Years ago, nephrologist Manjula Tamara, MD, treated a 23-year-old uninsured patient whose kidneys were failing. The patient’s medical options, at that point, were life-long dialysis or a hoped-for kidney transplant – bleak options for such a young person, and ones that adequate preventive care could have been avoided.

That memory, along with the federal government’s recent expansion of Medicaid spurred Tamura as a scientific researcher to pose the question: Does expanded Medicaid coverage translate into better care for low-income patients with chronic diseases, such as kidney disease?

According to the Stanford study published today in the Journal of the American Society of Nephrology, the answer is yes. Using data from national registries, Tamura, who is lead author of the research, and colleagues collected data on the more than 400,000 American adults who developed end-stage renal disease (or ESRD) between 2001 and 2008. As I explained in a release:

Medicaid coverage during those years among low-income, nonelderly adults ranged from 12.2 to 66 percent, depending on the state, with California averaging between 30 and 35 percent. For each additional 10 percent of the low-income, nonelderly population covered by Medicaid, the study found there was a 1.8 percent decrease in ESRD incidence.

The study is particularly timely because states are in the process of deciding whether to adopt the recent changes to Medicaid, which came with the passage of the Affordable Care Act. So far, only about half of the states have. The study discusses these recent changes and what the expansion in Medicaid coverage could mean to low-income Americans with kidney disease, along with patients with other chronic diseases:

Before the Affordable Care Act, only low-income Americans who were pregnant, had a disability or were parents of minors could receive Medicaid coverage if they met their state’s income eligibility levels. States now have the option to increase Medicaid coverage to all adults under the age of 65 with incomes below 133 percent of the poverty level regardless of whether they are pregnant, disabled or parents of minors.

“The care of patients approaching kidney failure or end-stage renal disease is a useful model to study the potential effects of Medicaid expansion on chronic disease care because ESRD care is costly and the quality of pre-ESRD care is tracked nationally,” Tamura said.

What the study did not look at was whether this expansion could ultimately result in financial savings. In the United States, 75 percent of health care dollars goes into the treatment of chronic diseases and these conditions – which include heart disease, diabetes, hypertension, and kidney disease – are all on the rise. In an interview, Tamura suggested that future research on this topic is needed.

Previously: Study shows higher rates of untreated kidney failure among older adults and Geography may determine kidney failure treatment level

Several times I’ve heard Stanford physician Abraham Verghese, MD, champion of hands-on medicine and bestselling author, answer the question: Which does he considers himself first – a doctor or an author?

Always, I’ve heard him give the same answer. He is a physician first. For him, medicine is “a ministry with a calling.” The meaning to his life is in his ministry to the patient; how best to fulfill that ministry is his life’s journey. This he tells the entering first-year medical students during orientation, reminding them to always hold onto to the desire that drew them to medicine in the first place. The desire to help people.

But obviously, it’s not that simple. For Verghese, the author of nonfiction and fiction books and numerous articles in both the general and academic press, the two passions are intertwined and feed into each other. For him, writing is a path of discovery to become a better physician.

Now, Verghese’s work of combining the two fields has again been honored, this time with Verghese being named today the recipient of the $250,000 Heinz Award for Arts and Humanities. In a news story I quote Teresa Heinz, chairperson of the Heinz Family Foundation, which administers the annual Heinz Awards in five categories, on the choice:

Dr. Verghese’s widely acclaimed writings touch the heart and inform the soul, giving people of all walks of life a true understanding of what it is to heal the whole person – not just physically, but emotionally.

Verghese, who will be the commencement speaker for the Stanford medical school graduation in June, said he was excited about the award, which he considers “a lovely validation of work that is in that realm of being on the edge of science yet very much about the art.”

He also received another recent honor. His only novel (he’s currently working on his second), Cutting for Stone, has made the list of Amazon.com’s “100 Books to Read in a Lifetime.” It’s an accomplishment, he told me in an e-mail, that he’s indeed proud of. What writer wouldn’t be honored to have their book listed alongside the likes of Hemingway’s The Sun Also Rises and W. Somerset Maugham’s Of Human Bondage?

Hearing of these two honors – along with recently having reread Verghese’s second memoir The Tennis Partner - reminded me of how close the author’s love for both art and medicine are wedded. And it reminded me yet again that for Verghese both art and science – which includes the entire medical establishment – ultimately exist as tools to help heal patients.

Previously: Abraham Verghese’s Cutting for Stone: Two years as a New York Times best seller, How Abraham Verghese writes, How a battle with Napoleon helped Abraham Verghese write his novel, Abraham Verghese at Work: A New York Times profile and Physicians turn to books to better understand patients, selves
Photo by Singer, 2012

Think of it like taking out the garbage.

That’s the way Stanford researcher Nicholas Leeper, MD, explained to me the findings of his recently published study.

Actually, it’s more helpful to think of the study’s discoveries on the genetics of heart disease as something of a garbage strike – at the molecular level.

Due to a genetic defect, the body’s ability to dispose of its daily tonnage of dead cells gets damaged, and as a result the body’s garbage - in the form of old cells and debris - starts to build up in the walls of its blood vessels. Normally, the body is extremely efficient at taking out the garbage. Two hundred billion cells die every day in our bodies and most get cleared out within a matter of seconds. But when this process breaks down and garbage in the form of necrotic cells starts building up in the walls of blood vessels, it’s not a good thing.

Leeper, a physician and assistant professor of vascular surgery, and colleagues Yoko Kojima, MD, Tom Quertermous, MD, and others set out to discover why genetic variation at the chromosome 9p21 location has been repeatedly identified as the most important commonly inherited DNA sequence for a wide range of cardiovascular diseases including stroke, heart attacks and aneurysms.

Conducting studies in mice with atherosclerosis, the researchers showed that loss of a candidate gene at this locus leads to impaired “efferocytosis” - from the Latin for “take to the grave” – the process by which dead or necrotic cells are removed. Literally, the burying of dead cells. Mice with this genetic variation showed an increase in buildup of these dead cells, further advancing their atherosclerosis as opposed to those that did not have the genetic variation.

In other words, a commonly inherited genetic variant, which is found in 20 percent of the population, contributes to the development of coronary artery disease (also known as coronary atherosclerosis) by stimulating the accumulation of necrotic debris within the evolving plaque. Coronary atherosclerosis is the process by which plaque builds up in the wall of heart vessels, eventually leading to chest pain and potentially lethal heart attacks. Leeper explained it to me further:

If you were born with genetic variation at the 9p21 locus, your risk of heart disease is elevated, though we haven’t understood why. This research gets at that hidden risk. You can be a non-smoker, be thin, have low blood pressure, and still be at risk for a heart attack if you were born with this variant. This work may help explain that inherited risk factor, and more importantly help develop a new therapy to prevent the heritable component of cardiovascular disease.

Photo by shooting brooklyn

Deep inside the ear, specialized cells that are confusingly called “hair cells” – they have nothing to do those hairs protruding from your Uncle Fred’s ears – detect vibrations in the air and translate them into sound. Without them, you can’t hear. Unlike non-mammalian species, in humans, there are a limited number of these cells, and if enough of them get damaged or killed off, hearing loss occurs.

Hair cells are the key to understanding the process of hearing. By figuring out how these cells work at a molecular level, scientists believe they can eventually develop better treatments and possible cures for deafness. Key to this goal is figuring out how to regenerate these cells if they get damaged or die off.

A new Stanford study published in the journal Development takes one more step along this pathway by showing that these early hair cells can be grown back in newborn mice.

“The study builds on the hypothesis that younger cochlea – that portion of the inner ear where the hair cells are located – can regenerate,” said Alan Cheng, MD, one of the senior authors of the study, which was done in collaboration with St. Jude Children’s Research Hospital.

“No spontaneous auditory hair cell regeneration has been observed in postnatal mammals prior to this study,” Cheng, an assistant professor of otolaryngology and pediatrics, told me. “Extensive efforts from laboratories around the world have focused on understanding mechanisms that can drive mammalian hair cell regeneration.”

In their study, the scientists induced hair cell loss in their mouse models at birth and then observed there was “spontaneous regeneration of hair cells.” One week after birth, there was no much regeneration.

The research also showed, interestingly, that most of these regenerated hair cells in the young cochlea didn’t ultimately survive. “This lack of survival posits a new challenge to regenerating hearing,” Cheng said.

Previously: Battling hearing loss on and off the battlefield, Stanford researchers gain new insights into how auditory neurons develop in animal study, Stanford hearing study upends 30-year-old belief on how humans perceive sound and Stanford chair of otolaryngology discusses future regenerative therapies for hearing loss
Photo by boltron-

Since January is the traditional month for making – and breaking – New Year’s resolutions (including diet-related ones), I thought it would be a great time to write about a new cooking course, the brainchild of two former Stanford students, that stresses healthy eating as a way of life.

When I heard these two young professionals, a doctor and a lawyer, had decided to put their careers on hold to get this project up and running at a local community center, I grew more curious to know what was motivating them. I learned that for the recently graduated doctor, Chloe Chien, MD, it was the multiple times she assisted on the foot amputations of diabetic patients during medical school. “I became increasingly bothered by lifestyle diseases” like diabetes and heart conditions, Chien told me. “Because they are so morbid, so expensive, so difficult to treat, so demoralizing yet at the same time, preventable.” As for the lawyer, Anna Rokoczy, it was years of struggling with fad diets and poor body image as a competitive ice skater in Australia: “I tried all the fad diets, everything.”

The two women were also influenced by the many overweight people they spoke with who had struggled and failed to lose weight:

“I was totally humbled by this,” Chien said. “Most people who are overweight have tried all kinds of diets, all kinds of programs. They told us they were sick and tired of food journaling or calorie counting or no-fat rules. They’d tell us, ‘Yeah, I lost weight when I was on a diet, but once I stopped I gained it all back and more.’”

The concept that Chen and Rakoczy came up with to battle the obesity epidemic and lifestyle diseases like diabetes? Bringing enjoyment back to eating and focusing on creating healthy, tasty meals that become a way of life. My article describes the personal experiences that led them to commit full-time to Homemade – 10-week-long community-based cooking courses that send each participant home with three-to-six days worth of prepared meals. And it discusses the surprise of Chien’s family, friends and medical school mentors when she withdrew her applications in the spring to medical residency programs to pursue Homemade. More from the piece:

“Friends keep asking, ‘Don’t you want to practice medicine? Don’t you want to go back?’” said Chien, who graduated from the School of Medicine in June. “I tell them I’m practicing the best medicine ever. It’s preventive, it’s inspiring and it’s joyful. … It’s so much more impactful than prescribing medicine one patient at a time.”

…

“I do miss a lot of other parts of medicine and hope to go back to it,” Chien said. But for now, she said she’s committed to Homemade. “When I pulled out of residency applications my mentors were telling me ‘Don’t do it; you’re crazy,’” Chien said. “At the same time, they were saying ‘Can I refer my patients to you?’”

Previously: Using a traffic light system to encourage healthier eating habits, What if obesity has nothing to do with overeating?, Learning weight-maintenance skills first helps prevent diet backsliding, Stanford study shows and Can cooking classes help curb childhood obesity?
Photo by Norbert von der Groeben

What better way to highlight how cochlear implants work than by sharing the story of 1-year-old Lucile Ross, an utterly adorable participant in Stanford’s growing new “teletherapy” program called BabyTalk?

In an Inside Stanford Medicine story published today, I write about the severely hearing-impaired Lucile and the program that helps her and 17 other toddlers learn to use their surgically imbedded cochlear implants to listen and speak. I describe what happened one day in June, about a month after her implant was first activated, when Lucile was busily eating Cheerios and suddenly grabbed her ear in astonishment. She had just heard something, prompting her hearing therapist to comment, “That was beautiful.”

My story goes on to discuss the technology behind the implants, the kinds of “sounds” that the tiny patients first hear, and how the children begin to interpret these sounds and learn how to speak:

A cochlear implant is an electronic device. One part includes electrodes that have been surgically implanted in the inner ear; another part, which sits outside the ear, includes a microphone. It can help the profoundly deaf and severely hard of hearing learn to listen and speak, and is particularly successful if implanted prior to the age of 3. The first three years after a child is born is the most critical period for the development of speech and language.

The device works by electronically transporting sounds from the microphone, which sits behind the ear, to the inner electrodes, which stimulate the auditory nerves and send sound information to the brain. The device doesn’t restore normal hearing; new recipients have described what they “hear” as sounding robotic or like ducks quacking, or just plain weird. Instead, it can give a deaf person a useful representation of sounds in the environment and help him or her to understand speech. But in order to do that, training is needed.

BabyTalk delivers that training – via the iPad – to geographically isolated patients and their families. For my story, I joined Lucile’s teacher, Sharon Nutini, at the Jean Weingarten Peninsula Oral School for the Deaf in Redwood City, Calif., Stanford’s partner in the BabyTalk program, for one of the virtual lessons with Lucile and her dad, Lyle, at home in Marin County. I had to agree with what Lucile’s mother had earlier told me over the phone: Watching Lucile learn to speak is an amazing experience. More from the piece:

 ”She’s giving us signs that she understands us, that she’s learning language,” Lizzie Ross said. “We think that she’s going to catch up quickly. Sharon gives us exercises that we do during the week. We sing songs that elicit certain language, we work on the recognition of animal sounds — the dog barking. There’s a lot of repetition, a lot of fun play stuff with her own toys — just what she would normally do on a daily basis.

“We knew it would be a hurdle. But for us, it’s been worth every minute of it. We were lucky that the opportunity was out there for her to hear and develop speech at a young age. It’s been a pretty amazing experience.”

Previously: Using the iPad to connect ill newborns, parents, “What’s that?” Stanford researchers identify cells important to hearing loss, Cochlear implants could help developmentally delayed infants, says Stanford/Packard study and  In people born deaf, auditory cortex takes on touch and vision, study finds
Photo of Lucile and her father, Lyle, by Norbert von der Groeben

As I blogged about here last week, I recently wrote a Stanford Medicine magazine story on the catastrophic health statistics from the Rosebud Indian Reservation in South Dakota. My piece came after following a group of Stanford students who travel there each year to volunteer and learn about health disparities in the United States.

While heart wrenching and difficult to read at times, the article has generated an encouraging response from both residents of the reservation and people who want to help change the situation. The story, which was picked up by Longreads.com and Byliner.com, has been read by bureaucrats, health-care workers, activists, educators and many who suffer first hand from the shockingly high rates of diabetes, alcoholism, and suicide rates in a community where life expectancy in the high 40s rivals many developing countries.

After reading the story, Rebecca Foster, PhD, a psychologist who I wrote about as dealing with suicide on the reservation daily in her job at the Rosebud Indian Health Service Hospital, paused to reflect:

I spent some time thinking about your story and was touched by the despair, sadness and fatigue of all those you interviewed. Working in the trenches everyday I forget how our lives appear to others. It was heartbreaking to see everything in black and white. I keep thinking that we keep working, living, laughing and crying and doing our best because the other choice is to give up and to do that is to dishonor and forget all those who have gone before us, the sacrifices that were made so we could be here and have a good life. By our actions to help our people in need now, we allow those that come after us, like my grandchildren to have a chance at a good life to continue to walk the red road in happiness, to sing the songs of our grandfathers and grandmothers with joy. So I rise everyday with the hope to help my people live through another day and hopefully find a sense of purpose again.

Foster would also be touched by the outpouring of e-mails I’ve received – including ones from an anesthesiologist who wants to volunteer her time on the reservation, a nurse in San Francisco who plans to write her Congressional representatives to ask for help, and teachers at the local tribal college, Sinte Gleska University, who are sharing the story with their students.

But what has most affected me is the gratefulness of many members of the tribe themselves for our exposing the situation on the reservation, where they’ve often felt isolated and forgotten. Josh Cossett, who has friends in their twenties who have died from suicide and alcohol-related accidents on the reservation, wrote to me:

There needs to be nation wide awareness to this problem. I get the sense that nobody cares because nobody realizes that these people exist… This is not a racial issue. It is a human rights issue. It has been going on for a century. The U.S. Government created this problem… Now, we ignore it like it doesn’t exist while holding on to our precious logos and memories of when Indians fought bravely against cowboy cavalries. People wonder why more Native Americans don’t stand up against the use of their image as mascots… Maybe that is something reserved for privileged white Americans. For Natives such as those on Rosebud, the debate over Indian nicknames is the last of their worries.

Previously: Broken Promises: the state of health care on Native American reservations, Finding hope on the Rosebud Indian Reservation and Getting back to the basics: A student’s experience working with the Indian Health Service
Illustration by Jeffrey Decoster

I traveled to Haiti a month after the 2010 earthquake to report on what was happening there for Stanford Medicine magazine. So when I went to the Rosebud Indian Reservation in South Dakota this year with a group of Stanford students, I was incredulous to learn that the average life expectancy in this community was one year lower than Haiti’s – 46 versus 47 - and a full 33 years shorter than the average American.

Statistically speaking, the poor health of Native Americans living the Great Plains of the United States rivals many developing countries. I had no idea. Diabetes, alcoholism, and depression rates are frighteningly high. Suicide rates are 10 times the national average.

My goal in writing my in-depth story, which appears in the current issue of Stanford Medicine and was just recommended as a Longreads pick, was to try to understand how this could possibly be true, and to lend some perspective as to what could be done to change it. What I found was a toxic mix of causative factors: isolation, poverty, poor nutrition, poor education - each of which has its roots in history. What became strikingly clear during my visit to the federally funded Rosebud Indian Health Service Hospital on the reservation was that the United States government has never kept its promises, made in multiple treaties, to provide health care to Native Americans in exchange for land.

From my piece:

One afternoon during a visit to the hospital, I walk from the ER to a separate wing to find the CEO, [Sophie Two Hawk, MD, who also happens to be the first Native American to graduate from the University of South Dakota's medical school]. Her door’s ajar, and she waves me in. She’s dressed in the military-style uniform of the U.S. Public Health Service Commissioned Corps, her long, gray hair pulled back in a braid that drops down her back. She’s doing paperwork — denying a pile of requests from her physicians for additional care for their patients. The requests are appropriate, she says, but the hospital just doesn’t have the money to pay for the care. “If someone shows up with a torn ACL, we can’t afford to fix it,” she says. “He will walk with a limp.” Two Hawk, like many others, links the poor health statistics of Native Americans not only to the lack of adequate (federal) funding but to the community’s tragic history. The hopelessness, the despair — it’s rooted in history.

The story delves into some of that history, including the forced relocation of Native American children to faraway boarding schools, another particularly ugly chapter in history that I knew nothing about. This forced relocation led to “cultural distortion, physical, emotional and sexual abuse, and the ripple effect of loss of parenting skills and communal grief,” a government study states. Hope on the second poorest county in the country – neighboring Pine Ridge Indian Reservation comes in first place – is a struggle to find. But it’s there, particularly in the strong bonds of the community itself:

Leaving Two Hawk, I head to the office next door where another Native American hospital employee, psychologist Rebecca Foster, PhD, works. When I knock on her office door, she’s taking a break to cradle her week-old grandson. Foster and her husband, Dan, also Native and a psychologist at the hospital, have 14 children — seven of those adopted from relatives on the reservation who were unable to care for them. All seven of those children are special needs, like the baby’s father, who was born with fetal alcohol syndrome… ” I see a lot of kids who are depressed, who talk about suicide,” she says, then pauses to look into the eyes of her grand baby. “And yet, kids are still resilient. They still have a desire to have a good life, to be happy, to accomplish things. No matter where you come from, you can never completely destroy that. There are very few kids here who don’t have a dream. What I tell young people is that there is a difference between having to stay here because you are trapped and choosing to be here because you have something to give. One’s a prison, the other is a home.”

Previously: Finding hope on the Rosebud Indian Reservation, Getting back to the basics: A student’s experience working with the Indian Health Service, Lessons from a reservation: Clinic provides insight on women’s health issues, Lessons from a reservation: South Dakota trip sheds light on a life in rural medicine and Lessons from a  reservation: Visit to emergency department shows patient care challenges
Illustration by Jeffrey Decoster

I recently spent an evening chatting at a table filled with first-year graduate students at Stanford’s Biosciences Orientation dinner, which made me particularly interested in reading an advice article from Stanford’s Ben Barres, MD, PhD, published today in Neuron.

This is a practical advice article from a well-respected scientist on how new graduate students should go about picking a good mentor. Barres, a professor of neurobiology, said that he picked a wonderful mentor as a student – “through sheer dumb luck” – and he wants to share what personal knowledge he’s gleaned over the years as a researcher and an advisor of students himself. He writes:

…It is the guide that I wish someone had handed to me the day I entered graduate school. I write this with some trepidation, as I am certainly not a Nobel Laureate…  But, as I always tell my students, the real Prize is enjoying doing science. This is a Prize that I have won. I want my students – and every aspiring young scientist – to win it too.

Choosing a good mentor is extremely important to the future success of a young scientist. The Stanford students who I talked with at the dinner were aware of this fact and were also constantly reminded of it by the speakers. And I could see it was a matter of intense concern for them. I know a step-by-step guide on how to go about this somewhat daunting task would be much appreciated.

More from the piece:

…[Why] do some talented students succeed as scientists whereas others do not? This is a question that has long intrigued me. I see it around me every day. Students who have always loved science from a young age enter graduate school, but some of these students leave not enabled to be a successful scientist and/or demoralized, having somehow lost their passion for science. I will argue here that for most students, selecting a good research mentor is the key

First, let me mention what a student should never ever do. An adviser should not be selected solely because he or she is the one researcher at your university that happens to work on the precise focused topic that you think you are most interested in (usually whatever you worked on in an undergraduate lab). In my experience, this is exactly what nearly every graduate student does!

Begin your search for an adviser by casting as broad of a net as possible, Barres advises. Try lab rotations in different areas, then create a broadly defined list of potential advisers in your general field of interest. Next, screen for scientific ability and mentorship ability. Barres even gives tips on how to find lists of former students to check out what they are doing now as a possible screening method. Basically, students should do what they’re good at: Research.

Previously: First-year science graduate students enter brave new world, Starting a new career in academic medicine? Here’s a bible for the bedside: The Academic Medicine Handbook and Distinction with a difference: transgender neurobiologist picked for National Academy of Sciences membership
Photo by L.A. Cicero/ Stanford News Service

In an effort to help the newest accomplished crop of science graduate students as they dive into their roles as “researchers exploring the unknown,” Stanford Biosciences recently held an orientation dinner warning of an uncomfortable new reality: feeling stupid. I attended the dinner and recently reported in Inside Stanford Medicine:

“The importance of succeeding in science is the ability to embrace your stupidity,” said Dan Herschlag, PhD, senior associate dean of graduate education and postdoctoral affairs, speaking to the crowd of about 120 diners in the Li Ka Shing Center for Learning & Knowledge. “And being comfortable with that adventure.”

Each student was asked to read an essay that had been left on their seats. It was the “The importance of stupidity in scientific research,” by Martin Schwartz, a microbiologist at the University of Virginia. “One of the beautiful things about science is that it allows us to bumble along, getting it wrong time after time, and feel perfectly fine as long as we learn something each time,” Schwartz writes. “No doubt this can be difficult for students who are accustomed to getting the answers right.”

“If we don’t feel stupid that means we’re not really trying,” he adds.

The 126 new students, who come from 19 countries and 82 undergraduate institutions, represent a wide variety of scientific disciplines and have already made great accomplishments in their fields. And yet, in chatting with several of the students, I learned it wasn’t uncommon for them to find themselves floundering a bit in a sea of insecurity. Don’t worry if you don’t feel like you like you belong, the faculty told them; the future will be challenging, but you’re definitely prepared.

Theresa Logan, who is entering the neurosciences program, told me it was a relief to hear the faculty talk about the “imposter syndrome” – the hidden belief that you aren’t supposed to be here among all these smart people. “Some of us apparently are thinking ‘Why did they ever accept me? It must be a mistake.’ It’s nice to know I wasn’t the only person who felt that way,” she said.

Previously: Stanford’s largest medical class ever starts school and No imposters here: Stanford grad students reassured as they begin school
Photo by Norbert von der Groeben