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.

The Opioid Crisis: Medicine X panelists explore the complexity of managing chronic pain

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Photograph courtesy of Medicine X

Saturday’s Medicine X session on the opioid crisis focused on how best to manage the chronic pain felt by millions of Americans every day. The session engaged panelists with different perspectives, including a patient in chronic pain and physicians struggling to decide when to prescribe opioids. All the panelists recognized that opioid addiction is a serious and pervasive problem, but they also warned that proper pain management is a complex issue.

Jeanmarie Perrone, MD, professor of emergency medicine at the Hospital of University of Pennsylvania, told the audience, “I need good pain management to work in the emergency room. We need these drugs, we just need to be conscientious about it.”

ePatient Britt Johnson, a Medicine X board member and owner of The Hurt Blogger, understands this all too well. She shared her story of needing opioids to function due to severe pain from spondyloarthropathy and rheumatoid arthritis, which she’s had for most of her life.

Johnson addressed the media’s oversimplification of the issue. “Pain is not politically correct,” she said. “The media tells me that all opioids are all bad. The media makes everyone believe that I, too, am struggling with addiction. And the media lumps me in with statistics on heroin usage and overdose deaths.” She went on to say that she winds up “feeling guilt and shame for constantly experiencing pain. And I’m reminded constantly how heart breaking overdose stories are, which they are. But my story is not connected to those stories.”

Pain expert Frank Lee, MD, agreed that “we’re starting to stereotype chronic opioid patients as heroin addicts and physicians as pill pushers.” Lee described the impact of this on his practice and how it increases his risk if he prescribes a large or moderate dose of opioids to a patient. “If I just follow the CDC guidelines and tell the patient that I can’t prescribe this medication, it makes my life easier,” he said.

Lee shared a story about one of his patients who recently died. In her 70s, Mary had severe rheumatoid arthritis and three back surgeries. When he “inherited” Mary from a different pain doctor, she was on massive doses of opioids — close to 300 mg morphine daily equivalents, several times the recommended dose. “Maybe I was naïve, but I went through all the dangers of opioids. I told her, ‘We need to come down on your dose.’ She was hesitant, but she said ‘if you really need to do this, okay.’ During the next three months, we went down from almost 300 mg to about 70 mg. She ended up in the emergency room twice, because she just couldn’t take it. It hurt too much,” he said. “She cared enough to try what I recommended and I felt like I owed her the chance. We went back to the insane amount of her opioids and she did well.” However, Lee expressed his concern over what the high opioid doses did to her body.

Lee and others discussed the need to distinguish between patients like Johnson and Mary from those who are prone to opioid addiction. Sean Mackey, MD, PhD, chief of the division of pain medicine at Stanford, declared the need for more quality data on pain — through programs like the National Pain Strategy — to help identify the risk factors of the people that are more vulnerable. Cynthia Reilly, director of the prescription drug abuse project at The Pew Charitable Trusts, professed that prescription drug monitoring programs are part of the solution.

The panel agreed that another solution is to make integrated medicine options more affordable. “At the pharmacy I get a bottle of 60 Percocet for ten dollars, yet I have to pay out of pocket for massage, acupuncture, heat therapy, ice packs, cognitive behavioral therapy, pain psychologists and anything else,” said Johnson. “Opioids have the cheapest barrier to access, yet raising the price of opioids is not the answer; putting complimentarily pain therapies on an even playing field is.”

Although mostly harmonious, the panel discussion became heated near the end when a member of the audience interrupted, asking to hear more from Johnson. Feeling that she was being left out of the conversation, she said, “I’m sitting here and the discussion about the pain crisis is happening around me, when I’m right here and it could be happening with me. We could be having a real discussion here.” The panel concluded that we need to do a better job bringing everyone together with different perspectives.

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

How can technology address the health needs of aging adults? A Medicine X panel offers tips

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Photo courtesy of Medicine X

Older adults aren’t usually the first adopters of new health technologies. But wearable devices and smart phone apps could help this growing population by improving patient-provider relationships, enhancing health literacy, increasing safety and engaging patients in their own health, a panel of speakers at Medicine X said Saturday.

Moderator Frances Patmon, PhD, RN, nurse scientist at Dignity Health, began the discussion by noting, “All our baby boomers are retiring in the next five to 10 years and it’s going to be problematic if we don’t know how to care for these older adults.” She believes that it’s vital to engage and educate older patients and their families and “technology is a great way to engage the older population.”

A major topic of the session was the need to customize technology. Perry Gee, PhD, RN, nurse scientist at Dignity Health, explained that 60 percent of older adults have some kind of functional deficiency, such as impaired vision, hearing, sense of touch or memory function. “We need to consider this when we design,” he said.

Panelist Christopher Snider, Medicine X executive board member, social media strategist at Smart Patients and patient community advocate at Symplur, agreed. Both Snider and his wife live with diabetes. “I’m looking forward to getting old with diabetes with my wife who has diabetes. And our eyes and touch aren’t going to be as reliable,” he said. “Am I going to be able to hear or feel my CGM [continuous glucose monitor] when it alerts me in the middle of the night? Maybe we need an older adult model with improved technology alerts that cause a seismic shift in the house?”

Gee noted that patients need to be part of this design process. “We need to invite older adults, who are struggling, to participate in the design process — bringing them into our design labs.”

In addition to innovative design, the panelists agreed that more training was needed — for patients, families and health-care providers. Michelle Litchman, PhD, nurse practitioner and assistant professor at the University of Utah College of Nursing, explained, “It takes a lot more time to train older adults on technology. Because of dementia, we also need to involve family members and other caregivers. And we have to tailor the training for that person and consider patient safety safeguards.”

Litchman described how technology and training helped her patient Lavon, an 85-year-old woman with Type 1 diabetes and dementia who lives in an assisted-living facility. In the past, home health-care workers came in to give Lavon her insulin, but she still had a lot of glucose variability because she only needed tiny doses of insulin. So Litchman provided her with an insulin pump along with “a ton of training.” The process started with a two-week practice run using a pump dispensing saline, followed by training all of her home health caregivers and family. In the end, Lavon got a more precise dose of insulin and her dizzy episodes were greatly reduced.

Although technology can help older adults remain more independent, Gee noted that the digital divide still exists and is even more pronounced for older adults. “We need to work with people that are 75 years or older who haven’t used technology. We need to bring them to the table and learn from them,” he said.

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

On the importance of patient empowerment and open source, a Medicine X panel weighs in

Core theme: Data + Devices panel with Ben West, Cedric Hutchings, Karen Sandler and Dana Lewis
Photo courtesy of Medicine X

It’s your body, so you should have access to all of your medical data, right? This morning at the Medicine X session on data and devices, I learned that liberating your own medical data — or devices — will probably not be so simple.

The conversation was started by Ben West, a software engineer and co-founder of the Nightscout Project, which supports the creation of open-source technology for people with Type 1 diabetes. He explained that he was given two computers when he was diagnosed with Type 1 diabetes 12 years ago: an insulin pump and a device that tells him how much insulin to take.

“These devices are literally in or on our bodies, so my relationship with these devices is extremely personal and intimate. And that’s true for many other patients,” he said. “But computers are programmed by people, so sometimes the computers can do the wrong thing. When something with one of these devices goes haywire — and you get a side effect because of the therapy rather than the disease — to what degree should you be empowered?” He said he believes patients should have the ability to fix or adjust the device themselves.

This launched West on his mission to reverse engineer his medical devices and develop open-source software to take control of his personal care.

Speaker Karen Sandler, JD, heartedly agreed that developing open-source software for medical devices is critical. She is the executive director of Software Freedom Conservancy, a non-profit organization that develops, promotes and defends open-source software. Her life was changed when she was diagnosed with a life-threatening heart problem and implanted with a defibrillator. “I went from someone who thought open source was cool and useful to someone who thought great open-source software was essential for our society,” Sandler said.

As a self-proclaimed “extreme geek” with technical programming experience, when her doctor gave her the defibrillator, Sandler asked, “what software does it run?” She found out that neither her doctor nor the device’s medical representative had ever thought about the software used on the device. But Sandler said she knew that all software has bugs, needs to be reliably backed up and needs to be protected from hackers.

“It’s clear that free and open-source software is better and safer over time,” Sandler explained. “If there is a problem, you don’t have to wait for the manufacturing company to admit the problem and then make and release a fix. With free and open-source software, anyone can make the fix. And that is really, really important, especially when you’re a special case.” Sandler speaks from experience: she was incorrectly shocked twice by her defibrillator when pregnant — a rare happening still in need of a technical solution. “With free open-source software, we remove the reliance on any single company and take back control,” she said.

Speaker Cédric Hutchings, co-founder and CEO at Withings, a consumer electronics company that develops health devices and apps, emphasized the importance of patient empowerment. “Empowerment is about getting insights to drive change,” he said, “ and we need to develop insights using population data.” He explained that this requires the involvement of researchers, patients, health-care providers and the community. It’s also essential to be “transparent and set expectations” with patients about how their data will be used.

Near the end of the panel discussion, moderator Dana Lewis, director of MDigitalLife, posed the question, “What is the secret sauce for the open-source community?” Perhaps not a secret sauce exactly, but the panelists said that the ability to access their personal data can help overcome a feeling of powerlessness.

However, West cautioned, “We’re intimately connected to these devices and they are on a hostile network. So when we design this kind of medical device, we need to think about it like a diplomatic pouch – something so secure and trustworthy that all your secrets in it are safeguarded.”

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

What color is your cloud? Study finds large variability in resident workloads

Photo by Scott Schiller
Photo by Scott Schiller

For decades medical residents have put themselves into two camps: “black clouds” and “white clouds.” Black-cloud residents carry with them the bad luck of consistently getting a patient load that requires more work; the perceived workload intensity and stress may keep them pacing the halls at night, while their white-cloud counterparts are likely to sleep peacefully while on call.

Does this cloud status actually exist, though? Adam Was, MD, fourth year Stanford resident of pediatrics and anesthesia, decided to find out. The results of his study were just published in Pediatrics.

“The study was inspired by my late-night argument with other interns about our workloads,” said Was. “We commonly discuss what type of cloud we have, meaning what kind of workload. So one of the interns said his workload was really high, but someone else argued that we all have the same workload and he was just complaining about it more. I realized that we could do an objective, rigorous study of actual workloads to get a real answer.”

With the help of KT Park, MD, assistant professor of pediatric gastroenterology and senior author of the study, Was measured the workload of twenty-six pediatric residents during the six core inpatient rotations of their intern year — to make sure they were comparing “like to like.” Using the Stanford Children’s Health research database, they quantified the workload intensity of each of the residents based on the number of electronic notes and orders that they wrote while in the hospital. Was explained:

“ We wanted to focus on objective data that described the work done at the hospital, as opposed to just the number of hours spent there. Residents do a lot of things that aren’t captured in electronic notes and orders, but we found this data to be the most robust and representative.”

And the outcome? The differences are real. The researchers found a very significant variability of workload intensity between the residents. High-workload residents wrote 91 percent more orders and 19 percent more notes than low-workload residents. Here’s Park:

“I really thought that we were going to conclusively lay to rest this idea that there is statistically significant workload variability between residents. I was very surprised. We did sophisticated mathematical models and there is no way around it — there are high-workload and low-workload residents. There is no ethological explanation right now, and it remains a big question mark especially for program directors.”

Thinking through the study’s implications from a program director’s point of view was the main role of the third author, Becky Blankenburg, MD, clinical associate professor of pediatrics and pediatric residency program director, who thinks the results can guide residency directors. “This data provides more information for resident assessments and will allow us to better individualize the residents’ curriculum based on what they’ve really been exposed to,” she said.

Determining the root causes behind this workload variability is beyond the scope of their study. However, the authors have a few of their own theories.

One belief: high-workload or black cloud residents behave differently than their white cloud colleagues. For example, some black cloud residents may be inefficient, while others may create extra work for themselves. And some white cloud residents may need to be more vigilant.

“I would like to get into the heads of the residents in real time,” Park said. “As they put in that note or order or take that phone call, what is the impetus? From my observation, anxiety and perfectionistic tendencies drive them to do more than what’s necessary for effective patient care.”

Blankenburg agreed, “Some residents early on learn to look at the big picture and some see only the trees without seeing the forest. Another important factor is how comfortable people are with ambiguity. If you’re able to deal with ambiguity better, you might not order as many tests.”

The researchers are contemplating how best to use this information and how to design a follow-up study to understand the root causes of resident workload variability. One idea is to somehow incorporate peer evaluations, since their study found self-assessments to be inaccurate. “I think peers would do the best job of picking up on cloud status or workload intensity,” Blankenburg said.

Although successful, did the study settle the late night argument that inspired it?

“The study data was annonymized, so we don’t know who was who,” said Was. “So I never got to settle my original argument of whether I was doing more or less work. Before the study, I thought I was a black cloud. Afterwards, I feel like I’m a confused and possibly grey cloud.”

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