Virtual reality helps train emergency physicians

Photo by sasint

Imagine you are an emergency medicine resident, trying to focus on your patient with abdominal pain — asking about his medical history and symptoms as you give him a physical — but you keep getting interrupted. A technician stops by to hand you another patient’s EKG. A staff member asks about an order for pain medication for a different patient. And then you are called to see a psychiatric patient who is agitated. You return ready to focus and then an attending physician breaks in to redirect your attention to a new patient with a high heart rate.

All told, you’re interrupted 12 times during the patient exam. How can you possibly maintain your train of thought? How can you build trust with the patient, when all these disruptions are stressing him out?

The above narrative was inspired by the script of a new training simulation, which was filmed at Stanford’s emergency department as a virtual reality video.

This is a typical scenario faced by emergency physicians, who are interrupted on average every six minutes. These interruptions increase the likelihood of errors, so it is critical for emergency doctors to practice how to multitask in this fast-paced, high-risk and disruptive environment.

The script was written by Henry Curtis, MD, a Stanford clinical instructor in emergency medicine, and Cameron Mozayan, MD, a Stanford emergency medicine resident.

“A problem with many current learning modalities is that they don’t engage modern participants in an active, immersive learning environment, so it’s difficult to sustain their attention,” Curtis said. “Virtual reality-based education presents an innovative solution to address this problem. Distractions are minimized as the learner excitedly engages in the VR world. The perception of the experience also triggers strong memories, which connect them to the educational content. So participants allot their full attention as they contemplate important medical decisions.”

Over 30 health care educators and providers at the 2018 International Health Humanities Consortium Conference at Stanford tried the training simulation recently. While viewing, the participants were asked to choose which interruptions were more important than the patient-physician consultation. The participants then viewed the video again with expert pro and con discussions — interactively testing to see if the others’ viewpoints swayed their opinions on the importance of the interruptions.

“Training is more powerful if the participants are seeing it in 360 virtual reality and they are being engaged in an interactive experience,” Curtis told me.

Participants said the VR training realistically conveyed what it was like to work in an emergency department. One health care worker declared, “This experience makes me feel like I’m in the emergency department. I feel like I’ve seen all of these things happen at work.” Another said, “Sometimes emergency medicine feels like a warzone.” A third participant added, “I was feeling so tense in there with all of the interruptions.”

The users also provided insights. For instance, one person was struck by how often technology caused the interruptions.

Curtis worked with Jason Lowe, MD, and Anne Merritt, MD, members of Stanford’s medical humanities team and with Stanford’s Education Technology team to create the first video. Now, they are analyzing the data from the conference, and are planning a series of VR training simulations.

For his next project, Curtis is also working with Aussama Nassar, MD, to film a trauma simulation with an agitated patient who deteriorates into neurogenic shock after a bicycle accident.

Curtis said he hopes the virtual reality series will enhance the quality of the lessons learned during the training simulations, in addition to extending their reach to a larger audience. He added:

“VR education can be transported globally to allow learners across the world to immerse themselves in the intricacies of innumerable clinical encounters, as well as receive structured debriefing in the virtual world by renowned experts from Stanford University and the like.”

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

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On writing about female physicians and the Grand Canyon: A Q&A

Photo by DomCarver

As a voracious reader, I particularly enjoy mystery novels featuring a female detective or medical examiner. And as physicians know so well, medical mysteries can be just as gripping, and surprising, as crimes. So I was eager to read the novel, Only Rock is Real, about a female doctor with a family practice at the Grand Canyon. I spoke recently with the book’s author, Sandra Miller, MD, who is a writer and retired family physician.

What motivated you to write novels?

I have always written poetry and essays, but crafting a novel pushes my writing to another level. The process of weaving a plot — while creating compelling and authentic characters, developing their growth and showing their stumbles — is riveting to me. The greatest compliment is when readers tell me they feel like they know my characters personally and care about them.

I’m also on a mission to promote family medicine and women physicians through fiction. I really want to encourage physicians to write, and especially to write fiction. There is little medical fiction being written currently, with the exception of the crime scene/thriller genre. I would love to see more fiction about everyday physicians and their trials and joys. And I welcome with any medical writers who want to brainstorm, share or seek feedback about their work.

How did you develop the main character, Dr. Abby Wilmore?

Like most fictional characters, Abby is partly a conglomerate of people I have known and partly made up. Every physician wants to be highly competent and strives for excellence, but there are many potholes along that path. Perfectionism and anxiety are common in doctors; finding your peace with an ever changing and critical career like medicine is no small task. I wanted to show how her confidence builds and then derails — the ups and downs of successes and errors, real or perceived, in both her professional and personal life. I wanted to show how very human physicians are.

How did you select which patient cases to include?

I tried to use a mix of cases representing a typical day: some common and some less common, some routine prevention and occasionally a very difficult case. I also wanted to include a mix of physical and mental health issues. I guess the teacher in me is always lurking, because I also selected cases where readers can learn about topics like diabetes, the morning after pill and contraception, heat injury and flu vaccines.

I keep them as realistic as I can. Sometimes you know the diagnosis immediately and other times it takes detective work. Sometimes you’re wrong because people aren’t textbooks and they don’t always follow the rules. I’ve put much effort into making all the science — medicine, geology and astronomy — as accurate as I can.

Why did you set your books in national parks?

For the last thirty years of my career in academic medicine, I helped train family medicine residents who often did a rotation at the Grand Canyon clinic. And I have friends who worked there for years. I know their stories, the human dynamics in such unusual places. Only a few national parks actually support a physician.

In addition, I have always felt a deep connection to the natural world. We’re all constructed of the same molecules; all follow the same rules of development and decay. The wonders around us are simply stunning and worth celebrating.

How do you describe your books?

I’m calling my books ‘evidence-based medical adventures.’ There is romance and a bit of a thriller plot, but the books are also filled with tons of real medicine, science and the quandaries physicians face every day. And the poetry of the night sky and the rock under our feet, not to mention the value of humor.

Are there similarities between writing and being a family physician?

I think it helps for both to know you can never know everything. And that much of life comes at us in tones of gray. Being a family physician certainly gives you a broad view of the world and the vagaries of the human mind. You need to know as much as you possibly can and you need to know what you don’t know. You keep trying your best. I think this experience helped me as a writer.

Photo by DomCarver

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

New course highlights how surgeons can serve their communities

Photo courtesy of Jecca Steinberg

Stanford medical students Jecca Steinberg and Paloma Marin-Nevarez want to spread the word that service-minded medical students can care for underserved communities by specializing in surgery. With the help of their mentor James Lau, MD, they have created an upcoming seminar series for medical students called “Service Through Surgery,” which showcases how surgeons can address health inequities.

Beginning in January, the new 10-week course will expose Stanford medical students to a diverse group of surgical leaders who are passionate about improving health equity through surgery. I connected with Steinberg, shown on the left in the photo, and Marin-Nevarez to learn more.

What inspired you to create the Service through Surgery seminar course?

Marin-Nevarez: “I emigrated from Mexico when I was 10 and settled in a low-income community in south Los Angeles. I never really considered myself disadvantaged until I went to college and experienced firsthand the shortcomings of my education system. Ever since, I knew I would make my life’s work to serve the underserved in communities like my own.

In my second year of medical school, I fell in love with surgery. However, when I thought about being a ‘community physician,’ I didn’t see how surgery would fit into that picture. The speakers in this course will show students with the same internal struggle as mine that they don’t need to compromise their values in order to pursue their dreams.”

What role can diversity play in overcoming health inequities?

Steinberg: “Low-income, minority communities continue to receive inadequate surgical services and bear unconscionable health burdens. Research has demonstrated that increasing diversity among physicians improves healthcare access and outcomes for traditionally disenfranchised communities, but surgery continues to trail behind other medical specialties in racial, socioeconomic and gender diversity. So the surgical workforce represents an underutilized resource for decreasing health inequities and improving the health of our communities.”

Marin-Nevarez: “A more diverse workforce leads to better outcomes for the underserved because minority patients are more likely to seek care from and be more comfortable with physicians from diverse backgrounds. And physicians from diverse backgrounds are more likely to treat patients of color in underserved communities.”

What causes surgery to be less diverse than other medical specialties?

Marin-Nevarez: “Because of unequal opportunities — especially for communities of color — surgeons are not as diverse as they should be. Because of this lack of diversity, there is a lack of mentorship that then perpetuates the cycle.

Mentorship can make a huge difference in recruiting people into a field. For example, James Lau, MD, is an amazing mentor — he was the first person to make me believe that being the first surgeon in my family may be an attainable goal. Those who ‘make it’ without mentorship most likely had access to extra resources or had to work much harder than their counterparts, or both.”

How will your seminar course inspire change?

Steinberg: “Our seminar course will create an opportunity for Stanford medical students to meet and form relationships with accomplished physicians who have combined their passions for diminishing inequities and surgery. It will show the incredible impact surgeons can make on their community. For example, Matias Bruzoni, MD, will talk about a Spanish clinic he created from scratch to improve the surgical experiences and outcomes of Spanish speaking patients. And Sherry Wren, MD, will provide her perspective on serving veterans domestically and populations around the world, exploring the adversity she faced in dedicating her career to social service.

When students connect with role models like these with a similar background and passions, they are more likely to follow in the trajectory of that role model and consider careers that might have previously seemed unattainable. We hope this seminar will provide that initial connection.”

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

Educating the next generation of surgeons: A Q&A

Photo by Rachel Baker

Research shows that many medical students view surgeons as intimidating, competitive and predominantly male workaholics — and these stereotypes can deter students from a surgical career. As a result, there has been a relative drop in applications for surgical residencies.

James Lau, MD, a clinical professor of surgery and the director of the Goodman Surgical Educational Center at Stanford, is working to combat this trend by spearheading educational initiatives. I caught up with him recently.

Why is there a declining interest in surgical careers?

“Medical students are becoming more sophisticated in choosing specialties, and a lot likely has to do with life style issues. I think there’s a misconception that surgeons work all the time and can’t have a work-life balance.

Medical schools are also getting shorter — some are even going to three years and some schools are emphasizing primary care — so students aren’t exposed early on to surgery. So we’ve built a mentorship component into our SURG 205 surgical training course to give first- and second-year medical students at Stanford the opportunity to go into the operating room and learn what surgery is like. And it sparks the flame and shows them more accurately the collegiality and dedication of those in surgery.”

What do your students learn in SURG 205?

“Previously the students would have to find a mentor and negotiate the system on their own to get the training to be allowed in the operating room. This course brings it all together —training them on technical skills, facilitating finding them a mentor, experiencing one or two operations and hopefully building an ongoing mentor relationship with an attending surgeon.

We want them to participate in the OR, so we train them on technical skills — from the simple skills like knot-tying and basic suturing to performing a full case on a cadaver. As we explained in a recent paper, we also teach them nontechnical skills, such as coaching them on how to get along with the operating team, so they feel more comfortable when they go to the OR.”

What other educational efforts are underway?

“Surgery residents and surgeons have to know more than technical skills to do operations. They also have to work well together in teams in different settings. They have to be able to interact well with patients and make clinical decisions. And the techniques are changing all the time. So we provide a skills and simulation center with a curriculum — to help teach and mentor these skills.

We also must train inter-professionally in surgery. The nurses, anesthesiologists and surgeons all work together but traditionally train separately, which makes no sense. In a new program, we’re having monthly simulations in the operating room with surgeons, surgery residents, anesthesiologists, anesthesiology residents, OR assistants, scrub technicians, circulating nurses, and anyone else that would normally be in the operating room. We want people to understand that everyone has a role and should speak up in crisis. We’re trying to change the culture by training together.

We also have a resident as educator program, because our residents are automatically teachers and mentors to the medical students. To be a good teacher, you have to be a constant learner and create a safe learning environment. A good teacher is a good communicator and their learners include the patients.”

Why did you recently get a Master’s Degree in Health Professions Education?

“I oversee a two-year surgical education fellowship that has surgery residents teach, create curricula and evaluate the work that they do in the clerkships and residency education programs here at Stanford. Our goal is to prepare them to be thoughtful program directors, helping to make them the next generation’s education leaders in surgery. As part of the program, we encourage them to complete a master’s degree in education. To be a mentor for them, I decided to ‘walk the walk’ and get a masters degree in education. After a decade in education, I wanted to inform myself in the formal discipline of education to become more effective in the programs that we create for learners here at Stanford.”

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

What history can teach us about medicine: A Q&A with a Stanford medical student

Photo by Shivam Verma

When I think of history, I think of the famous quote: “Those that fail to learn from history are doomed to repeat it.” This is often brought up in reference to politics, but what role does history play in science and medicine? To learn more, I spoke with Julie Barzilay, a second-year medical student at Stanford who has studied the history of science.

How did you first become interested in the philosophy and history of science?

“As an undergraduate at Harvard, I took an incredible course on the history of Darwin and evolutionary theory that introduced me to the world of history and philosophy of science. It was fascinating and powerful to think about scientific knowledge as something that was created by humans in particular contexts and as something that was constantly being evaluated and re-imagined. I was especially drawn to the history and philosophy of medicine, where complex issues of identity, power, stigma, hope, fear and biopsychosocial dynamics all seemed to intersect. Once I began thinking like a historian, I could never see science and medicine the same way again — and I think that is a very good thing.”

How can this enrich the everyday practice of science and medicine?

“All knowledge has a history. Analyzing the ways that humans constantly create and revise their understanding of scientific processes makes us more innovative and critical when it comes to challenging assumptions in our fields. I also believe that thinking historically and sociologically builds empathy. Sociologists, historians, philosophers and anthropologists of science have made us think hard about concepts like the power dynamics in the doctor-patient relationship, or how a patient’s identity changes when given a diagnosis. And thinking about medicine in these terms adds so much depth to the care a physician can give a patient.”

What motivates you to still pursue this interest as a busy medical student?

“I think history is incredibly colorful, fun and important. I am also curious about the history of the profession I’m joining, and often find the questions that excite me the most live at the intersection of history, ethics and sociology of medicine.

I want to share these frameworks and passions with my peers. This is what motivated me to develop the upcoming lunch series on the history of science and medicine, which I created with the support of the Biomedical Ethics and Medical Humanities Scholarly Concentration, particularly Audrey Shafer, MD, and my advisor for this course Laurel Braitman, PhD. The class will introduce students to an array of talented historians, sociologists, anthropologists and bioethicists at Stanford as we rotate through a new speaker each Thursday at 12:30 pm. I hope the speakers inspire students to think historically and ask tough questions about our assumptions in all scientific fields.”

What are your career plans?

“After completing my MPhil in history and philosophy of science at the University of Cambridge and finishing my premed courses in a post-baccalaureate program at Johns Hopkins University, I worked at ABC News as a production associate in their medical unit in New York. I love communicating about health and medicine, and hope to integrate health communication into my career one day. In terms of clinical practice, I am most interested in pediatrics, but am open to exploring other fields during my upcoming clerkships. I hope to teach, write and practice, in some combination.”

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

Stanford medical student juggles his studies, graphic art and numerous extracurriculars

Collage by Ryan Brewster

I’m a freelance science writer adept at multi-tasking. But I feel like I’ve been sitting on both hands when I read the jam-packed resume of Stanford medical student Ryan Brewster.

For nearly two decades Brewster competed as a nationally ranked mogul skier, but knee Injuries led to his retirement in 2011 and a new career in medicine. While studying molecular biology and biochemistry at Middlebury College, he kept himself busy as an EMT, an advocate of sustainable agriculture in Rwanda, a Spanish-English medical interpreter at a community health center, a senior admissions fellow and the co-founder and graphic designer of Ron’s Closet Apparel Company — and that’s just a few highlights. After working as a research assistant at Harvard Medical School, he headed to Stanford for medical school last fall.

Intrigued, I spoke with Brewster about what he’s doing now. I admit that I was hoping to learn his multitasking secrets, but I was also really interested in his graphic art.”

How did you get started as a graphic artist?

“For as long as I can remember, visual art has been an important tool for self-expression. An engineer, architect and carpenter, my father encouraged me from a young age to communicate ideas in creative ways. I spent most of my childhood drawing before teaching myself computer software, such as Photoshop, in high school. It soon became clear that this interest could be applied to all my activities — from biomedical research to community service.

My skills in graphic design and illustration have been honed experientially rather than through any formal training. Starting a clothing brand, creating visual aids for community health workers in Rwanda and maintaining a healthy habit of doodling, among so many other opportunities, has allowed me to develop technically and stylistically. My style has largely been informed by Owen Davies, Chip Kidd, Jorgen Grotdal, Frank Netter and Mary Kate McDevitt. Furthermore, I have benefitted tremendously at Stanford from the support of Samuel Rodriguez, MD; Audrey Shafer, MD; Jacqueline Genovese; and artist Lauren Toomer, who have provided many opportunities to further my training in the arts.”

What have you been working on recently?

“I was the student coordinator for this year’s Medicine and the Muse symposium. I designed the marketing and branding materials, and exhibited a collection of anatomy-inspired illustrations (shown above).

Another first year MD candidate, Jacob Blythe, and I were fortunate to be selected as recipients of the Stanford MashUp Grant. It awarded us $600 to produce an art installment. We created a 3-D collage of the humerus and associated vasculature encased in glass. The piece is based on the novel Blood of the Lamb, which concerns a young girl who passes away from leukemia. Jacob and I wanted to capture this narrative of illness using related ‘artifacts,’ including blood smears, medical charts and actual pages from the book.

Also, earlier this year, James Lock, MD, approached me on behalf of a Stanford Medicine-wide diversity committee. They wanted to make a pin to be worn by physicians as a mark of LGBTQ alliance. The design features a DNA molecule with the traditional pride colors. This was a particularly rewarding project and we hope to have the pins fabricated and distributed by the end of the summer.”

And you sing, too?

“Another important artistic passion has been acoustic guitar and songwriting. The same imperatives that motivate me as a graphic designer similarly motivate me as a musician. Composing and performing a song challenges you to not only bear your emotions and feelings, but also to communicate them in a way that is relatable to your audience. Knowing that so many students held identities beyond that of future physician, Stanford medical students Shay Aluko, Andrea Garofalo and I founded the Stanford Medicine Open Mic to create a space for musicians, dancers, poets and other artists to showcase their talents.”

Are there other interests you’d like to mention?

“In the fall quarter, I completed the course Biodesign for Mobile Health, which exposes students to the emerging field of mobile technology. My project team — comprising two medical students, an undergraduate product designer and a bioengineering PhD student — developed a platform targeting users of the Supplemental Nutrition Assistance Program. Specifically, our NuLeaf team aims to provide individualized nutritional recommendations based on one’s health condition, budget, location and cultural preference. As Biodesign NEXT fellows, we have developed a functional prototype and have established strong partnerships with the Second Harvest Food Bank, physicians and other stakeholders. We hope to pilot the product with a local user population by the end of the summer.

Athletics also remain central to my wellness and extracurricular activities. Since retiring as a skier and college baseball player, I took up distance running and have struggled through several half- and full-length marathons. I am also an avid backpacker and camper. In fact, a major reason for choosing Stanford was the allure of the many outdoor playgrounds found in the state.”

How do you balance your different interests?

“Each of my activities serves as a reprieve from the other. Art balanced by science. The outdoors and fitness balanced by studying (unfortunately the latter wins out more often than not). Self-care balanced by community. That said, the past months have been a tremendous exercise in time management. ‘Triaging’ my commitments has not been easy, but it has allowed me to continue the things I value most.”

What are your career plans as an artist and physician?

“On one hand, I hope my career will marry the arts and medicine in direct ways, through medical illustration and data visualization. Perhaps of greater importance is the ethic of the artist carried by the physician. Doctors must be storytellers. They must be able to enter the patient’s world, listening, absorbing and acting on his/her narrative to inform treatment. The humanistic orientation in medicine requires the strengths of an artist — the observational skills to examine details beyond how they superficially appear, the perspective to understand information in isolation and in its broader context, and the empathy to acknowledge the human life that stands before them. It is in this framework where I see the noblest goals in medicine.”

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

East meets west: Stanford students can sample Tibetan medicine during clerkships

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Stanford medical students must master genetics, biochemistry and immunology, among other disciplines. But school leaders don’t want these future doctors to be stumped when their patients describe their acupuncture sessions, or have questions about herbal supplements or other alternative therapies.

To help familiarize Stanford medical students with these practices, the students spend a day shadowing a practitioner at a participating integrative medicine clinic during their family medicine clerkship.

“We want to introduce students to the idea that the patients they see in clinic are using these other health-care systems,” said Art Johnson, coordinator for the family medicine clerkship. “They need to partner with patients in managing their health in the best way possible, and utilize all available resources.”

The Kunde Institute, a center for Tibetan wellness and healing located in Daly City, is one of these participating clinics. It offers a unique opportunity for students because most integrative medicine clinics in the Bay Area focus on Chinese medicine, Johnson said. About 10 Stanford students per year shadow practitioners at this center, said Tracy Rydel, MD, who directs the family medicine clerkship.

Tibetan Medicine, which originated more than 4,000 years ago, attributes the roots of all disease to an imbalance of the three Nyepas (rlung, tripa and peken) that emanate from the three mental poisons of desire-attachment, hatred-anger and closed-mindedness. Treatments at the Kunde Institute include herbal medicines, hot oil therapy, acupuncture, copper cupping, and individualized counseling on diet, nutrition and lifestyle behaviors.

At the Kunde Institute, the participating students learn from Menpa Yangdron Kalzang, LAc, who has a Tibetan medicine degree from the Tibetan Medical University in Lhasa, Tibet and a master’s in traditional Chinese medicine from Five Branches University in Santa Cruz. They learn about the connection between the physical, emotional and mental health of patients, one student told me.

Stanford medical student Victoria Boggiano first learned about Tibetan medicine when she attended a symposium at Stanford, she said. When she shadowed Kalzang, she told me she became very interested in how Tibetan medicine can complement the biomedicine traditionally taught in medical school. Boggiano described her experience via email:

“I spent an afternoon with Menpa Kalzang shadowing her as she saw patients with a variety of ailments. I remember really distinctly that two separate patients we saw that day had very bad plantar fasciitis, an inflammation of thick tissue in the foot that leads to pain in the heel and bottom of the foot. Before coming to the institute, neither patient had been able to walk without feeling terrible pain that had been resistant to any of the medications or physical therapy that their primary care physicians had provided them. Both patients started seeing Menpa Kalzang to receive acupuncture and herbal remedies, after which they both saw dramatic reductions in their symptoms. It was incredible to see how much Menpa Kalzang had helped them!”

Since 2008, about 100 Stanford students have visited Kunde, Kalzang said. She said she plans to continue with the program.

“I do this to build bridges between the Western and Eastern medical systems,” Kalzang said. “We need to establish integrative medical systems that allow providers from different disciplines to share information and put in referrals for both types of treatments. This is particularly important for patients with complex cases when Western or Eastern medical systems alone can’t answer or solve the problem.”

Boggiano hopes to be part of this vision of integrative care. After medical school, she plans to specialize in family medicine and work in a primary care clinic. She explained:

“I am eager to learn more about alternative medicine, and particularly Tibetan medicine, both by continuing to work with Menpa Kalzang and by gaining additional clinical experience. It would be incredible to work at a clinic where both biomedicine and alternative medicine are practiced side by side. Tibetan medicine encourages us to view patients in a holistic way and reminds us that mental health and physical health are incredibly intertwined. Patients deserve to receive both types of health care.”

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