Medical students turn to peer-support groups for assistance: A Q&A

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School can be overwhelming, especially medical school. But Stanford Medicine offers many different forms of mental health support, including a peer-to-peer support program for medical students called Ears 4 Peers. To learn more, I spoke with Dina Wang-Kraus, MD, a Stanford psychiatry and behavioral sciences resident and co-founder of the program.

What inspired you to start the Ears 4 Peers program?

“In 2012, I was a first-year medical student and I was noticing that a significant number of my classmates were experiencing compassion fatigue and burnout. We were encouraged to reach out to the counseling and psychology services but there was some hesitancy, either from busy schedules or anxieties surrounding stigma. So, Norma Villalon, MD, and I decided to found a peer-to-peer support program. I started a similar program in college at Johns Hopkins, called A Place to Talk.

The hope was to have near-peers — those who were just walking in your shoes — provide support. Our goal was to bridge the distance students often feel when in a competitive, challenging situation. We may have been adults in our mid-twenties to forties, but we were only in the infancy of our training.

Rebecca Smith-Coggins, MD, is our faculty adviser and leader. From day one, she’s believed in our cause.”

What are some issues the program addresses?

“We receive calls regarding issues like academic stress, interpersonal relationship conflicts, imposter syndrome, intimate partner violence, Stanford Duck syndrome and suicidal thoughts. We also receive calls from students feeling lonely, disconnected and homesick, especially around finals, holidays and medical board exams. And some students call hoping to be referred for additional support.”

How are Ears 4 Peers mentors selected and trained?

“Ears 4 Peers mentors are nominated by their peers or self-nominated. They complete an application to tell us more about themselves, what draws them to this type of work and what they hope to gain from the experience.

We’re very lucky to have the support of Alejandro Martinez, PhD, the Associate Dean of Students for the Stanford undergraduate campus. He and his team designed a curriculum specifically for Stanford School of Medicine.”

What role do you play in the program now?

“As a resident, I’ve transitioned out of being an official Ears 4 Peers mentor but I continue to remain actively involved in near-peer mentoring for medical students. Two years ago as an intern in psychiatry, I worked with Jessi Gold, MD, to inaugurate Stanford’s  Medical Student Reflection Groups. Each group is made up of four to 10 medical students who commit to joining for six to 12 months. We meet every other week, and groups are facilitated by psychiatry residents trained in group therapy and psychotherapy. As resident physicians, we remain near-peers; however, we’re able to facilitate a different kind of support and personal growth given our psychiatry training.

Stanford students are welcome to reach out to me at sdwangkraus@stanford.edu to learn more.”

What advise can you give medical students and residents?

“I recall medical school to be an exhilarating time, but it also felt like I was drinking from Niagara Falls, one cup at a time. There were times when I felt overwhelmed and even burnt out.

We see a lot of beauty and humility in medicine, but there are also times when we see a lot of tragedy and suffering. Having peer-support, knowing that I was not alone, was empowering and liberating — and it continues to be.”

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

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Blasting radiation therapy into the future: New systems may improve cancer treatment

Image by Greg Stewart/SLAC National Accelerator Laboratory

As a cancer survivor, I know radiation therapy lasting minutes can seem much longer as you lie on the patient bed trying not to move. Future accelerator technology may turn these dreaded minutes into a fraction of a second due to new funding.

Stanford University and SLAC National Accelerator Laboratory are teaming up to develop a faster and more precise way to deliver X-rays or protons, quickly zapping cancer cells before their surrounding organs can move. This will likely reduce treatment side effects by minimizing damage to healthy tissue.

“Delivering the radiation dose of an entire therapy session with a single flash lasting less than a second would be the ultimate way of managing the constant motion of organs and tissues, and a major advance compared with methods we’re using today,” said Billy Loo, MD, PhD, an associate professor of radiation oncology at Stanford, in a recent SLAC news release.

Currently, most radiation therapy systems work by accelerating electrons through a meter-long tube using radiofrequency fields that travel in the same direction. These electrons then collide with a heavy metal target to convert their energy into high energy X-rays, which are sharply focused and delivered to the tumors.

Now, researchers are developing a new way to more powerfully accelerate the electrons. The key element of the project, called PHASER, is a prototype accelerator component (shown in bronze in this video) that delivers hundreds of times more power than the standard device.

In addition, the researchers are developing a similar device for proton therapy. Although less common than X-rays, protons are sometimes used to kill tumors and are expected to have fewer side effects particularly in sensitive areas like the brain. That’s because protons enter the body at a low energy and release most of that energy at the tumor site, minimizing radiation dose to the healthy tissue as the particles exit the body.

However, proton therapy currently requires large and complex facilities. The Stanford and SLAC team hopes to increase availability by designing a compact, power-efficient and economical proton therapy system that can be used in a clinical setting.

In addition to being faster and possibly more accessible, animal studies indicate that these new X-ray and proton technologies may be more effective.

“We’ve seen in mice that healthy cells suffer less damage when we apply the radiation dose very quickly, and yet the tumor-killing is equal or even a little better than that of a conventional longer exposure,” Loo said in the release. “If the results hold for humans, it would be a whole new paradigm for the field of radiation therapy.”

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

A look at the cigarette epidemic in China

Image by Dimhou

The imagery of a cuddly panda bear has often been used to sell tobacco products in China. So a new book that examines China’s cigarette industry seems aptly titled: Poisonous Pandas: Chinese Cigarette Manufacturing in Critical Historical Perspectives.

The book brings together an interdisciplinary group of scholars — including Stanford editors Matthew Kohrman, PhD, a professor of anthropology, and Robert Proctor, PhD, a professor of history. Together the team has investigated how transnational tobacco companies have worked to triple the world’s annual cigarette consumption since the 1960s. They focus on the China National Tobacco Corporation, which currently produces forty percent of cigarettes sold globally.

In a recent Freeman Spolgi Institute Q&A, Kohrman discusses how he got involved in this work. “When I began my ethnographic fieldwork on tobacco in China, I initially studied mostly consumer behavior. But I quickly realized that focusing solely on cigarette consumption, without considering the relationship between supply and demand, was like studying obesity while ignoring food,” he says.

Kohrman explains that cigarettes have become the single greatest cause of preventable death in the world today and the problem is getting worse. “Instead of declining as we would expect based on our impressions living here in California, the number of daily cigarette smokers around the world is projected to continue climbing,” he says. In particular, he explains the big tobacco companies are targeting less-educated people from lower- and middle-income countries.

Kohrman does offer some hope in light of the Chinese government’s recent initiatives to restrict tobacco advertising and smoking in public places. But he says that there is a lot more work to do.

“The road towards comprehensive tobacco prevention in China is going to be a long one,” Kohrman concludes.

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

Inherited Neanderthal genes protect us against viruses

Image by Claire Scully

When Neanderthals and modern humans interbred about 50,000 years ago, they exchanged snippets of DNA. Today, Europeans and Asians still carry 2 to 3 percent of Neanderthal DNA in their genomes.

During contact, they also exposed each other to viruses. This could have been deadly for the human species since Neanderthals encountered many novel infectious viruses while living for hundreds of thousands of years outside Africa. Luckily, the Neanderthals’ immune systems evolved genetic defenses against these viruses that were passed on to humans, according to a study reported in Cell.

“Neanderthal genes likely gave us some protection against viruses that our ancestors encountered when they left Africa,” said Dmitri Petrov, PhD, an evolutionary biologist at Stanford’s School of Humanities and Sciences, in a recent Stanford news release.

In the study, the researchers gathered a large dataset of several thousand proteins that interact with viruses in modern humans. They then identified 152 Neanderthal DNA snippets present in the genes that make these proteins. Most of the 152 genes create proteins that interact with a specific type of viruses, RNA viruses, which have RNA encased in a protein shell.

The team identified 11 RNA viruses with a high number of Neanderthal-inherited genes, including HIV, influenza A and hepatitis C. These viruses likely played a key role in shaping human genome evolution, they said.

Overall, their findings suggest that the genomes of humans and other species contain signatures of ancient epidemics.

“It’s similar to paleontology,” said David Enard, PhD, a former postdoctoral fellow in Petrov’s lab. “You can find hints of dinosaurs in different ways. Sometimes you’ll discover actual bones, but sometimes you find only footprints in fossilized mud. Our method is similarly indirect: Because we know which genes interact with which viruses, we can infer the types of viruses responsible for ancient disease outbreaks.”

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

Looking beyond opioids: Stanford pain psychologist briefs Congress

Photo by K-State Research and Extension

Reducing opioid use has become a national priority, but where does that leave the millions of Americans who suffer from underdiagnosed or undertreated chronic pain?

Do alternative treatments strategies like cognitive behavioral, physical and pharmacologic therapies alleviate chronic pain? And how should these alternatives be implemented for different populations with different needs?

These questions will be explored at an upcoming congressional briefing in Washington, D.C. on Oct. 2, which is organized by the Patient-Centered Outcomes Research Institute. Beth Darnall, PhD, a clinical professor of anesthesiology, perioperative and pain medicine at Stanford, is one of the speakers.

Congress is considering legislation — The Opioid Crisis Response Act of 2018 — that would affect the federal funding allocated to address the opioid crisis, including funding for non-opioid pain treatments. So it is critical that Congress understand evidence-based research on implementing safer chronic pain treatments in real-world clinical settings, Darnall told me.

Darnall was invited to speak about her EMPOWER study, a clinical trial in which participants partner with their clinicians to slowly reduce their opioid dose over a year. Patients are randomized to receive pain self-management classes, cognitive behavioral classes for chronic pain, or tapering only.

“The goal is not zero opioids. We’re aiming to help patients reduce to lower, safer doses without increasing their pain,” said Darnall. “We are testing whether the two types of classes help.”

Darnall argues that the best pain care is comprehensive and personalized to each patient’s needs. Although she recognizes that staving the flow of prescription opioids is important and can save lives, she says opioids can be part of a comprehensive care plan that works for some patients.

Darnall explained:

“Much of the overprescribing of opioids was born from a lack of opioid data, lack of clinician education about how best to treat pain and lack of accessible alternatives. Limiting opioids alone will not solve these three underlying problems. We need to better train physicians, psychologists, physical therapists, nurses and all healthcare clinicians on how to treat pain, so patients have access to evidence-based pain care.”

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

Bill for later school start times is defeated, but Stanford sleep specialist isn’t

 

Photo by Santiago Gomez

The medical evidence is clear — teens are suffering physical and mental health problems due to chronic sleep deprivation. That’s why the American Academy of Pediatrics and many other health organizations recommend starting classes at all middle and high schools at 8:30 am or later.

“We’ve known for decades that teenagers are not getting enough sleep,” says Rafael Pelayo, MD, a clinical professor in psychiatry and behavioral sciences with the Stanford Center for Sleep Sciences and Medicine. “Senate Bill 328 came out of presenting the strong evidence-based, peer-reviewed data to elected officials. Even the people opposed to the bill accept the science.”

So if everyone agrees that our teens need more sleep, why didn’t the bill pass? The main objection of teachers, school boards and ultimately Governor Jerry Brown centers on giving the local community control of individual school decisions.

“We’ve stepped into this ongoing battle between state control and local control of schools,” Pelayo says. “But I don’t consider this a political issue. This is a public health issue. Hundreds of schools have already changed and they see the same result — kids are healthier and perform better. This is a matter of honoring kid’s biology. It doesn’t work to just say they should go to bed earlier.”

Pelayo’s push for later school start times is also inspired by his professional experiences. “My career as a sleep doctor began through my knowledge of adolescent sleep. During medical school, my research found a link between suicidal thinking and sleep problems in teenagers. I’ve been learning about poor sleep and mental health issues in teens since the 1980s.”

Despite this recent setback, Pelayo plans to keep volunteering. For years, he’s been giving talks about sleep at many local high schools and middle schools. “Teenagers are interested in sleep apnea, their dreams and all aspects of sleep. I’ve given a bunch of talks on sleep for years,” Pelayo says.

He’s also recently become a director of a national organization called Start School Later. Overall, he hopes to promote more education, research and funding for this issue.

“About 300 school districts have already mandated a later school start time,” Pelayo says, adding that San Diego schools are planning to implement later start times by 2020. “If California had passed SB 328, it would have accelerated this process. Instead, we’ll have to do it piecemeal. And that’s too bad, since kids need sleep now.”

But, Pelayo says, “This issue is not going away, it is actually gaining momentum.”

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

Tai chi may help prevent older adults from falling, a study finds

Photo by Craig Nagy

As our parents age, we worry about them falling. Falls in older adults can lead to emergency department visits, hospital admissions and even death. At best, falls cause anxiety for patients and their loved ones.

Studies show that regular exercise can reduce the risk of falling, but it is unclear which kind of exercise is most effective for older adults. Now, a new multi-institutional clinical trial has assessed the effectiveness of two proven exercise interventions — tai chi and a multimodal exercise program — which were compared to a control intervention of stretching.

Tai chi is an ancient Chinese practice involving a series of movements performed in a slow, focused manner. Traditionally, people practicing tai chi flow between as many as 100 different postures. However, the study investigated a simplified form focused on eight core movements that were selected to improve balance for older adults.

The researchers also evaluated a more conventional, multimodal exercise program that incorporated aerobic, strength, balance and flexibility exercises.

The 670 participants were 70 years and older with a high risk of falling, based on impaired mobility or a history of falling in the previous year. They performed a 60-minute exercise session twice weekly for 24 weeks, which was randomly assigned as either tai chi balance training, multimodal exercise or stretching.

These interventions were primarily evaluated by the incidence of falls, which were self-reported monthly and then confirmed using follow-up appointments and medical records.

The study found tai chi balance training to be more effective than the conventional exercise approaches for reducing falls, as recently reported in JAMA Internal Medicine. During the 6 months, 152 falls occurred among 85 participants in the tai chi group, 218 falls among 112 participants in the multimodal exercise group and 363 falls among 127 participants in the stretching group.

TC Cowles, a nurse and program manager at Stanford Health Care’s Supportive Care Program, said he wasn’t surprised that tai chi reduced falls. These new findings agree with previous smaller studies, including a meta-analysis study. However, he was very excited to have it confirmed with so many participants.

“This is the largest study I’ve seen focused on tai chi as a fall prevention. It’s encouraging to see that it reduces falls by 58 percent compared to the stretching exercises and 31 percent compared to a multimodal exercise intervention,” Cowles said.

Cowles manages similar tai chi classes on Tuesdays through the Neuroscience Supportive Care Program and on Thursdays through the Cancer Supportive Care Program. These classes are very popular — almost 900 people have attended the tai chi classes in the last year, he said. Many of the participants are in their mid-60s or 70s.

“I like the practice because it is modifiable. You can start in a chair with arms to decrease the risk of falling during some of the movements. And if you strengthen, you can advance to a standing position,” said Cowles.

According to Cowles, however, attending consistently is key. “Patients that come regularly report that they feel less wobbly and can walk better on their own,” he said. “They also build core strength, so they can hold themselves upright for longer periods of time. And they build confidence, so they’re more apt to participate in other programs and activities.”

Stanford Supportive Care Programs also offer weekly classes on qigong, meditation and yoga, which can increase stability too. And all the classes are free and open to the community.

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