VENTURE INTO THE FUTURE
Trends, research and innovation
Sept. 27-28, 2004
James H. Clark
Center
Stanford University School of Medicine
Palo Alto, Calif.
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PRESENTATION DETAILS
"Cultivating Students' Passion for Medicine"
The academic and financial pressures of earning a medical degree can quickly deflate the idealism that prompted students to want to become doctors in the first place. Julie Parsonnet, MD, believes Stanford’s new curriculum will help students emerge from the training with their enthusiasm bolstered.
Parsonnet, the senior associate dean for medical education, said the goal of the curriculum – which was launched in the fall of 2003 – is to enable Stanford medical students to fashion their own medical education. The primary mechanism for this is the “scholarly concentration,” which helps students develop critical-thinking and research skills in areas of individual interest.
For instance, a student whose mother has heart problems might be interested in finding novel ways of alerting at-risk women to methods of preventing cardiac disease. The student could select the “Community Health and Public Service” concentration and work with a faculty mentor to develop disease-prevention strategies that could be disseminated through public health programs. Parsonnet said the goal is to help students learn how to pose relevant questions and then conduct research to answer those questions throughout their careers, propelling them toward becoming leaders in the field of medicine in addition to being superb physicians.
“It’s a small part of the total number of hours in the curriculum, but the concentrations are the anchor of the medical school experience,” Parsonnet said. Students are expected to spend about 200 hours on their scholarly concentration during the course of their medical education.
Stanford’s new approach differs significantly from traditional medical education in which students spent two years cramming their brains with basic science knowledge, followed by two years of seeing patients under the tutelage of residents and physicians.
Allowing students to shape part of their training, rather than forcing them into a one-size-fits-all program, will keep them connected to the spark that first kindled their interest in medicine, Parsonnet said. In addition, the new curriculum introduces stronger clinical training earlier in the education process and adds basic science “refreshers” during the clinical years.
The curriculum changes, coupled with dramatic advances in the use of simulation and other high-tech training methods, make this “an incredibly exciting time to be involved in medical education,” Parsonnet said.
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Focus session on Cancer/Stem Cell Biology
An embryonic stem cell has the potential to form any type of cell in the body, from heart muscle to nerve or liver cells. “You are inevitably fascinated by the potential of these cells,” said Seung Kim, MD, PhD, assistant professor of developmental biology.
Kim hopes to harness the potential of both adult and embryonic stem cells to replace the islet cells lost in type-1 diabetes. He’s one of several medical school researchers investigating stem cells in the possible treatment of cancer, diabetes, immune diseases, Alzheimer’s and Parkinson’s disease, stroke, and to prevent transplant rejection.
Although embryonic stem cells can become a wider range of cell types, stem cells isolated from adult human tissues have already shown promise in treating diseases in those organs. Irving Weissman, MD, who directs the Institute for Cancer/Stem Cell Biology and Medicine, first isolated the blood-forming stem cell in adult mice and then humans.
It’s these stem cells from the bone marrow that Stanford doctors use to replace the blood system in people after high doses of chemotherapy or radiation. The same cells can produce a new immune system in people whose immune cells attack their own tissues, such as lupus or multiple sclerosis. Similar adult stem cells from other organs such as the brain or liver could replace damaged cells in diseases of those organs.
Weissman hopes that studies with adult, embryonic, and fetal stem cells by institute researchers will lead to both new insights and new cures for a range of human ailments.
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Focus session on Cardiovascular Medicine
Former President Bill Clinton’s recent quadruple bypass surgery underscored how much is still to be learned about the development of heart disease, according to researchers from the Cardiovascular Institute. Clinton presumably had the best of health care and a history of jogging and recent weight loss (despite his affinity for fast food), and yet he developed heart problems that went undiagnosed until they became life-threatening.Figuring out what lies beyond the known cardiovascular risk factors is at the heart of the institute’s research, said Thomas Quertermous, MD, the William G. Irwin Professor in Cardiovascular Medicine and director of research in cardiovascular medicine. His lab is screening 2,000 people with heart disease and 2,000 without the disease to look for genetic differences in those groups. “We have identified a hundred genes this year that we have good reason to believe play a role in the heart disease process,” he said.
In addition to understanding risk factors, better visualization of what is going on inside the heart and blood vessels could spare patients unnecessary invasive procedures and help detect blockages that can rupture and cause heart attacks. Michael McConnell, MD, assistant professor of cardiovascular medicine, is focusing on the development of precise imaging for guiding therapy.
The institute operates much like a Silicon Valley start-up company, with non-traditional collaborations with other groups, such as bioinformatics, engineering and stem cell research, said Robert Robbins, MD, associate professor of cardiothoracic surgery and director of the institute. Robbins also discussed his research on the use of embryonic stem cells to reconstitute damaged heart tissue.
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Focus session on Immunity/Transplantation/Infection
In an overview of the new Institute of Immunity, Transplantation and Infectious Diseases, Mark Davis, PhD, the Burt and Marion Avery Professor in Immunology, and his colleagues presented recent findings and projects that show that the overlap between these three fields is more significant than the divisions.
New appreciation of host-pathogen interactions are pointing to effective ways of fine-tuning the immune system to reduce the overreaction of allergy and autoimmune diseases, said John Boothroyd, PhD, professor of microbiology and immunology. This work also can lead to better methods to quench the rejection response in transplantation and help boost the body’s defenses against microbial invaders, he said. Emerging infectious diseases like SARS and West Nile virus remind us that we still have a long way to go in keeping ahead of the microbes, he said, and deadly strains of smallpox or anthrax loom as potential agents of bioterrorism, highlighting the need for better comprehension of the immune response.
Advances in the ability to analyze what is going on in an immune reaction – desirable or undesirable – may make it possible to tailor therapies, said Garry Fathman, MD, professor of medicine (immunology and rheumatology) and director of the Center for Clinical Immunology at Stanford.
The ultimate goal of the new institute, concluded Davis, is to direct research in a way that will impact patient care. David was recently named director of the institute.
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Focus session on Neurosciences
William Mobley, MD, PhD, has a single goal for the Neurosciences Institute, which he directs: to refocus the efforts of Stanford’s world-class basic neuroscience researchers and clinicians to curing patients. “The only real goal we should have is helping people who are sick,” said Mobley, the John E. Cahill Family Professor of medicine and neurosurgery.
Currently, Mobley said most research is directed either toward laboratory studies or patient trials, with too little research taking place at the intersection where patients can influence the direction of basic research and where basic research first transforms into potential cures.
This boundary includes engineering hurdles involved in translating brain waves into the motion of prosthetic arms or computer cursors. Krishna Shenoy, PhD, assistant professor of electrical engineering, is working to develop devices to overcome this problem.
Similarly, a miniature camera originally developed for the telecommunications industry has helped Larry Recht, MD, professor of neurology, see how brain tumors develop in real time. This device could help him study what happens in developing brain tumors and eventually use these discoveries to improve treatment for patients.
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"Healing Cancer: Life Imitating Art"
Sept. 11 hit home for some of the cancer patients in David Spiegel’s supportive care program: for them, being struck by cancer was as emotionally and physically traumatic as the explosion of the twin towers in New York. Spiegel, MD, the Jack, Samuel and Lulu Willson Professor, described the healing process for these cancer patients during a lunch presentation at the new Stanford Cancer Center.
He said it’s important for people who experience traumatic stress to face that trauma, not avoid it, for it will otherwise come to haunt them. Part of the process, particularly for women who’ve undergone mastectomies, is for patients to develop a new relationship with their changed bodies. Some patients turn to art to come to grips with this change, sculpting or drawing images of their new bodies, which they may view as mutilated, he said.
Spiegel, who also directs the Center for Integrative Medicine, said many patients turn to alternative treatments for answers. More U.S. patients visit alternative practitioners than primary care doctors and spend more out of pocket on alternative medicine than on mainstream treatments – $34.4 billion compared $27 billon, he said.
In his own psychotherapy groups for women with metastatic breast cancer, he said he aims to help relieve anxiety associated with the disease and assist patients in facing their mortality. “If there is one thing I’ve learned in 25 years, it’s that confronting mortality helps people. It doesn’t harm them,” he said. His studies have shown that the group therapy process significantly reduces symptoms of stress among these patients.
He said many cancer patients feel more anxious after their treatment has ended than during the treatment process itself. That is because they feel they’re no longer actively fighting the disease and have lost control. Through therapy, they learn to regain a sense of control over their lives, he said.
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Robert Klein, chair of the California Stem Cell Research and Cures Initiative, believes we have the opportunity to change the future of medicine. The Palo Alto real estate developer recently penned the California Stem Cell Research and Cures Initiative, which would finance stem cell research with $3 billion in state funds over 10 years. The hope is that this research could help mitigate and possibly cure a handful of diseases.
During his talk Klein spoke about the importance of the research and the passage of the initiative, known as Proposition 71, on the Nov. 2 California ballot. He detailed how this “investment in medical and intellectual property” could help people like his young son and mother – who have type-1 diabetes and Alzheimer’s disease, respectively – while also lowering the state’s healthcare costs ($14 billion a year and rising) and boosting the state’s economy.
Klein’s emphatic declarations [“This is a moral imperative for us as families”] made it clear that he is extremely passionate about the issue. And he’s seemingly not alone: a group of U.S. senators fighting a congressional bill that would criminalize stem cell research recently expressed support for the state initiative. When meeting with Klein, he said they told him to “move as fast as you possibly can.”
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"Childhood Obesity: Stemming the Epidemic"
Perhaps the best way to prevent childhood obesity is the sneaky way. Never mention the words “nutrition” or “healthy diet,” don’t expect traditional physical education and health education classes to make a difference, and don’t push parents to control their kids’ eating.
Instead, “Look to motivate new, healthy behaviors by providing motivators that work on kids,” urged Tom Robinson, MD, MPH, associate professor of pediatrics and of medicine. Robinson recently co-authored a report of the Institute of Medicine on recommended approaches to tackling childhood obesity.
“It’s really a hard thing – getting people to change,” said Robinson, who is also director of the Center for Healthy Weight at Lucile Packard Children’s Hospital. “We need stealth interventions that motivate kids to change their behavior for their own reasons.”
Children are motivated by fun, challenges, choices and control, opportunities to feel pride and look good, social pressure, social interactions and (yes, even in teenagers) parental and adult approval, said Robinson. Thus, obesity prevention interventions shown to be effective include a curriculum designed to reduce TV watching in third- and fourth-graders and their families; an after-school dance program for African-American girls; and a soccer league for overweight kids.
With programs like these, Stanford’s Center for Healthy Weight is poised to be a major player in helping reduce the incidence of childhood obesity. “We’re way ahead of other groups in terms of intervening in entire communities,” said Robinson.
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"Will the Health-Care Bubble Burst? Challenges for the Next President"
Much press has been devoted to spiraling health-care costs and the fact that such expenditures now gobble up 14 percent of the nation's GDP. According to Laurence Baker, PhD, though, high health-care costs may not be such an awful thing – especially if they’re helping to save or improve lives.“There might not be anything inherently wrong with [such high spending] if we’re getting value for our money,” said Baker, who joined Kate Bundorf, PhD, in addressing key health policy issues during the morning presentation.
Baker discussed medical technology’s role in boosting the country’s health-care expenditures and pointed to studies showing that patients’ lives could be extended by the use of high-tech procedures and equipment. Although he said the expense of such technology is usually “hands-down worth it,” he stressed the importance of allocating technology more efficiently and keeping cost-benefit considerations in mind.
Bundorf followed his talk with a discussion of the growing number of uninsured Americans. She explained how difficult this population is to track down (it is common for people to transition in and out of health coverage) or to categorize (she mentioned that middle-income and high-income Americans account for more than 40 percent of the uninsured). Because of this diversity, universal health-care coverage might be difficult to achieve and will require significant reform of our existing system, she said.
Baker and Bundorf are both assistant professors of health research and policy.
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"Resilience to Stress: Lessons from 9/11 and
Cancer"
Since the 1980s, David Spiegel has been studying the impact of stress on the body, particularly in cancer patients. He did a landmark study, published in 1989 in the Lancet, in which he found that women with metastatic breast cancer who participate in psychotherapy support groups live on average 1.5 years longer than those who don’t have the benefit of this support. He has been working for the last 11 years on a study to replicate those findings and expects to publish the results soon.Other studies on the subject have had conflicting findings; while several studies have shown that psychosocial support can reduce the incidence of distress, depression and pain among these patients, some have not found that this support results in any better survival rates.
Spiegel has examined the underlying mechanisms through which stress can cause physical damage to the body. He has found that two-thirds of cancer patients have abnormal levels of the stress hormone cortisol in their bodies. He also has found that patients with abnormal cortisol patterns are more apt to die sooner.
He said the there is evidence that cortisol may trigger tumor growth and dampen the body’s immune response, thus accounting for the difference in mortality rates. He now has a major grant, a collaborative effort with other researchers at Stanford, to study how cortisol levels affect the pattern of disease in a variety of individuals, including those with Alzheimer’s disease and Alzheimer’s caregivers.
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Women's Health – "Baby Boomers and Satisfying
Sex" and "Diminishing Fertility: Finding the Culprits"
The clinical focus session on women’s health addressed two of the biggest medical concerns facing women today: sexual dysfunction and infertility. In her presentation on female sexual arousal, Mary Lake Polan, MD, PhD, MPH, the Katharine Dexter McCormick and Stanley McCormick Memorial Professor of gynecology and obstetrics, discussed her work with sexual dysfunction, a complaint common among post-menopausal women and women taking a class of antidepressants known as selective serotonin reuptake inhibitors.
To better understand the causes of this condition, Polan and a team of researchers are first working to understand what happens during arousal in sexually functional women.
Their research correlates women’s reported experience of arousal with areas of brain activation, as shown in fMRI images, and physiological responses such as changes in respiration rate and vaginal blood flow. Using this information, Polan hopes to establish a baseline for arousal in healthy women against which to evaluate sexual dysfunction.
In her presentation on fertility issues, Linda Giudice, MD, PhD, professor of obstetrics and gynecology, assessed the impact of environmental pollutants on fertility. With endometriosis, polycystic syndrome, testicular cancer and sperm abnormalities on the rise, a growing body of literature suggests that synthetic chemicals in the environment are behind these and other conditions considered surrogate markers for infertility, she said.
Studies from around the world demonstrate the “body burden” of environmental chemicals at both low and high doses. Commonly used chemicals such as Bisphenol A, a plastic used in tin cans and baby bottles, and the pesticide atrazine have been associated with infertility in men and women, pregnancy loss, preterm deliveries, congenital abnormalities and complications in newborns.
Though the literature to date is alarming, Giudice noted that the full toxicity of environmental chemicals will not be known until a number of large-scale epidemiological studies now under way in the United States are completed.
"Climbing to Mars: Expedition to the World's
Highest Lake to Test NASA's Newest Medical Instruments"
The complexity of the life science cries out for the analytical tools of engineers.
“A single cell is more complicated than anything a human has ever built,” Greg Kovacs, MD, PhD, associate professor of electrical engineering, said in an overview of the Stanford’s new Department of Bioengineering.
A tangible example of the fusion of biology and engineering comes from Kovacs’ own work: he presented a portable physiological monitor he has developed through a collaboration with NASA. The wearable computer detects information from adhesive sensors. It can read heart rate, respiration, body temperature and orientation, blood oxygen level and blood pressure.
In the testing of his prototype monitor, he has taken it to the extremes of this planet, including a lake 20,000 feet high in the Andes and on NASA's KC-135, a jet airplane that climbs and plunges sharply to create the experience of twice normal gravity and zero gravity. In his presentation, he took the audience on a virtual tour of the testing sites.
With an eye toward fusing engineering with the life sciences, Kovacs has culled from the best of both worlds in designing an entirely new curriculum for the department. The core will be quantitative biology, he said, with the emphasis on the holistic – systems, networks and populations.
The program – the first new department at Stanford since 1962 and the only one spanning two schools – welcomed the first graduate students the week of Sept. 20 and will offer an undergraduate degree beginning in 2007.
"Challenges of New Technology on Human Identity:
A Bioethics Approach"
Maren Grainger-Monsen, MD, senior research scholar at the Center for Biomedical Ethics, is an independent filmmaker who is using film to educate the public and health-care professionals about important issues in bioethics. Monsen currently has six films in production, including two that deal with disparities in health care.
She showed a clip of one film, “Hold Your Breath,” in which she chronicles the experiences of a traditional Afghani man with cancer who has a cultural collision with the Western medical care system. The patient, who now lives in the Bay Area, is shown on his prayer rug in an exam room at Stanford Hospital before he meets with his oncologist to discuss chemotherapy treatment. The patient questions the value of the treatment, given that it will cause him suffering without guaranteeing him a cure.
Monsen also is producing a film called “Worlds Apart” in which she is following four families – one Laotian, one African-American, one Afghani and one Puerto Rican – who experience a cultural clash with Western medicine. She is collaborating with Judy Illes, PhD, senior research scholar the Center for Biomedical Ethics, on a third film titled “Mindful Incisions,” in which they are following a woman with chronic pain who is expected to be the first to undergo a revolutionary new neurosurgical procedure.
Monsen’s films are currently used in 250 institutions across the country, including 40 medical schools, a number of hospitals and the American Medical Association. She said she’s gratified that her work has led to important policy changes, including a change in allocation of donor kidneys to make more kidneys available to African-American patients who need them.
The bioethics center recently received a $3.8 million NIH grant to study the ethical, legal and social implications of genetic research. Mildred Cho, PhD, associate director of the center, said the group aims to anticipate issues that could arise from new technologies, rather than wait until these technologies become available to come to grips with them.
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"High-Tech Healing: The Marriage of Technology and Medicine"
Stanford researchers involved with the Bio-X initiative are looking for better ways to predict how well drugs or devices will work for a particular patient. One approach being pursued by Charles Taylor, PhD, assistant professor of mechanical engineering, pediatrics and surgery, uses computer simulation of the cardiovascular system to help physicians decide on an appropriate course of treatment for specific patients.
A typical cardiologist treats a patient with heart disease by first performing a thorough MRI scan of the individual and then choosing what is hoped to be the best treatment based on his previous experience with other patients, said Taylor. The physician has no way to evaluate different treatment options for an individual patient’s disease symptoms or particular anatomy.
“Why not create a 3D computer model using the diagnostic MRI?” said Taylor. Then the clinician can look at how blood is flowing through the diseased arteries and model various treatment options – whether they may be stents, surgery to reduce blockages, or bypasses.
In other fields of engineering, computer simulations have been used for years to design devices and predict outcomes. Airplanes are flown, trains and cars are crashed, bike helmets are tested – all without building or doing anything in the real world. It’s much cheaper and easier to use computer simulation than trial and error.
“Failing to use these tools is like building a bridge and then driving across to see if it works,” said Taylor. Already he has shown simulation’s potential value for treatment of several specific cardiovascular diseases.