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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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.

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.

4 H’s and 4 T’s Walk Into a Bar…”: A joke? No, an episode from a medical education podcast

Photo by Patrick Breitenbach

Medical school is jam packed with information to memorize as well as with high-stakes exams and expectations, creating a cauldron of stress and tension. Enter the mnemonic-filled Humerus Hacks podcast, part of a growing movement to make medical education more entertaining and accessible.

I recently learned about Humerus Hacks from its Australian founders and hosts Karen Freilich, MBBS, education coordinator at The Nookie Project, and Sarah Bush, MBBS, medical intern at Western Health. They started the bimonthly podcast to liven up their studies, but have continued it after graduating from medical school despite hectic intern schedules. Each 10- to 40-minute episode is filled with humor and casual conversation, which should be no surprise given episode titles like, “4 H’s and 4 T’s Walk Into a Bar…” (Which, for non-cardiologists, is a reference to potential causes of cardiac arrest.)

What inspired you to create a podcast?

Freilich: “Sarah and I have been mates since we were ten years old, and study buddies since day one of med school. We were both constantly overwhelmed by the sheer quantity of information we had to learn, especially when it came to learning the tongue-twisting names of medications. We began breaking down our curriculum into funny snippets to make it easier to learn, but also more enjoyable to study.

The tables turned in our penultimate year of medicine, when I was commuting over two hours daily to placement and Sarah hurt her back and couldn’t properly sit down at a desk to study. We raked through the medical podcast world to find something aimed at our level that wouldn’t put us to sleep, and there wasn’t too much out there. And so, Humerus Hacks was born. We picked the name because it was dorky, fun and medical — just like us.”

How did you learn to make podcasts?

Bush: “As an avid podcast devourer, going through at least four hours of content a day during my commutes about town, I became interested in the sound engineering — and turn’s out its super simple! We opted for high quality microphones, although we didn’t figure out how to use them properly until episode 3 or 4. And I learnt how to edit using Audacity. And then I just give it to a podcast hosting company, and voila!”

Why do you format the episodes as conversations?

Freilich: “We wanted to create content that was funny and enjoyable to listen to. We always aim to include banter and tangents, because that’s what keeps learning interesting. Before an episode, we often write down the three most important things we want the listeners to learn that episode. If our listeners can learn those things, and be entertained at the same time, then we’ve done our job.”

You mentioned that you’ve had feedback from patients. Isn’t your podcast for medical students?

Freilich: “Doctors, nurses and other health practitioners often have jargon so deeply ingrained that it makes it hard for them to explain a health topic simply. We didn’t initially intend to incorporate patients in our listenership, and we are still surprised and quite honored that people have used our podcast as a way to further understand their condition. It’s great that Humerus Hacks can help improve access to medical education.”

What is your favorite Humerus Hacks episode?

Bush: “My favorite is definitely the murmurs rap (at time 9:20) about ejection and pansystolic murmurs, because it has helped me out in real life diagnosis. And it has the added benefit of teaching people how to beat box: start by saying boots and cats, and we’ll go from there. Also I get to rap, which is always fun and embarrassing.”

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

Reimagining Nutrition Education: Doctor-chefs teach Stanford medical students how to cook

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Photograph courtesy of Michelle Hausman

Stanford medical students still learn traditional topics like anatomy, genetics and neuroscience. But now, they can also learn how to cook, thanks to a new hands-on course developed in part by Stanford’s Michelle Hauser, MD.

A former Le Cordon Bleu chef, Hauser is currently an internal medicine-primary care attending for Stanford residents and a postdoctoral research fellow at the Stanford Prevention Research Center. She teamed up with Stanford pediatrics instructor Maya Adam, MD; physician Tracy Rydel, MD; nutrition researcher Christopher Gardner, PhD; physician-chef Julia Nordgren, MD; and Stanford chef, David Iott, to launch the new class, which is featured in a video.

Hauser said the course aims to teach future clinicians how to cook healthy food, so they can more effectively counsel their patients on nutrition and diet. Intrigued, I spoke with her recently.

Why did you introduce this course?

“Diet is the most significant risk factor for disability and premature death in the US. However, less than one-third of medical school and residency programs offer a dedicated nutrition course to their students. When courses are available, many schools use outdated, overly long and complicated online modules rather than in-person nutrition instruction. They often just focus on nutrients, whereas patients think of nutrition in terms of food. And most schools don’t teach how to effectively counsel patients to change their behavior around eating — people know it is healthy to eat more vegetables, but how do they accomplish this? We need to better prepare physicians to treat the underlying causes of disease and to prevent diet and lifestyle-related diseases from occurring in the first place.”

How can your course help?

“Teaching kitchens are the perfect, hands-on medium to help doctors learn about food. By learning to prepare delicious, healthy food for ourselves, we become healthier — and studies show that physicians with healthy habits are more likely to counsel patients on those habits. Additionally, it’s more fun and memorable to learn about food and nutrition while cooking and sharing meals together than it is to sit in a lecture hall.

As a platform to teach about nutrition, our new teaching kitchen elective focuses on how to prepare healthy meals based on plants and whole foods, a diet that is ideal for the majority of the population. We also teach a concept called the “protein flip” — instead of having the center of your plate be a large piece of meat, you use meat as a garnish for a plate full of plant-based foods, such as vegetables, fruits, whole grains, legumes, nuts and seeds. Think veggie chicken stir-fry with brown rice or a main course salad with a small portion of grilled salmon.

Our sessions use a flipped classroom format. Before class, students view engaging preparatory videos online (and many of these are available through Stanford’s Food and Health series). At Stanford’s teaching kitchen, they watch the chefs’ cooking demonstrations and then lace up their aprons and start chopping and cooking. In addition, Tracy Rydel, Maya Adam, Christopher Gardner and faculty from other medical programs are cooking alongside the medical students to represent the lay cook’s perspective, as well as spread the idea of using teaching kitchens to others in the Bay Area and beyond. At the end of each session, we all share and eat together.”

How do you make healthy food appealing?

“Healthy food has gotten a bad rap for far too long. We need to make sure that healthy food is delicious if we expect people — including ourselves — to eat it so that it can nourish our bodies and prevent nutrition-related chronic diseases. Food is a huge part of all of our cultural identities and is intricately linked with many of our fondest memories. I often see medical professionals in training and in practice tell patients to stop eating a whole variety of things — many with personal and cultural significance — without helping them figure out what and how to eat differently. And these conversations often make it sound like the patient needs a ‘special’ diet inappropriate for the whole family. Instead, we need to celebrate the togetherness of sharing healthy food.

 For the final project, the students will make favorite healthy foods that mean something to them. For instance, I would make hummus, tabouli and falafel wraps (falafels rolled up in warm whole-wheat pita bread with chopped tomatoes, scallions, cucumbers and spring mix drizzled with lemon-tahini sauce). As a vegetarian with a dairy allergy, my Irish-immigrant family’s traditional Christmas dinner normally left me with a lonely potato and a few token veggies. However, a few years back I cooked this Middle Eastern meal for my family and it was a hit. And this year, my mom requested that we make the meal as the centerpiece of our Christmas spread!”

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

Stanford medical student illustrates mnemonics

Illustration courtesy of Nick Love
Illustration courtesy of Nick Love

Medical students frequently turn to mnemonics to master human anatomy, but they’re usually just catchy phrases. Now, Nick Love, a second-year Stanford medical student, has created a more entertaining way to memorize anatomy: a set of illustrated mnemonics, which he has published in the form of a book and website. I recently spoke with Love about his project.

What inspired you to illustrate the anatomic mnemonics?

“When I began medical school, I was totally unaware as to the central role mnemonics play in medical education and beyond. They are everywhere! Their sometimes wacky and ridiculous wordings intrigued me — I wondered if they could serve as a unique source of ‘found imagery,’ starting points for visual exploration. I brought up this idea with Audrey Shafer, MD, director of the Biomedical Ethics and Humanities medical school track, and she kindly encouraged me and linked me up with an awesome mentor for the project, pediatric anesthesiologist and painter Samuel Rodriguez, MD.”

Where did you get the mnemonics and how did you choose your illustration style?

“They are all essentially common med school mnemonics. Fourteen of the 16 mnemonics were passed on to us as medical students, mainly by our clinical anatomy teaching assistants via the ‘whiteboards’ in the anatomy lab. I sourced one mnemonic directly from the internet, and I altered another because its original form was too raunchy for publication. At the moment, I am, unfortunately, too behind on too many things to add more.

In terms of illustration, I was motivated to try a digital-analog-digital process. I’m currently intrigued by combining the reproducibility of computer-aided illustration with the inherent chaos of spreading paint or ink. Also, I wanted to maximize color usage, insert a bit of whimsy into the illustrations and experiment with recursive imagery.”

Do you have a favorite mnemonic?

“My favorite mnemonic is ‘canned soup, really good in cans.’ It helps one remember the branches of the descending aorta — canned soup, really good in cans, representing celiac, superior mesenteric, renal, gonadal, inferior mesenteric, and common iliac arteries. The phrase ‘canned soup, really good in cans’ strikes me as rather humorous, like it was made for an ad campaign when soup was first put into cans. Genius, whoever came up with it.”

Do you have any art training? Who are your favorite artists?

“Before coming to medical school, my training was mainly in science. However, last year I took two art classes at Stanford, ‘Digital Photography’ and ‘Video Compositing,’ both of which were awesome. As a kid, I mostly played sports, video games and outside. The desire to make things came later.

My favorite artists include Alphonse Mucha, David Hockney, Kiyoshi Yamashita and Andy Warhol. Currently, my favorite museums are the Cantor Arts Center and the Anderson Collection — right here at Stanford and only about 1 km from the medical school! I also try to go to the Tate Modern when I’m in London.”

Do you hope to include art somehow in your future medical practice?

“I’m very much interested in learning more about what is referred to as the ‘art of medicine,’ and I hope to have the time to keep creating. At the moment, I’m most drawn to visually-based medical specialties, such as dermatology, pathology, radiology and nuclear medicine.”

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