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.

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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.

Training anesthesiologists to handle emergencies using simulation

Photo courtesy of David Gaba

Most anesthesiologists excel at routine procedures. But how do they fare when faced with an emergency, such as a sudden cardiorespiratory arrest, a severe allergic reaction or a massive hemorrhage?

“Like airline pilots, it’s the ability to handle the unexpected that patients, or passengers, are really paying for,” said David Gaba, MD, a professor of anesthesiology, perioperative and pain medicine at Stanford.

Gaba helped pioneer mannequin-based simulation tools used to hone the skills of both novice and highly-experienced physicians. During a simulation, a computerized mannequin fills in for the patient. “The mannequin has pulses and eyes that blink. It breathes, talks and provides all the waveforms and numbers to the clinical monitor displays that physicians and nurses are used to seeing,” said Gaba. “The instructor can tell the system to do all sorts of things, and can recreate many situations.”

These mannequins are particularly useful to practice how to handle unexpected life-threatening situations, he said. “We can allow medical students and residents in training to be the final decision-maker in simulation, whereas fully-experienced physicians will take over to protect a real patient,” Gaba said.

Since practicing teamwork is critical, the simulations are sometimes done with a full team of anesthesiologists, surgeons, nurses and technicians. Sometimes, teams members such as nurses are following the instructor’s directions; in other situations, all participants are new to the scenario,” Gaba said.

In a recent study, 263 board-certified anesthesiologists participated in simulated crisis scenarios with team members who were working with the instructor. In one scenario scripted by Stanford, the simulated patient undergoing an urgent belly surgery had a severe heart attack, causing an abnormal heart rhythm and dangerous drop in blood pressure.

The study identified different types of performance deficiencies: lack of knowledge, reluctance to use more aggressive treatments or failure to fully engage the surgeon. However, the most important lesson may be the need to call for help sooner. “When help was called, it almost always improved the overall performance of the team,” Gaba said.

In the scenario described above, for example, the unstable patient’s dangerously low blood pressure necessitated the aggressive treatment of shocking the heart with a defibrillator, he told me. “Although most anesthesiologists know this, they are more familiar with using a variety of medications and some participants were reluctant to do the appropriate, but more invasive action,” Gaba said.

Gaba identified various ways to overcome these performance gaps, such as using role-playing, verbal simulations with a colleague, full simulations and emergency manuals.

During the 30 years he has been researching mannequin-based simulations, Gaba said he’s witnessed many changes:

“When we started, people thought that simulation was a ‘nice toy,’ but they couldn’t see all of its applications. They thought that it was good just for simple technical things like CPR. But, we saw the cognitive parallels between our world in anesthesiology and worlds like aviation. Similarly, 30 years ago the notion of emergency manuals would have been called ‘a cheat sheet’ or ‘a crutch.’ It is now recognized that smart people use such cognitive aids because no one can remember everything, especially in the heat of a crisis. That’s why pilots and others use them – just common sense.”

Despite this progress, Gaba said that simulations are still not fully embedded in health care training. He estimates that only about five percent of practicing physicians have been through a meaningful simulation, beyond the basic life support or advanced CPR courses.

But he is still hopeful. “We’re pretty sure that there are hearts, brains and lives that have been saved due to our work, and I’m not retiring any time soon,” he said.

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

Bringing innovative education to emergency medicine: A Q&A with a doctor/filmmaker

Photo by PublicDomainPictures

What do immersive simulations, filmmaking and emergency medicine have in common? One answer is Henry Curtis, MD, a Stanford clinical instructor in emergency medicine who’s using innovative tools to educate medical students and residents about emergency medicine.

Curtis’s latest endeavor is a class called EMED 228: Emergency Video Production, which teaches students how to impact emergency care through film by “telling a story that matters.” I recently spoke with him about his use of filmmaking and simulation games.

Why do you use simulations and filmmaking as education tools?

“Both simulation and filmmaking serve different purposes for emergency medicine education. Immersive simulation is an arena. It’s a place where learners can experience a medical emergency in a safe environment. They make medical decisions, perform procedures and communicate with the patient and their team. When it is all over, they reflect on what happened. Aside from real life clinical experience, there is no better educational technique.

Filmmaking imagines and documents life. Video based learning has many advantages, not the least of which is reproducibility —a final cut is independent of individual human factors that could affect quality on any given day. It is fascinating to bind the experiences unfolding in a simulated medical emergency with videos. For instance, engagement videos can function to more powerfully immerse the learner into a given clinical scenario. Information videos can relate valuable educational cues more effectively than a photo, announcement or text flashed on a screen. Video based debriefing allows playback of the important moments in a scenario.”

What inspired you to create the EMED 228 course? What does it entail?

“I’ve been pursuing a master of fine arts in directing for the last few years at the Academy of Art University in San Francisco. I wanted to give back to Stanford and share the filmmaking skills I’ve acquired with students.

EMED 228 is open to undergrads, grads and medical students. We were fortunate to have a nice mix of students of all different educational interests and filmmaking experience enrolled. They were exposed to an overview of filmmaking. We began the first day with theory. The class then quickly progressed to understanding and implementing the practical aspects of creating a final product — using a robust array of equipment, including multiple high-definition DSLR cameras, GoPros, drones, remote focus pulling devices and gimbals.

The entire class culminated in a screening and Q&A session of the documentary that we created titled, Care Flight in the Golden Hour. We aimed to provide insight into the process and people delivering care to critically ill patients in Lake Tahoe requiring air medical evacuation. These caregivers provide a service, which oftentimes will make the difference between life and death of healthy people who are having a tragic day. We chose to film on location in Truckee, California. Hannah Rasmussen, a first-year medical student, acted as a teaching assistant. Her efforts were invaluable in organizing our remote and on-site collaborations.”

As a child, did you want to be a film director when you grew up?

“I did not always know that I would be so drawn to the storytelling art of filmmaking or that I would prefer to be in the role of directing. I did know that I preferred film to photos when creating memories. In fact, I have many more short videos than photos in the memory closet. During the last year of my emergency medicine residency, I chose to concentrate on the use of film in disaster medicine education and this is where my filmmaking life really began.

Stanford University is a rich world of opportunity. It has encouraged me to chase my interests and carve out a niche in the medical humanities. The department of emergency medicine is fully supportive of my journey. With such resources and encouragement offered at so many levels, I encourage everyone to seek out their passion in this environment.”

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

Discussing cancer: Online course offers tips to tackling tough conversations

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Photo by Serena Wong

Have you tried to talk to a friend or family member about cancer? It’s not easy. You might have blurted out something offensive, offered advice you weren’t quite sure about, or tried to minimize cancer’s severity or prevalence. Or maybe you just avoided the conversation entirely.

Even those with medical training struggle with cancer discussions. In response, a London-based nonprofit has created a free online course called “Talking About Cancer,” which offers strategies for discussing cancer risks, preventing and screening.

The three-hour course — which is designed for health-care workers, counselors, volunteers and others — is organized into short, self-paced modules made up of videos, quizzes, online discussions and role-playing with actors. I recently spoke with one of the course organizers, former journalist and Stanford alumni David Risser.

What is the course like?

“The course quickly reviews cancer myths and facts, and then concentrates on how to have confident conversations about cancer prevention. It’s an important area, because more than four in ten cancer cases could be prevented by lifestyle changes. Another goal is to boost early diagnosis, by training people to encourage others to see a doctor.

We wanted to present an engaging course with varied activities, including a ‘real-life’ narrative that runs through the course. We hired improv actors to play two characters, Anita and Brian. Anita has health difficulties but is reluctant to see a doctor. Brian feels invincible, but has multiple habits — smoking, drinking too much, a poor diet, and even refusing to use sunscreen — that put him at higher risk… We were amazed at how strongly participants identified with the experiences of these characters, leading to passionate discussions about effective ways to talk about cancer.

The course is led by our cancer awareness trainers — two nurses with experience in engaging doctors, nurses and people without medical training. It’s open now, but you must sign up by October 31. Otherwise, we plan to offer another free, public run of the course early next year.”

What inspired you to get involved?

 “I am a Stanford graduate with a B.A. in history, and a past managing editor of The Stanford Daily. I joined Cancer Research UK after a 28-year career in journalism, in part because of my own experience with several family members who have had cancer. I struggled to talk to one family member who didn’t seem to want to talk about her cancer. That made it easy for me to avoid talking about it, which wasn’t the ideal outcome.

It was also difficult to talk to another family member about being more proactive about her medical care, which was inadequate at the start. It’s still difficult to know whether or how to talk to friends about prevention.”

What have you learned while working on this project?

“I learned that there are widespread gaps in knowledge about cancer, from causes to treatments to chances of survival. For example, many people don’t know that obesity is the second most-preventable cause of cancer or that alcohol is linked to a range of cancers.

I think the most common mistake when talking about cancer is feeling you have to know everything. It’s more effective to say ‘I don’t know, how do you think we can find out?’ or `What have you thought about doing?’ than to avoid the subject, make pronouncements or communicate incorrect information. Another common mistake is failing to listen, listen, listen, rather than fix everything. Sometimes it’s better to guide the person through what they are feeling and what they are concerned about, keeping it about them and not about you or your solutions. The bigger issue in both cases is to gently help people see what they can do that works for them.

While the course focuses on cancer information, prevention and early diagnosis, most of it is about how to have conversations about difficult subjects. The greatest lesson in the course is how to talk to people in ways that encourage behavior change. And that can save lives.”

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

“Ultimately about discovery”: High school students experience hands-on biology research

Photo of Seung Kim and former student Emma Herold (Steve Fisch)
Photo of Seung Kim and former student Emma Herold (Steve Fisch)

In high school, most science classes involve students reading a textbook and doing experiments with known answers. Not Bio 470: Biology Research — an experimental molecular genetics biology course developed in partnership with Phillips Exeter Academy in New Hampshire and Seung Kim, MD, PhD, a professor of developmental biology at Stanford.

Kim was inspired to develop this unique high school biology class several years ago after visiting Exeter, his alma mater. He explained in an interview:

“I became aware that they were teaching science in a way very similar to how I’d learned it, which gave me pause as a practicing scientist because it didn’t reflect how science is really done. When we learn things in school, there should be no distance between us and the primary material. When you learn to play baseball or music, you don’t just read about it in textbooks. Instead, you play and try to mimic what professionals do.”

As a result, two Exeter instructors, Anne Rankin and Townley Chisholm, and a few of their students came to Kim’s research laboratory at Stanford the following summer to learn basic techniques for breeding and genetically manipulating fruit flies. Based on this training, the team launched an 11-week biology research course with 12 upper level students per year. The instructors teach the course at Exeter each spring, but both the teachers and students are in regular contact with Kim and his colleague, Lutz Kockel, PhD.

Drosophila, or common fruit flies, are an important model organism widely used in thousands of bioscience laboratories around the world, because these fast-breeding insects share much of our genetic heritage – fruit flies have 75 percent of genes that cause diseases in humans.

In class, students delve into fly genetics, molecular biology and embryology to generate and characterize new fruit fly strains. Kim explained their research:

“People have developed ways to turn genes on or off in fruit flies, using genetic tools that exploit elements from yeast gene control factors; there are whole libraries of these yeast-based genetically-modified fruit flies stocked around the world. But you need more than one independent system, so you can study complicated things like how cells talk to each other or how they interact in time during development. The research goal of our class was to generate a whole new set of genetically-modified fruit fly stock that used bacteria instead of yeast — creating a resource for the scientific community to perform their own research.”

If they succeed, great. But success isn’t guaranteed.

“The students, instructors and researchers don’t know what the outcome will be of their work, so it creates the actual emotions, effort and experience of being a scientist. The goal is to give young people a deeper understanding of what science is, which is ultimately about discovery,” Kim said.

The model worked well for Maddie Logan, an Exeter alumnus who is now a premed undergraduate at Yale University. She called it an incredible experience: “Biology 470 was very different from other classes in that it was 90 percent lab work. Every day we’d come into class, check in with the theory behind what we were doing that day, and then go to the lab benches to do our research. I learned that things in the lab only occasionally go as planned, and a real scientist has to be able to figure out what went wrong and how to correct it for next time.”

After taking Bio 470, a few students like Logan come to Stanford each summer to continue the research in Kim’s lab. “The whole strategy was to not worry about finishing anything in 11 weeks,” said Kim. “Over the last four years, students have accrued reliable data that we’ve now put together into a unique paper.”

Their paper has just been published in the journal G3: Genes, Genomes, Genetics— a major milestone for the project. According to the manuscript’s peer reviews, the students have produced a novel collection of fruit fly lines that will be “very useful to the scientific community to study diverse biological questions.”

Starting this fall, Kim and Lutz are expanding their genetics educational program to include Commack High School, a public school in Long Island, New York. They are also hoping to create a similar biology research course in a “high-needs” high school in the future.

For Kim, the project is a personal passion. “The thing that gives me the most joy is to see students’ faces light up when they really understand and really engage in the scientific process,” Kim said. “I’m trying to get people to see the beauty in science.”

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

Stanford medical student co-authors guidebook for aspiring science students

Photograph courtesy of James Pan
Photograph courtesy of James Pan

Academic hurdles in college stymie many budding doctors, engineers and researchers: More than half of all college students who enter science, technology, engineering and mathematics (STEM) fields change their majors or drop out.

As an undergraduate, Yoo Jung Kim — now a first-year Stanford medical student — and three colleagues at the Dartmouth Undergraduate Journal of Science observed this attrition first hand and decided to do something about it. Together, they wrote a practical guide for aspiring science students, providing insider advice on topics ranging from how to pick a major to how to start a research project. Kim told me about her new book, What Every Science Student Should Know, in recent emails:

What inspired you to write this guide for science students?

“In November 2011, the New York Times published an article titled, Why Science Majors Change Their Minds (It’s Just So Darn Hard). At that time, all of us had seen friends struggle with their science classes; some of our peers had even been discouraged enough to change their majors. This article confirmed to us that the problems with STEM education were a nationwide phenomenon and we felt like we already had some of the solutions.

We started interviewing highly successful science students at Dartmouth and other colleges throughout the country to see what they were doing differently. From there we distilled those observations into sample chapters that we pitched to literary agencies and publishers. Too many college students planning to study science and medicine change their minds later in their academic careers. Many of these students slip through the cracks in massive lecture‐based classes where they don’t necessarily get much advice or attention. We feel that our book could provide the guidance that most students need.”

Who is your target audience?

“We wrote this book primarily as a resource for early college students and ambitious junior and senior high school students interested in the sciences. However, its content can benefit anyone from a high school freshman to a recent college graduate. Our book covers ways in which students can improve their study skills, master their courses, find mentors who can guide them, conduct scientific research and prepare for their future careers.

Our hope is that readers will find the book to be a pretty comprehensive guide to their life as a science student, as well as their transition from college to the outside world. The book draws on interviews with a full spectrum of different science majors, winners of national scholarships like the Rhodes, founders of startups, researchers, and more — to give a broad overview of where science can take you.”

How did you find time to write a book during college?

“By the time we had secured a publishing contract, most of us had graduated from college already. We were literally dispersed throughout the world — Beijing, Michigan, and New Hampshire — so we held Skype meetings every two weeks. We kept to a tight schedule based on an outline we had come up with early on in development. As for myself, Dartmouth College let me work on the book for academic credit as part of an independent writing project during my senior year. We all spent many nights and weekends writing the manuscript over the course of a few years time.”

Are you planning to write any more books?

“Yes! There are a couple of subjects that I’ve been wanting to pursue, but the biggest problem is finding the time, especially since medical school is already a full‐time endeavor. In the future, I want to write a book that showcases scientific research as a human endeavor filled with setbacks and triumphs.”

What advice do you want to pass on to new college students?

“Don’t get overly discouraged by a bad grade in a science class. Throughout the country, science classes tend to give students lower grades than classes in other subjects. A bad grade is not necessarily a reflection of your work ethic or aptitude for science.

By the end of my sophomore year, I had racked up several Bs and B minuses in college science courses. I wondered whether I’d be able to get into any medical school, let alone Stanford. Fortunately, I found mentors at Dartmouth who helped me regain my confidence: physician mentors who helped me prioritize my time and upperclassman who shared their study tips and cheered me on. Starting in junior year, I aced all of my courses. I asked the upperclassmen that helped me to succeed — Justin Bauer, Andrew Zureick and Daniel Lee — to join me in writing our book, so that everyone could have the mentorship experience that I had been lucky enough to receive.”

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