial effect was seen only in depressed patients who were also insulin-resistant.

Depression is remarkably common. Stanford psychiatric researcher Natalie Rasgon, MD, PhD, the study’s senior author, told me that close to one in five Americans are diagnosed with depressive illness at some point in their lives.

Insulin resistance, a stepping stone on the path to type 2 diabetes (not to mention cardiovascular disease and probably Alzheimer’s), is even more common: About one in three otherwise healthy Americans – and an even greater share of people with depression – are insulin-resistant. Especially prevalent among overweight people, insulin resistance also occurs more often than one might expect even among thinner folks, a lot of whom don’t have the faintest idea that’s the case.

Insulin, released by the pancreas in response to food intake, alerts cells throughout the body to the presence of glucose, the body’s primary energy source, in the blood. Insulin-resistant people’s cells fail to take up glucose adequately, leaving high residual blood levels of the sugar to wreak havoc on the body’s tissues. Because the brain is a glucose glutton – it soaks up about 20 percent of all glucose consumption in a healthy, active person – it’s easy to imagine that lousy glucose uptake in the brain would have all kinds of deleterious effects, including effects on mood. Food for thought, anyway.

Here’s how my news release described the study:

[R]esearchers were blinded as to which patients were receiving pioglitazone versus a placebo. The patients didn’t know which they were getting, either. … All the patients had been experiencing episodes of depression lasting, on average, more than one year. Their symptoms had failed to remit under standard treatment regimens. They remained on these regimens for the duration of the Stanford study and, in addition, were given either pioglitazone or a placebo. … The patients were tested for depression severity and insulin resistance at the study’s outset and then roughly every two weeks from the beginning of the trial to the end.

A total of 37 patients – 29 women and eight men – completed the 12-week study. The insulin-sensitive subjects did about as well on the drug as they did on placebo. But among the insulin-resistant group, those given pioglitazone showed a much greater improvement than those who got a placebo. They also showed more improvement than insulin-sensitive patients did.

The more insulin-resistant a participant was at the beginning of the study, the better the drug’s antidepressant effect. Possible, but not proven, explanation: It could be that for some patients standard antidepressant therapies can kick into gear only once these patients’ insulin resistance is reduced. Hungry brains gotta eat.

Previously: Survey shows nearly a quarter of U.S. workers have been diagnosed with depression in their lifetime, Revealed: the brain’s molecular mechanism behind why we get the blues, and International led by Stanford researchers identifies gene linked to insulin resistance
Photo by S.Hart Photography

Addiction, Ask Stanford Med, Health Policy, Public Health, Stanford News

Is a proposed ban on smoking in public housing fair?

Is a proposed ban on smoking in public housing fair?

smoking ban sign - 560

Cigarette smoking kills nearly half a million Americans each year, making it the leading preventable cause of death in the United States.

So the Department of Housing and Urban Development thinks it’s time to ban cigarette smoking from some 1.2 million subsidized households across the nation.

HUD Secretary Julián Castro unveiled a proposal last week intended to protect residents from secondhand smoke in their homes, common areas and administrative offices on public housing property.

“We have a responsibility to protect public housing residents from the harmful effects of secondhand smoke, especially the elderly and children who suffer from asthma and other respiratory diseases,” Castro said, adding the proposed rule would help public housing agencies save $153 million every year in health-care, repairs and preventable fires.

Stanford Law School professor Michelle Mello, PhD, JD, who is a core faculty member with Stanford Health Policy, has researched and written about this issue extensively, including in a 2010 article in The New England Journal of Medicine.

In a piece published yesterday, I asked Mello about her views on the federal smoking ban proposal. A sampling of the Q&A:

What would be the greatest benefit to banning smoking in public housing?

There are lots of benefits, but to me the greatest benefit is to the 760,000 children living in public housing. Although everyone knows that secondhand smoke exposure is extremely toxic, not everyone knows how much children in multiunit housing are exposed — even when no one in their household smokes. Research shows that smoke travels along ducts, hallways, elevator shafts, and other passages, undercutting parents’ efforts to maintain smoke-free homes. Also, chemicals from cigarette smoke linger in carpets and curtains, creating hazardous “third-hand smoke” exposure that especially affects babies and small children.

Beth Duff-Brown is communications manager for Stanford Health Policy.

Photo by Getty Images iStock

Medical Education, Pediatrics, Stanford Medicine Unplugged

Empathy and the darker side of pediatrics

Empathy and the darker side of pediatrics

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


I’m currently just over halfway through my pediatrics rotation, having recently finished up four weeks on inpatient peds and just started my month of outpatient peds.

Before this rotation, when I thought about pediatric medicine, I thought about diagnoses like asthma, croup, foreign body ingestions, and rashes. I never really thought about child abuse, or – as the medical terminology goes – “non-accidental trauma.” And yet, I saw all too much of it this past month on the wards.

Our 6 a.m. sign out one morning went something like, “Patient X, here for NAT, steadily improving, currently in CPS (Child Protective Services) custody, awaiting foster family placement.” When we met this young patient later that same morning, I found a strong mix of emotions stirring inside me: first disbelief, then overwhelming sadness, then – rapidly – anger.

How could ANY parent do this to their baby? This question repeated itself in my mind, over and over and over. I literally could not wrap my head around it. Here is this beautiful, helpless little human being – what could possibly make someone do harm to this child?

I was distressed and distracted throughout rounds that morning, until finally – unable to stay quiet – I confided my thoughts to one of the other members on the medical team, who said: “I know it feels hard to understand. But, take just a moment, and think about it from the parents’ perspective: They are no longer allowed to visit their own child. And they have to explain to literally everyone they know – friends, family, colleagues, other children in the home – why they no longer have their baby.”

Her words stunned me into momentary silence. Never had I thought to empathize with the parents of our NAT patient.

Somehow, I had taken that 2-minute sound bite uttered during morning sign-out and transformed it into a mental battlefield, with the health-care team on one side, fighting valiantly to protect this child, and the parents on the other, a medical story of “good” vs. “evil.” But my fellow team member was right: This situation was awful all around. These parents no longer had a child, the child no longer had parents, and sometimes – if the patient had siblings – the siblings too were taken into CPS custody.

This experience taught me how absolutely vital it is to find ways to empathize with every patient and every family, no matter what the circumstances. 

I feel like this is particularly relevant in the inpatient setting, where we see patients for days – which sometimes become weeks and months – at a time. We connect with our patients: They’re often the first people we see when we get into the hospital and the last ones we see when we leave. We feel like we know all about them, about their families, about their values. But we don’t.

We’re witnessing this small window of their lives that has brought them to the hospital. And as easy as it is sometimes to ask question and judge – particularly in the setting of something as sensitive as child abuse – it’s not our place to do so.

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

Photo by 3rdparty

Research, Stanford News, Surgery

Immune cell linked to surgery recovery time, Stanford scientists find

Immune cell linked to surgery recovery time, Stanford scientists find

surgery shotWe don’t think about doctors getting sick, or about them feeling just as lousy and miserable as the rest of us when they’re recovering. But it happens.

“In medical school I had a chest surgery and had a horrible recovery — in the hospital 10 days, and exhausted for about two months,” recalled Dan Sessler, MD, professor and chair of the Department of Outcomes Research at the Cleveland Clinic, when I spoke with him recently. “I was so tired I couldn’t pick up a remote and turn on the television.”

Sessler did recover — his was a successful surgery — but going into the operation neither he nor his doctor had any inkling that Sessler wouldn’t experience the normal two-week recovery.

Now, research published online in the journal Anesthesiology could lead to an “immune stress test” where blood taken from a patient prior to surgery could help predict when the patients would be back on their feet. The investigators, including co-senior authors/Stanford physicians Garry Nolan, PhD, and Martin Angst, MD, collected blood from 25 hip replacement patients and exposed the blood to chemicals to mimic how the immune system would respond to a traumatic event like surgery. They found the behavior of a white blood cell called a monocyte was related to how quickly patients recovered.

The researchers are working to replicate the findings in a larger study of 80 patients, and they plan to adapt their findings into a test that can run on standard hospital lab machines. As I wrote in our press release about the practical benefits of such a test:

Knowing the likely recuperation times will help patients plan better for their return to work and other post-surgery commitments. For patients at risk for longer recovery times, doctors could schedule additional physical therapy or special care, or the surgery could be postponed while exercise, dietary changes and stress-release techniques are implemented.

As for Sessler, who was not involved in this study, he said he sees great value in adapting the paper’s results into a test. Predicting a patient’s recovery is “clinically important, and we don’t do a good job” of it, he said.

Kim Smuga-Otto is a student in UC Santa Cruz’s science communication program and a former writing intern in the medical school’s Office of Communication and Public Affairs.

Previously: Discovery may help predict how many days it will take for individual surgery patients to bounce back, New device identifies immune cells at an unprecedented level of detail, inside and out and The importance of human connection as part of the patient experience
Photo by ChaNaWiT

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