Month: October 2017

Physicians urged to talk to their patients about guns

Physicians often discuss sensitive issues such as sexual behavior and substance use with their patients. Although everyone may squirm a bit, these conversations help doctors identify health risks so they can properly counsel their patients.

Now, there is a growing movement to add guns to the exam room discussion. Many professional organizations, including the American College of Physicians, recognize that gun-related injuries and deaths are a major public health problem, not just a criminal violence issue. So they advocate that physicians speak with their patients about firearms and intervene when patients are at risk for injuring themselves or others due to firearm access.

Editors from the Annals of Internal Medicine recently wrote, “Regardless of whether one believes guns hurt people or that people hurt people with guns, we have a public health crisis and health care professionals have an obligation to do what we can to combat it.” They later added in the editorial, “Physicians and other health professionals at the frontline of patient care can help prevent firearm-related harm one patient at a time.”

Although horrifying, mass shootings account for only 1 to 2 percent of deaths from firearm violence; other incidents involving guns cause about 95 such deaths per day. Such statistics inspired Garen Wintemute, MD, a professor of emergency medicine and director of the Violence Prevention Research Program at the University of California, Davis, to research firearm violence.

In a recent article in Annals of Medicine, Wintemute explained that people who commit firearm violence — whether against others or themselves — have well-recognized risk factors that often bring them into contact with physicians. These risk factors include alcohol and substance abuse, a history of violence, suicide attempt(s), poorly controlled severe mental illness and serious life stressors, he wrote.

However, not all physicians are comfortable discussing firearms with their patients, even if they think it is appropriate. For instance, they may feel they don’t know enough about firearms. Wintemute urges doctors to educate themselves and hospitals to develop continuing education programs on the benefits and risks associated with owning and using firearms. He also urges physicians to make a public commitment to ask their patients about firearms.

There are online resources to help physicians get the conversation started. For example, the Massachusetts Medical Society has online materials and a CME course that covers practical tips on how to talk to patients about gun safety. Wintemute is also happy to provide resources and to follow-up with physicians who make the online pledge — just click the box giving him permission to contact you.

An opinion piece in the Washington Post provides some additional guidance. In the article, Stanford resident Nathanial P Morris, MD, gave practical advise to physicians that identify a patient who owns a gun and wants to self-harm or harm others. “We can pursue a range of options, from handing out gun locks to requesting family or friends temporarily hold onto firearms to asking that local police perform a welfare check at the patient’s home,” he said in the piece. “In extreme cases, if patients pose an imminent risk to themselves or others because of mental illness, we can place them on a legal hold to evaluate them in the hospital for up to 72 hours.” The goal of these actions, he wrote, is to limit patients’ access to guns to protect them from transitory suicidal or homicidal impulses. Morris added:

“ We’re not out to get anyone’s guns. We don’t wake up hoping to infringe on patients’ personal lives. But, to keep patients and communities healthy, clinicians need to be able to ask about firearms.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

How to improve care for LGBT patients

Photo by Gustavb Guanaco

No one facing health concerns should have to worry about receiving inequitable care because of their sexual orientation or gender identity. But studies and surveys show that many lesbian, gay, bisexual and transgender individuals experience discrimination by healthcare providers — including clinicians who refuse to provide needed care, refuse to touch them or use excessive precautions, are disrespectful or simply blame them for their health status.

Fortunately, healthcare providers can improve clinical care of their LGBT patients by taking proactive steps, as outlined in a recent viewpoint in JAMA. In particular, Alexia Torke, MD, and Jennifer Carnahan, MD, professors of medicine at the Indiana University Center for Aging Research, focus in the paper on how to optimize care for older LGBT adults, who are the first generation to be more open about their sexual orientation or gender identity.

The authors recommend that clinicians use inclusive language, such as using a patient’s preferred name and pronoun and asking about a spouse or partner regarding marital status. Forms disclosing sex should also include options for transgender patients, such as “male-to-female,” they say.

In addition, they recommend that physicians learn about the medical concerns specific to LGBT patients, such as hormone treatment and gender affirming surgery for transgender individuals. They also state that screening and diagnosis for medical conditions should be based on a person’s anatomy rather than their gender identity, giving the example that a female-to-male transgender patient is at risk of gynecologic cancers if he has not had a hysterectomy.

Torke and Carnahan also indicate that clinicians should better understand the unequal treatment that many sexual and gender minority patients face, which can have financial, social and health consequences. For instance, these individuals may not have access to health insurance due to employment discrimination or as an unrecognized spouse.

They also recommend that LGBT-friendly clinicians register as a “safe physician” with organizations like the Gay and Lesbian Medical Association.

A key to improving care for these patients is training, according to the authors and other experts. So the Human Rights Campaign has established best practices for health care organizations and provides free online training for healthcare providers.

The campaign also evaluates the implementation of these best practices and publishes an annual report. In the 2017 report, almost 600 healthcare facilities participated in the related survey and more than 900 non-participating hospitals were also researched. Happily, over 300 of the participating facilities were rated as a “leader in LGBTQ healthcare equality” with a score of 100 — including Stanford Health Care.

The authors conclude in the paper:

“Although lesbian, gay, bisexual, and transgender older adults face barriers to good health and health care, clinicians can take proactive steps to improve the care they deliver. These steps include education about prior discrimination and major health needs, as well as policies that ensure respect for the individual patients and equal treatment in all health care settings.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

Stanford chemists produce chemical — originally from marine creature — needed for new drugs

Photo by Fitzgerald Marine Reserve Docent

One person’s weed is another’s flower. A good example of this is spiral-tufted bryozoan, an invasive marine organism that fouls up marine environments. Although considered a pest by many, spiral-tufted bryozoan is much sought after by researchers since it can produce biostatin 1 — a chemical critical to the development of promising new drugs to treat HIV/AIDS, Alzheimer’s disease and cancer.

Although this bryozoan is abundant, bryostatin 1 is very scarce because it’s difficult to harvest from the sea creature and complex to synthesize. In fact, the National Cancer Institute’s stock of bryostatin 1 is nearly depleted from supplying over 40 clinical trials. So Stanford chemists have developed a new, easier way to synthesize bryostatin 1, as recently reported in Science.

Paul Wender, PhD, a professor of chemistry and of chemical and systems biology at Stanford, has been working for years to develop bryostatin analogs that are more effective for drug development. However, the dwindling supply of bryostatin 1 inspired him to synthesize the drug itself.

“Ordinarily, we’re in the business of making chemicals that are better than the natural products,” Wender said in a recent Stanford news release. “But when we started to realize that clinical trials a lot of people were thinking about were not being done because they didn’t have enough material, we decided, ‘That’s it, we’re going to roll up our sleeves and make bryostatin because it is now in demand.’”

The researchers devised a much simpler synthesize process, cutting the steps down from 57 to 29. They also dramatically increased the yield, making it tens of thousands of times more efficient than extracting bryostatin from spiral-tufted bryozoan and significantly more efficient than the previous synthetic approaches. And they confirmed with a wide range of tests that their synthetic bryostatin was identical to a natural sample supplied by NCI.

So far, the team has produced over two grams of bryostatin 1, and a single gram can treat about 1000 cancer patients or 2000 Alzheimer’s patients, according to their paper. After scaling up production, they expect manufacturers to produce about 20 grams per year to meet clinical and research needs, Wender said in the news release.

They also expect their work could facilitate research using bryostatin analogs derived from their synthesis process. The paper explains that these analogs “are proving to be more effective and better tolerated in comparative studies with cells, disease models in animals, and ex vivo samples taken from HIV-positive patients.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

Measuring patient experience in two words

Photo by mcmurryjulie

How much can you convey in just two words?

Quite a bit, according to new research from the University of Alabama at Birmingham. Researchers there assessed physician performance by asking patients, “Please describe your provider in today’s visit in 2 words,” using a free-text comment box that was distributed electronically or on paper immediately following a clinic visit. This simple query was added to the standard, lengthier patient experience survey that typically takes 15 minutes to complete.

The research team analyzed the resulting two-word scores for 716 physicians at a large academic medical center. Positive and negative word rates were calculated for each physician and shown to correlate well with the standard performance scores, such as a physician’s national percentile rank.

The research appears in JAMA.

The data was also used to create positive and negative response word clouds in which the font size equaled the frequency of the word — providing a visual representation of the patient’s perception of the clinician.

In addition to improving survey response rates, the researchers hope this new qualitative and visual assessment will help physicians better understand their strengths and weaknesses so they can improve their performance.

The study data is already being used for a variety of purposes, including professional reviews and assessment of clinical education. The researchers also said they are collaborating with other institutions to explore the use of this survey method in different health care settings.

In the paper, the authors concluded:

The 2-word innovation is a simple, relevant, and actionable approach to capture meaningful information about a physician and has already piqued the interest of other health systems.

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

Local knowledge key to building healthier communities

Photo by Chris Waits

Your zip code is just a number meant to guide mail delivery, but studies show that it predicts your lifespan better than your genetic code. For instance, the average life expectancy in New Orleans varies by as much as 25 years in communities only a few miles apart.

This health disparity is driving health care providers, researchers, urban planners and community members to work together to build healthier, more equitable communities — addressing the key factors that determine health and well-being outside the clinic.

““It’s not enough to ask how we can build healthier, happier and greener communities without first addressing the real inequalities that are impacting the design of our cities,” said Antwi Akom, PhD, an associate professor of environmental sociology, public health and STEM education at San Francisco State University, at Stanford Medicine X earlier this month.

However, this design movement depends on access to reliable data, which led the Obama administration to launch The Opportunity Project to “unleash the power of data and technology to expand economic opportunity in communities nationwide.” The project released 12 smartphone apps to provide easy access to governmental data on housing, transportation, schools, neighborhood amenities and other critical community resources.

One of these apps, called Streetwyze, was developed by Akom and Aekta Shah, a PhD candidate at Stanford University, through the Institute for Economic, Educational and Environmental Design. Streetwyze is a mobile, mapping and SMS platform that collects real-time information about how people are experiencing cities and local services, so the data can be turned into actionable analytics.

“The real challenge of the 21st century health data revolution is how do you bridge this gap between official knowledge and local knowledge in ways that make the data more reliable, valuable, authentic and meaningful from the perspective of everyday people?” said Akom at Medicine X. “We think the missing link is real-time two-way communication with every day people so they can participate in the design solutions that meet their every day needs.”

Streetwyze harnesses local knowledge to address questions like: How walkable is my neighborhood? Where can I buy affordable healthy food? How safe is my local park?

For example, a map of East Oakland based on county and city business permits shows many grocery stores in the area. But the reality, according to Akom and Streetwyze, is that most of these supposed grocery stories are actually liquor or corner stores, where you can’t find fresh vegetables or food.

In addition to providing more reliable data to design healthier communities in the future, the Streetwyze data already plays a critical role for community members and some organizations. “Every community has assets,” said Shah. “The Streetwyze platform actually helps lift those up, so that communities can better share those resources and organize around those assets that already exist.”

At Stanford, Shah is using Streetwyze to research how this digital technology may impact youth self-esteem, civic engagement, environmental stewardship and more.

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.