Medical Education

Now, this is cool: A medical student practicing how to examine and diagnose patients wound up discovering a real, and serious, disease in an older man who was playing the role of patient. ABCNews.com has the story on how the student came to diagnose the man, who had no idea he had a health condition and was subsequently treated with surgery for his abdominal aortic aneurysm. “Jim’s life was saved by a University of Virginia medical student, no doubt about it,” his wife said.

Previously: Exploring the “fading art” of the physical exam and A journalist’s experience as a ‘standardized patient’

Medical missions can provide immediate relief after a natural disaster or support for local doctors in low-resourced countries. But global health efforts that involve education and training for medical students and residents may build a community’s capacity to be self-sufficient over a longer term. One example of this type of intervention – enhancing technological competency – can further help sustain medical care and research for populations in need from within a community.

Stanford’s Center for Innovation in Global Health, led by Senior Associate Dean Michele Barry, MD, FACP, is in the fourth year of a five-year, 10 million dollar NIH Medical Partnership in Innovative Education (MEPI) grant with the University of Colorado, Denver aiming to strengthen medical capacity in the University of Zimbabwe College of Health Sciences, the country’s primary medical school. Barry wrote in an e-mail that the effort, part of the Novel Education Clinical Trainees and Researchers (NECTAR) Program, has three goals:

1. Enhance Zimbabwean faculty development, update technology and develop a competency based curriculum

2. Train future educators and support and develop faculty medical specialists

3. Mentor future researchers

Why Zimbabwe? Barry explains the country’s particular needs and how MEPI has helped:

Zimbabwe is a country of 12 million people that saw a massive brain drain of physicians due to economic issues and political instability. A total of only 998 doctors were left practicing when the grant started, with two adult cardiologists available for the entire population. Only 39 percent of the 314 faculty positions at the medical school were filled.

…

Since the grant began there has been a 152 percent increase in enrollment in the medical school, from 92 students to 237, and that was felt to be due to the excitement this grant has generated. Zimbabwean students and faculty have had opportunities to come to both Stanford and University of Colorado to learn specific skills and exchange knowledge. More than 75 faculty from the partner universities have rotated to Zimbabwe to teach and fill gaps in the curriculum.

Continue Reading »

Five years ago, I sat down to write my college application essays and found myself struggling most with questions that read, “Tell us why (insert school name) is the right fit for you.” Despite having perused college websites for hours on end, looking up interesting courses, professors, and organizations, I had very little sense of what the students at each college were like, and as such, I had trouble saying with confidence that I would fit in at the various schools to which I was applying.

Every medical student has a number of amazing, humbling “firsts:” first time interviewing a patient, first time seeing a baby born, first time comforting a family that has experienced the death of a loved one. These are moments that should be captured, frequently revisited, and never forgotten.

Searching for more insight into college student life, I stumbled across MIT’s admissions blog, where a select number of students and admissions officers wrote entries on their day-to-day lives, detailing everything from grocery shopping to homework to summer adventures. As I read entry after entry, I gained incredible insight into MIT culture and began to feel connected to the students there. Several months later, when I was accepted at the university, I immediately applied to be an admissions blogger, recognizing how influential these blog entries were to my understanding of and appreciation for MIT.

Over the next four years, I wrote nearly 85 entries on my life in college and through these entries, had the privilege of interacting with prospective students, current students and alumni who shared their thoughts with me through blog comments or e-mails. In addition, these entries gave me the opportunity to take a step back and reflect on my MIT experience as it sped by, with days fading into months and months fading into years.

As a current medical student, I recognize now more than ever the importance of sharing stories and reflecting on experiences. Every medical student has a number of amazing, humbling “firsts:” first time interviewing a patient, first time seeing a baby born, first time comforting a family that has experienced the death of a loved one. These are moments that should be captured, frequently revisited, and never forgotten.

This ambition to reflect on medical school and related experiences is the inspiration for “SMS Unplugged,” a new series here on Scope wherein five medical students (myself included) will write about their respective medical school lives. The goal is simply to share our stories, with anyone who might be interested, and when we graduate with MDs, to remember what inspired, humbled, and motivated us along the way.

There are some individuals whom I’d like to take a moment to thank, for without them this blog idea would have remained just an idea, not a reality:

• Dean Charles Prober, MD – for listening to me as I excitedly described this medical student blog idea and for facilitating my interaction with the medical school’s communications office
• Michelle Brandt and M.A. Malone – for helping integrate SMS Unplugged into Scope and selecting the five blog writers for this new series
• Michael Nedelman, second-year medical student – for the name of this series, SMS Unplugged
• Natalia Birgissonm, first-year medical student – for collaborating with me to get this idea off the ground by creating a blogger application and acquiring funding for this initiative

On behalf of all five SMS Unplugged writers, I want to say thank you in advance to you, the readers, for taking the time to read our pieces. It is such a privilege for us to share our medical school journeys with all of you.

Hamsika Chandrasekar is a first-year medical student at Stanford’s medical school, with an interest in medical education and pediatrics.

Figure 1, a free medical photo-sharing app for health-care professionals, has been likened to Instagram for its social functions of posting, favoriting and commenting on photos. It’s also a useful learning tool. Co-founder Joshua Landy, MD, a Toronto-based critical care physician, had an idea to expand the reach of the “teachable moments” he and his fellow ICU physicians would photograph on the job and exchange among themselves. Technical co-founder Richard Penner, a software developer, ensured a smooth user experience as well as a face-blocking algorithm. (All identifying information about a patient must be removed or blurred from photos, and content providers sign a quick, HIPAA-compliant consent form for each photo uploaded.)

Last summer, Landy spent time at Stanford as a visiting scholar, working with anesthesiologist Alex Macario, MD, on mobile-health research and online tools for medical education. He answered questions about their work together and his vision for Figure 1; his responses appear below.

What needs of your practice did you fill with Figure 1′s medical photo-sharing and collaboration abilities? Or the practices of your colleagues?

Figure 1 has been a useful resource to me for expanding the number of cases I’ve seen in my practice. It’s also been a great place for me to share a lot the moments I’ve learned from.

One of the unexpected benefits of Figure 1 for me is that it takes the sometimes lonely practice of medicine and makes it a more communal experience. At any time, I know that I can connect with people in similar circumstances who are focused on solving similar problems in healthcare.

What was the nature of your mobile-health research with Dr. Macario?

We researched online approaches to medical education, resulting in several articles describing new trends in the field, including a new trend of delivering curricular content online from home and converting class time to tutorial sessions with a professor (known as the flipped classroom). Our group also conducted a survey of mobile device use in medical students and residents.

What did those survey results show?

One conclusion we reached was that different specialties have different content and application needs when it comes to smart device apps. Some physicians, like neurologists, will use photo-sharing and text messages to communicate; others, like internists, will use reference apps to look up drug doses and side effects; some surgeons use anatomy teaching apps to help educate patients.

This particular study was meant to present the perspectives of the residents, giving a voice to the health-care professionals that are on the front lines of patient care. Seeing the native behaviours that evolve among trainees permits us to learn about what new tools may be needed, and which of these tools are likely to be accepted or rejected. We found that 60 percent of our physicians were exchanging patient care-related photos and text messages, and 45 percent acknowledged using their device “as a medical reference, textbook, or as a patient care related study aid.”

How do you think Figure 1 could contribute to medical education?

Growing your skill set as a medical practitioner is directly related to the number of cases you see. Seeing more cases, even in a lightweight format, will hopefully drive medical curiosity and influence learners to study real-life cases. Additionally, having another professional to interact with at the other end of the case provides a vibrant learning experience.

Figure 1 users can search by anatomy or within specialties. I was surprised that palliative medicine and psychiatry, which seem more challenging to capture in photos than something like orthopedic surgery, were included among the disciplines. What do you hope to include down the line?

When we started Figure 1, we had some ideas about which specialties would lend themselves well to being photographed. Psychiatry, as you mentioned, is a category where one might not expect many visual findings. To our surprise, we are seeing that innovative users are finding visual manifestations of mental illness and many other diseases too. These images help one appreciate the more subtle, human aspects of disease.

In the future, I think it would be great to introduce more photos showing what happens under the microscope. So much of medicine happens on a smaller scale than we appreciate. It would also be great to include toxicology or more laboratory based categories. Ultimately, we have a mandate to document the entirety of medicine and its visual representations, so there are likely to be many more categories added.

Are there any conditions you could consider inappropriate to photograph?

A health-care professional’s duty is to treat their patients with respect and empathy. I think almost anything can be photographed if it’s done with patient privacy in mind, and in the interest of helping other healthcare professionals and their patients. If the image would help somebody else in a similar experience, then I think it’s an appropriate and beneficial medical image.

Previously: Image of the Week: Sigmoid volvulus and A conversation about smart-device use among resident physicians
Photo by Figure 1

Two Stanford School of Medicine students are among the 11 recipients of this year’s Albert Schweitzer Fellowship – San Francisco Bay Area Chapter. Founded in 2006, the fellowship supports health-focused graduate students in year-long projects working with vulnerable communities to address health disparities locally. Michael Fu and Karen Hong, both second-year med students, chose projects that align with their personal values of providing community service and working with youth. Fu’s project provides a seventh-grade class with weekly, thirty-minute mindfulness-based stress reduction sessions over 10 weeks. He described his work in an e-mail:

Our project has two goals. First, through our mindfulness-based stress reduction (MBSR) program, we hope to positively impact students’ abilities to perceive and cope with stress. Second, we hope to build a self-sustainable curriculum that can be implemented by the entire Ravenswood City School District as a behavioral intervention tool. … Each session is structured around one of four central themes (paying attention to the present moment, paying attention with kindness, paying attention with curiosity, and responding vs. reacting) and involves a combination of formal mindfulness practices and reflection.

Hong is working with Prevent Blindness Northern California and told me:

They are a community based non-profit that screen preschool children using a high-tech screening device called the Retinomax. It is quick and extremely effective in detecting possible vision problems. Vision problems in this age group are important to detect and treat, as more emphasis is placed on using these years to ensure school readiness for kindergarten. Vision problems can result in permanent vision loss, or children being mislabeled as inattentive or behavior problems. … [Our project] will be piloted primarily in low-income schools, with great attention given to connecting those who fail the screening with appropriate vision care for full exams and treatment, if indicated. This is an expansion of a current program currently using paid staff and will be the first time it will be implemented by volunteer screeners.

Fu and Hong both said that service will continue to be part of their careers beyond the scope of their projects and their terms as medical students. Fu noted that a collaborative component of the Schweitzer Fellowship – previous fellows providing mentorship and consulting help to the current ones, and monthly meetings of the 2013 class – underscored the importance of team work in any service project.

Previously: Getting back to the basics: A student’s experience working with the Indian Health Service, Sowing the seeds of change: Medical students pen book on leadership, action and social innovation, What I did this summer: Stanford medical student works to improve pediatric surgical care in Tanzania and Stanford team provides healthcare in rural Guatemala
Photo by Michael Fu

Clinical informatics, a field at the intersection of clinical medicine and information technology, has reached a new milestone: Physicians can now become board-certified in this medical sub-specialty. Christopher Longhurst, MD, who is the chief medical information officer at Lucile Packard Children’s Hospital Stanford and the leader of a new Stanford clinical informatics fellowship training program for physicians, talked with Scope about where this field has been and where it’s going.

First off, what exactly is clinical informatics?

In clinical informatics, we leverage information technology to improve outcomes for patients. Research has been done in this area since 1960s and 70s, but what’s different now is the ubiquitous nature of computing devices. Everybody has access to information and communications technologies. The majority of U.S. hospitals are implementing an electronic health record.

And yet electronic health records are not something most front-line doctors are really excited about – they can be seen as disruptive to the patient-care process. I really think we have yet to deliver on the promise of electronic health records. There’s a tremendous opportunity to use data in those records to build a health care system that can make personalized care recommendations and automatically learn from patients.

How is clinical informatics changing the way that medical discoveries are made?

The idea when I was in grad school was that randomized trials were the gold standard for medical evidence. But, increasingly, people are recognizing that this “level A” evidence is cost-prohibitive to generate. And the subjects are so narrowly selected that the results are not always generalizable. I know what medication to give a white male in his 50s because of high blood pressure, but what if I have a different kind of patient?

So a lot of people are advocating for a shift away from traditional trials, toward using enormous, anonymized data sets gleaned from existing electronic medical records. The idea is that you can make valid conclusions based on retrospective research if the data set is large enough.

That’s why we want to create a “patients like mine” button in every electronic health record that would essentially allow real-time comparative effectiveness studies. Then, if you’re treating a 40-year-old, half-Vietnamese, half-black woman for high blood pressure, you can instantly generate a similar cohort and see which medications have provided the best outcomes for those patients.

A “patients like mine” button would also help us start to understand what questions doctors ask. Today, we don’t always know what physicians’ information needs are. If we start to collect this meta-data, we can better focus randomized controlled trials so that they match doctors’ biggest questions.

How does Stanford lead the field?

Stanford is often considered the place where clinical informatics all started. The father of this field, Ted Shortliffe, MD, PhD, was a graduate student at Stanford when, in the 1970s, he wrote a software program called MYCIN to make decisions about prescribing antibiotics. MYCIN performed better at those decisions than your average internist. Shortliffe came back to Stanford in the early 80s and founded the division of medical informatics, now the Stanford Center for Biomedical Informatics Research, starting the Masters and PhD programs.

More recently, we have a really solid history of finding unique ways to use and study electronic medical records: For instance, we’ve provided automatic daily updates to parents whose infants are hospitalized in our neonatal intensive care unit, reduced unnecessary use of blood transfusions, assisted in selecting the appropriate IV fluid to give to kids and more, all under this one umbrella.

We have nine physicians who received the new board certification, placing us among the largest programs in the country.

Continue Reading »

Inspired by a previous wig-wearing, in-lab parody of a Lady Gaga song, graduate students at the University of California, Berkeley have produced and starred in “in PLOS,” after the artist’s “Applause” song.

The science version of the music video begins with a disgruntled PhD candidate who’s trying to build her resume but faces rejection from numerous journals before turning to the open-access publication PLOS ONE. She sings of her paper, “I’ll submit this to PLOS, to PLOS, to PLOS / It’s Science, Nature, Cell‘s loss / Publish me in PLOS, PLOS.”

As described on the PLOS blog, itself, “the idea for the PLOS video came when we were watching Lady Gaga as a lab,” Mary Anne Kidwell, the lead singer, says. “We booked a conference room for a late night viewing of her recent show and her music inspired us.” 

Previously: Late nights in the lab, expressed through song

A few years ago I had an appointment with a doctor who got so deeply absorbed in reading and updating my electronic medical record, there was precious little in the way of eye contact during the appointment. As he sat there staring at the screen and tickling the keys on his laptop while he talked, I was tempted to say, “Hey, doc, my eyes are up here.”

Without eye contact, I felt as though I was talking to someone immersed in a crossword puzzle, only speaking to me absentmindedly in hopes I could cough (please) up an answer to help him fill in the blank squares.

Yes, I want my doctor to be conversant with the latest medical technology, but not at the expense of conversing with me.

The problem of electronic absorption in the doctor’s office seems to be common, as evidenced by a Viewpoint article (subscription required) published online today by the Journal of the American Medical Association.

In the piece, two medical school physicians and a colleague at another university make the case that appropriate integration and use of electronic medical records needs to become part of the standard curriculum in medical education.

Natalie Pageler, MD, MEd, clinical assistant professor in pediatrics, and Christopher Longhurst, MD, MS, clinical associate professor in pediatrics, while extolling the many benefits of EMRs in enhancing communication among doctors and patients, point out that, “the introduction of the EMR has also introduced a wide range of unintended negative consequences.”

They cite papers from medical literature describing pitfalls such as medical trainees paying more attention to a patient’s EMR than information gleaned first-hand from the patient’s physical exam, as well as the ease with which doctors can inhibit the readability of appointment notes by overstuffing them with large amounts of cut and pasted data.

The authors recommend a number of ways in which appropriate use of EMR can be broadly incorporated into medical education. Pageler is medical director of clinical informatics at Lucile Packard Children’s Hospital and Longhurst is chief medical information officer at Packard Children’s, so they’re well acquainted with the promise and pitfalls of EMR.

If you’re interested in this – and every health care consumer probably should be – check out the article.

Previously: A conversation about smart-device use among resident physicians, A new view of patient data: Using electronic medical records to guide treatment, Abraham Verghese on health-law battle: “We’ve worried so much about the process, not the patient” and A call for extended bedside-manner training

“You’re going into medicine? Let me give you a piece of advice: Don’t.”

A community physician said those words to me more than three years ago, right before I started medical school, and I’ve heard variations on the theme ever since: Medicine is a thankless profession. Contrary to popular opinion, it’s hardly the path to riches. You can’t spend enough time with patients. It’s depressing.

In recent days, I asked several peers at different medical schools what they thought of the ACA. The overwhelming answer: “I don’t know enough to have an opinion.”

Now I stand poised to enter the world of MDs. And with the passage of the Affordable Care Act, my classmates and I, the newest generation of doctors, look out at the horizon without knowing the shape our careers will have. We are reasonably sure about one thing — along with providing unprecedented access to insurance for Americans, the new health care law will change how we practice medicine, including how many patients we see and possibly how we get reimbursed.

Yet when the endless wave of media coverage crashes over us, it’s rare to find an examination of how the law will affect us, your future health-care providers. Instead, we get a big dose of political posturing from all sides.

Why does this matter? Because the first and probably saddest truth I can tell you is that most medical students know very little about the Affordable Care Act, or about insurance and health economics in general. We get the occasional lecture about health systems, but the information shows up on none of our exams or evaluations. In recent days, I asked several peers at different medical schools what they thought of the ACA. The overwhelming answer: “I don’t know enough to have an opinion.”

I find myself in a unique position. Thanks to Stanford and NBC News, I’m spending the year learning more about health journalism. So I’ve pulled my head out of the textbooks and hospitals and gotten a chance to really see how health-care issues affect communities. If not for this opportunity, I probably would have been one of those students who knew next to nothing about a law that will alter my career.

As medical students, we’re exposed to certain physicians who don’t consider costs and money; they tell us that such thoughts are not only unbecoming of a physician but also a distraction from caring about your patient.

I don’t see it the same way. Physicians are meant to be advocates for patients, and that means pursuing appropriate medical treatment in the context of a patient’s real life. Being uninsured is a health problem, pure and simple. A 2009 study revealed a direct correlation between lack of insurance and increased mortality, suggesting that nearly 45,000 American adults die each year because they have no medical coverage.

Whether or not you support the Affordable Care Act, that figure alone makes it our business to care about this issue.

Continue Reading »

Are you smart about antibiotics? That’s the question the CDC is asking as part of its week-long effort to educate people about antibiotic resistance – something the organization calls “one of today’s most pressing public health threats.” Its Get Smart About Antibiotics website offers valuable tips and information on antibiotic use, and CDC Director Thomas Frieden, MD, MPH, will be answering questions on the topic during a live Twitter chat Friday morning. (Follow the hashtag #CDCchat at 10 AM Pacific time tomorrow to join the conversation.)

Stanford, meanwhile, is aiming to educate medical professionals by launching a free online course called “Antimicrobial Stewardship: Optimization of Antibiotic Practice.” The course, directed by Stan Deresinski, MD, head of Stanford’s Antimicrobial Stewardship Program, will “offer a practical approach to prescribing antibiotic therapy and development of antimicrobial stewardship across all specialties and settings.” As for the need for such a course, the website explains:

Antibiotics are among the most frequently prescribed classes of drugs and it is estimated that approximately 50% of antibiotic use, in both the outpatient and inpatient settings, is inappropriate.  At the same time, in contrast to any other class of drugs, every antibiotic use has a potential public health consequence – inappropriate use may not harm only the individual patient, but contributes to societal harm by exerting an unnecessary selective pressure that may lead to antibiotic resistance among bacteria.

The course is sponsored by the Division of Infectious Diseases and Geographic Medicine in the Department of Medicine. Participants have the option of taking the course for CME credit.

Previously: Side effects of long-term antibiotic use linked to oxidative stress, New method may speed identification of antibiotic targets, Harnessing evolutionary forces to develop more effective methods for treating superbugs and Norway’s strategy for fighting drug-resistant bacteria
Photo by Iqbal Osman1