everyone included

Medical Monday: Breaking News from the World of Obstetrics and Gynecology

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I spent this week at Stanford MedX Conference. This conference covers some of my fondest professional interests. In particular, we covered various themes of technology in medicine, such as the use of devices and apps for patients to use to follow chronic disease conditions like diabetes. We covered the increasingly important role of apps in research. 

We explored the phenomenon of peer to peer connections among patients and discussed how it is especially helpful with rare or undiagnosed conditions. 

Another prominent theme at the conference was design in health care. We heard lectures and  participated in workshops in human centered design, or more particularly patient centered design. We used design thinking to create maps of the patient experience, then took that information forward to inform features as disparate as language used in phone notifications, seating in exam rooms, and interior decor. 

One theme of the conference was “everyone included”. I already knew this meant the voices of all genders. I also learned it meant all those in health care, not just patients and caregivers. Namely, it also included family members, medical researchers, device makers and all those who design and evaluate the health care experience. 

The genius of the conference in my mind was that it brought together those who were traditionally separate. In my two years of attending the conference it became readily apparent that fantastic synergies were possible by bringing together people from these varied  backgrounds. Patients, physicians, scientists, designers and computer scientists, sat around around common tables to learn methods to solve vexing problems in health care. And yes, we were given large sheets of paper, colored markers and sticky notes. 

But... the people ! This was the best part of all. I am here to report that there are plenty of good and brilliant people in the world with the ability to conceive of solutions to serious problems. At this conference, they came in all shape, sizes, ages, nationalities and genders. You could not pick them out at a grocery store. But if they had a conversation at your dinner table, you would quickly learn how special they were.  

On to policy. The Congressional Budget Office (CBO) continues to predict a 15 percent rise in premiums for policies under the Affordable Care Act (ACA). They have reported that this will likely be the case due to uncertainty over the Federal government’s willingness to pay subsidies to defray the cost of health care. Also likely contributing might be reduced  number of enrollees now that the individual mandate is not being enforced. 

GOP Senators have pared their efforts down to a one point bill. This final attempt to repeal and replace Obamacare basically takes Medicaid expansion money and shifts it to block grants administered by States. 

At the same time, Senator Bernie Sanders has proposed a near opposite. He has proposed retooling Medicare in the image of Obamacare and providing it to everyone. This is the so called “Medicare for all” proposal. While this has no likelihood of passing this Congress, it is espoused by most of the potential upcoming Democratic candidates for President. The rationale here is that such a plan would save money in the long run. The reasons for this being conceivable have been discussed before and elsewhere. In a nutshell, it has to do with people’s willingness to keep up on their prevention, screening, contraception and prenatal care, thus avoiding costlier more severe phenomena. 

The Senate Finance Committee has obtained an easy bipartisan agreement to refund CHIP, the children's health insurance program,

In another strikingly bipartisan move, Congress has rejected deep cuts to the National Institute of Health. Indeed lawmakers on both sides of the aisle have defied the Commander in Chief and increased spending on biomedical research. 

In medical news, HPV vaccination rates continue to be sub par. However new data shows that vaccinations that have been given may be conferring a herd immunity as HPV infections have decreased 32% between 2009 and 2014. 

Vaping is viewed as a safe alternative to smoking in pregnancy. There is NO data to support this. In fact, newer data show an association between maternal vaping and asthma in the offspring.

Marijuana is viewed as safe in pregnancy. However, it is associated with learning difficulties in grade school  offspring. The State of Nevada is beginning a program to educate about this. 

In concerning but unsurprising News, pregnant women’s exposure to pesticides appears to be associated with premature delivery and low birth weight. 

 A recent study shows a faint correlation between two flu shots in row and miscarriage. Ever hear of signal to noise ratio ? This is probably noise. ACOG continues to reiterate the real demonstrated need for flu vaccine in pregnancy. 

Belly fat; it’s always the last weight to come off. However, it is well worth the effort. We’ve known for some time that belly fat was associated with increased rates of cardiovascular disease. However, new research indicates that central obesity is associated with increased rates of several cancers. Moreover, in the case of breast cancer, it is more closely associated with higher risk forms of hormone receptor negative cancer. 

As data science improves, so do our results. New research published in JAMA, the Journal of the American Medical  Association, constitutes the largest longest and best designed trials on the safety of postmenopausl a hormone replacement therapy. Happily, it does not increase the risk of premature death. This is medicine’s way of saying that the therapy is safe. 

 

Thanks for reading. Stay tuned next week for more exciting news from the world of Obstetrics and Gynecology. 

Wellness Wednesday: Stanford Medx 

I just knocked something off my bucket list. 

Stanford Medx is a multi-day conference on innovation in health care. The conference is akin to it’s older and more popular cousins TEDx and TED, programs which are available online to everyone and which deal with topics in technology, entertainment and design, really all the big issues. 

Medx brings together people interested in moving medicine to a new and better place. It’s themes are people, technology and design. I would like to share with you some of the material that I encountered and the people that I met, together with a few images. 

On Wednesday my first day, I travelled. It is always an entertaining shock to change biomes so quickly, going from the alpine to the sonoran in little more than a couple hours. From cool pine I went to warm eucalyptus. After getting settled, I attended presentations and a workshop at the D school - The Design School on the Stanford Campus. There I met designers, architects and medical people all coming together to make buildings, objects, and even procedures which would make getting medical care more effective and pleasant for patients and caregivers. I met a women who is involved in renovating the Women’s and Children’s hospital at Stanford, just as I am at my hospital. I also met the grandson of Charles and Ray Eames who reviewed principles of design though a survey of his grandparents’ work. I also met the mother of an unexpectedly premature baby who had struggled with expressing colostrum. She had, as a result, developed a clever and inexpensive device to modify existing pumps to make them more effective. We expect its use to become widespread. 

Day two was a workshop on shared decision making. This was meant to be decision making between anyone and anyone else: doctor-patient, doctor-nurse, and family member to family member. Shared decision making was a key theme which dovetailed into one of the main themes of the conference, EVERYONE INCLUDED.

Decisions from the top down can be problematic, and partake of hierarchy. Hierarchy for its own sake is to be banished from medicine. Effective communication, and therefore better results, satisfaction and even safety grow out of shared decision making. This was amply explained an demonstrated across all the varied content of the conference.

Communication needs more than clarity. To be optimal, it is two way, and involves empathy. EMPATHY was another key theme echoed over and over again. As physicians, engineers and designers, we must employ empathy in all our thinking. We need to ask the patients and the users for input at all stages of development. Such a process creates more user satisfaction and better results. 

On day two, we partnered up. Our group was composed of the professionals I mentioned, but also of special “ e-patient scholars”. These were medically sophisticated patients with serious chronic medical conditions who could speak to us about their long experience in the medical system. They were there to help us see through their eyes. I was paired with an older woman in a wheelchair with end stage MS and lupus. Since I have lupus we exchanged notes about that. But it was her MS that was making the critical problems. She spoke about her end of life plan. Even so, she was as pleasant and sparkling as a person could be.

On days three four and five we had presentations from morning until evening, often rapid fire. That is when the conference really took on a life of its own. The conference designers were smart. They had substantial breaks every hour or two, and provided food, and tables, and encouraged everyone to live tweet the conference. The session to break ratio was optimally dialed for stimulation and interaction. All the speakers made themselves accessible, so not only did you hear these phenomenal stories, you met the phenomenal people. Bread was broken and contact information was exchanged. 

Key themes were as follows: 

  • open medical data, especially genetic data
  • open research data 
  • the quantified self 
  • gamification of healthy lifestyle goals
  • getting patients, doctors and researchers together, often through the internet
  • patient education, often self education, through apps and the internet
  • collaborative and integrative medicine
  • collaborative end of life planning

A lot of this came together under the topic of PRECISION MEDICINE. This means care tailored to one's precise condition, down to the genes if possible. It also means giving exactly the right amount of medical care, not too much, and not too little. It also means care tailored precisely to the patient’s wishes. Finally it means oversight so that care dollars are used optimally. 

By far the most stunning presentation was that of Dr. Lucy Kalanithi, the widow of Dr. Paul Kalanithi, Stanford neurosurgeon who wrote “ When Breath Becomes Air”. Her presentation detailed the reality of love and connection despite suffering and death in a way that I have never imagined. Her presentation had more power than any I have ever heard. I recommend the book. 

Besides being stunned, I was also charmed. I got to meet so many delightful people who were also talented beyond measure. The same people were uniformly willing to share their insight and experience. Noteworthy among these was Dr. Wendy Sue Swanson, Seattle Mama Doc. She is a Pediatrician, mom, and writer extraordinaire. Check out her website, blog, and book " Mama Doc Medicine".

It was also great to meet Dr. Kyra Bobinet, who shares my interest in helping patients realize their goals in fitness, nutrition and health in general. She told me that everything she knows is in her book, " Well Designed Life". I didn't believe her but I can't wait to read it. 

Medicine is moving forward folks, and you will want to come with it. Medicine needs your input to be what it needs to be. Monitor yourself. Get your health data. Try to connect with your caregivers. Tell your story. Listen and see an alternative point of view. Have a discussion.  This is the basis of the future of medicine, medicine 2.0. 

Not nearly everything from the conference is uploaded, but a Stanford MEdx youtube channel exists. Check out the link below and I know you will be inspired. 

https://www.youtube.com/channel/UCK1chhgXNHf7iB5mlqzXODA