Stanford Medicine 25 Blog

The Internet: The Elephant in the Examination Room

Damiana Andonova

Peter Conrad, a sociologist at Brandeis University, spoke of the rise and fall of the medical authority in the doctor patient office encounter in his many scholarly articles. With the internet becoming the “elephant in the doctor’s office,” the dynamic of medical authority has certainly changed.

As the internet evolves into a virtual space for communities and patients to disclose personal medical information and seek sustenance and support from one another (preemie parent communities, pregnant mom  communities, Parkinson’s groups, cancer groups, dermatology forums, etc.), how does a clinician negotiate his/her medical expertise and the information available on the internet that their patients have brought to their exam table?

The advantages of the internet are many—its ability to accumulate and disseminate information, its ability to provide a platform to connect and share medical experiences, and of course its potential to store health records, improve accessibility, and improve patient education. But, its use also raises issues of privacy, misuse of medical information to self-diagnose, and misleading medical information.

“Internet-induced hypochondriasis” is not un-heard of. We all know of patients who’ve googled their symptoms and rushed to their health practitioner the following day. We should not hold them in contempt of getting their medical advice from WebMD. Instead, we should applaud them for their initiative to take part of their health care, for their enterprise and interest to learn about their condition, for their correct intuition to follow up with their physicians.

While the internet can raise serious issues that merit attention, the internet has also provided patients a means connect to physicians and to learn more how to care for their condition. Consider the many Google searches for diabetes friendly recipes, how to talk to a sick relative, and how to keep a low FODMAP diet. The internet, in other words, illustrates the demand for patient education and it is up to clinicians to take initiative to offer just that.

Most certainly, the bedside is a great place to start that discussion. Instead of letting the internet become the elephant in the room, the physical exam can allow the clinician to negotiate medical authority. The mother of the pediatric heart patient has no doubt become the leading expert on her child’s heart condition, but, perhaps, it is the pediatrician’s evolving role to not only examine, and coordinate care for her child, but also help the parent navigate through the wealth of information that is literally available with the tap of the index finger

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Abraham Verghese Interviews with Medscape’s Eric Topol

The leader of our Stanford 25 program, Abraham Verghese, recently sat down with Medscape’s Editor-In-Chief, Eric Topol. This interview was part a number of popular videos for a Medscape’s One-On-One series that is newly published today. In the video, Dr. Verghese discusses his early years, upcoming book and talks about his career path to becoming a physician and writer. Click here or the picture to be taken to the full video and transcript.

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Stanford 25 Website Passes One Million Visitors!

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The purpose of the Stanford 25 is more than teaching the physical exam. The original calling that brought us all to medicine, and to the care of the sick resides to such a large degree in connecting with the patient, and in the interaction at the bedside. It is both important to the patient, and an enduring source of satisfaction to us as practitioners.

With over one million unique visitors (and over 1,360,000 total visits) to our website alone, we want to thank everyone for their support. Together with the collaboration of Stanford faculty and others abroad (including internationally), we will continue to grow. This year, we will be expanding the “25” to include many more topics (while keeping our name the same). Please keep visiting our website, YouTube channel, and social media sites (Twitter, Facebook, Google+)

Interview with Dr. Eric Topol (editor-in-chief of Medscape)

The editor-in-chief of Medscape, Dr. Eric Topol, visited Stanford to sit down and do an interview with our Dr. Vergese for the Medscape One-on-One online video series. During this visit I got to meet with him to ask him a few questions. Dr. Topal is a cardiologist, geneticist and researcher. He has also been a key player in wireless medicine since it began.

abe and Eric

Dr. Ozdalga: Hi Dr. Topol, Thank you for speaking with me today. The first question I have for you is: What is your take on the new changes in technology and how it affects patient care? What are your thoughts on things we’ll see in the future regarding patient care as technology improves?

Dr. Topol: Well,  I think the biggest thing is that the tools that we’ve used to do the physical exam haven’t lost their primacy and importance, but the tools that we use now are so much more capable. So whether it’s being able to do things with a smartphone or using a pocket ultrasound, those sorts of things, it’s really revamped our approach to the exam. And it could revamp a lot of unnecessary sophisticated imaging.

The other big thing is of course the virtual contacts, and they’re really increasing exponentially. To the point that by the end of this year it’s projected one out of six doctor visits will be virtual; and that is really indicative of the shake-up that’s occurring in medicine.

So the question: We’re not really ready for virtual medicine, we’re not ready for the patients to do the physical exam and have it sent electronically. We have to gear up for that, that’s a whole different type of training and it’s going to become more commonplace. There still will always be a need for physical office visits, but these are for the more routine things like, for example, a child with an ear infection. Obviously many things can be done remotely that don’t require the physical visit.

Dr. Ozdalga: As you know Dr. Verghese and the Stanford 25’s main emphasis is not only the physical exam, but connecting with the patient. How do you feel that changes with the virtual patient? Will it affect the ability for doctors to connect with them?

Dr. Topol: Well, I think the connection will actually be exquisite, because now the patients will feel much more activated. They’re really going to be integral to this whereas before they were in another orbit. So technology can actually paradoxically bring things closer. I like to use the portable ultrasound as an example because I now show the patient their scan in real time whereas before they couldn’t even get the result! They would call and beg “what did my test show?” So to be able to show it and share it in real time is actually an intimacy. They’re still touching the patient, doing the exam, but you’re sharing very impressive information whether it be sensors or whether it be imaging, and the patient really enjoys it.

Dr. Ozdalga: Beautiful. It’s been said that the physical exam and the art of the exam is dying, and a big reason for that is because of technology. Do you agree with that?

Dr. Topol: No, I actually think the physical exam is as important as ever, but it’s just a different physical exam. It’s using technology integrated with the exam, it’s also being able to interpret physical exams that are not done physically. Some of the parts can be done by the patient. So it’s a different look but it’s more important than ever before.

Dr. Ozdalga: Thanks so much Dr. Topol, this has been really great.

Errol Ozdalga MD
(Transcription by Serena Brown)

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Dr. Topol interviewing Dr. Verghese for the Medscape Medscape One-on-One online video series.

Do You Know How to Measure an Ankle Brachial Index?

The ankle brachial index (ABI) is a common and useful exam in the outpatient setting to detect peripheral arterial disease. ABI’s should be measured in all people over the age of 50 if they are a diabetic or a smoker. It should also be checked in patients over the age of 60.

While many doctors simply order this test, we show you how to quickly measure the ABI yourself with a doppler and blood pressure cuff. Visit our page on ABI here and watch the video below to learn how to measure an ABI on your own!

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The History of Bedside Ultrasound: From Submarines to Sub-Interns

By Michael Vogel

Among the myriad of modern diagnostic tools, few can claim the certainty, consistency, and intimacy of ultrasound. In contrast to other dominant types of medical imaging characterized by large, foreign machines and uncomfortable noise and positioning, this sound-based imaging technique is one of the least intimidating and widely-used exam method, applied in fields ranging from Pulmonology and Gastroenterology to Obstetrics and Gynecology. However, conventional ultrasound can trace its roots to a form of militarized SONAR developed heavily in the period between World War I and II. Prototypes of “Ultrasonic Metal Flaw Detectors”, developed in tandem by Soviet scientist Sergei Y Sokolov and American engineer Floyd A Firestone in the early 1930s were used as an alternative to conventional RADAR methods for detecting submerged vehicles. These tools used short, high-frequency ultrasonic pulses to measure imperfections in the cast metal bodies of submarines, and their application in therapeutic medicine was simultaneously explored by American physicians. During a period stretching from the mid-1930s to the late- 1940s, ultrasound technology was used to perform a primitive form of craniotomy, by using high-frequency pulses to destroy parts of the brain. Additionally, this homeopathic application of ultrasound attempted to treat in patients with Parkinsonism, as well as other illnesses that include rheumatism, carcinomatosis, eczema, urinary incontinence, and elephantiasis. In fact, ultrasound wasn’t considered a diagnostic method until October of 1949 with the publishing of the “June ’49 Report” by George Ludwig. Since then, ultrasound has matured into “medical sonography”, and has expanded to become the primary diagnostic method for identifying the size, location, and pathology of muscles, tendons, and most internal organs.

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At Stanford Hospital, as well as many other prominent medical facilities worldwide, the use of bedside ultrasound is an essential tool in the repertoire of a hospitalist. Conventionally defined, Bedside Ultrasound refers to “a limited ultrasound examination performed at the bedside by the treating physician to answer specific clinical questions”. While bedside ultrasound originated in the quick decision-making of E.R. Physicians, it has now also found a home in internal medicine. Physicians use ultrasound to estimate central venous pressure through visualization of the inferior vena cava, estimate left ventricular function with limited echo, assess abnormalities in the lungs, evaluate the presence of ascites and pleural effusions, and to assist with procedures. As part of the physical exam, bedside ultrasound gives the opportunity to foster the physician-patient relationship. The Stanford Medicine 25 team provides informative resources that explore the depth of ultrasound technique, from the proper placement of the transducer to motions and technique that maximize diagnostic efficiency while minimizing patient discomfort. Ultrasound technology, with its rich history and varied application remains today as one of the most widely-utilized assisted-examination techniques, and is a fantastic way to integrate imaging technology into a comprehensive and patient-forward physical exam.

P.S: Some facilities warm their ultrasound gel before applying it on a patient’s body. This action serves no diagnostic purpose and is purely for the patient’s comfort, a philosophy we could extend to our physical exams as well!

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SOURCES

http://www.ob-ultrasound.net/history1.html

http://aquasonicultrasoundgel.com/blog/top-five-benefits-of-an-ultrasound-gel-warmer/

http://www.nlm.nih.gov/medlineplus/ency/article/003336.htm

http://www.slredultrasound.com/Filesandpictures/Guidelines2.pdf

The Babinski Sign

By Michael Vogel

Among the key players in the neurological revolution of the early 19th Century, few may claim as much lasting relevance as Jean-Martin Charcot. Lending his eponym to phenomena such as Charcot’s Joint (diabetic arthropathy), Charcot’s Triad (acute cholangitis) and most notably Charcot’s Disease (ALS), the French physician is widely considered to be a progenitor of modern neuroscience and psychology. However, one of Charcot’s most influential contributions to medicine is that of his protégé and contemporary, Joseph Babinski. Coming to professional fruition in 1893, Babinski is credited with the analysis and identification of several neuroses, including a peculiar diagnostic cue bearing his name today. First identified in a 26-line short form presentation at the 1896 Société de Biologie meeting, Babinski’s Sign became one of the neurologist’s most notable discoveries, and remains an invaluable resource for the modern practicing physician today.

Babinski

Babinski’s sign is a neuro-pathological cue embedded within the Plantar Reflex of the foot. Elicited by a blunt stimulus to the sole of the foot, the normal adult Plantar Reflex presents as a downward flexion of the toes toward the source of the stimulus. Babinski’s sign is observed when the Hallux (big toe) exhibits dorsal extension in response to the same plantar stimulation. While a response similar to the sign exists when the plantar reflex is elicited in infants, Presence of Babinski’s sign in adults can be indicative of a lesion or damage in the corticospinal tract, and identification of the sign remains one of the least-invasive methods for supporting an Upper Motor Neuron damage diagnosis. The sign became such an integral part of neurological doctrine that Babinski’s prototype reflex hammer, developed in 1912, became one of the essential tools of a modern neurologist. Even to this day, modern neurological examination textbooks refer to Babinski’s sign as “the most colorful exam finding in neurology”. All in all, Babinski’s sign and similar examinations of the plantar reflex (Chaddock sign, Cornell sign) are fond reminders of the utility of a comprehensive physical exam and that, with proper care and attention to detail, a physician can make confident diagnostic choices using simple, concise, and interactive methods.

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References:
Goetz CG (2009). “Chapter 15 Jean-Martin Charcot and the anatomo-clinical method of neurology”. Handb Clin Neurol. Handbook of Clinical Neurology 95: 203–12. doi:10.1016/S0072-9752(08)02115-5. ISBN 978-0-444-52009-8. PMID 19892118.

http://www.nndb.com/people/825/000207204/

Goetz CG (2002). “History of the extensor plantar response: Babinski and Chaddock signs”. Seminars in neurology 22 (4): 391–8. doi:10.1055/s-2002-36761. PMID 12539060.

http://stanford25blog.stanford.edu/2013/04/the-history-of-the-reflex-hammer/

Campbell, W. W., & DeJong, R. N. (2013). DeJong’s The neurologic examination (7th ed.). Philadelphia: Lippincott.

On Chekhov: The Marriage of Medicine and Literature

By Damiana Andonova

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Anton Chekhov, Russian physician-playwright from Tagranog, must have written about more than a hundred physician characters in his literary career. They’ve appeared in plays from Platonov to The Three Sisters and many short stories. Each character is unique, variable in personality, in medical attitude, and method. What caricatures: the pompous speaker, the narcissist, the genius, the devout healer, the scatter-brained, boorish feldsher!

Students of literature are regularly reminded of Chekhov’s gun; his contributions to the literary world are many. By 1886, he had already found fame in St. Petersburg and beyond. But, what of him as a physician?

He practiced medicine during most of his literary career but officially retired from the medical profession in 1889. Despite this, he continued to provide free care in Melikhovo and often dabbled in public health initiatives. But what is perhaps most attractive about his medical career is how he bridged medicine and literature. He is quoted saying,

“Medicine is my lawful wife, and literature my mistress.”

His fascination with medicine, he unreservedly explored in his literature. To say that he created over a hundred fictitious physicians is perhaps only a small testament to his interest in unpacking the medical profession through literary means. He also used his medical competency to richly write about tuberculosis in “Late Blooming Flowers”, typhus in “Typhus”, and many other evocative scenes of medically urgent occasions. His dark descriptions, often besotted with reflection over medical attitudes explains why he wrote such aphorisms:

“People who have an official, professional relation to other men’s sufferings, for instance—judges, police officers, doctors—in course of time, grow so callous, that they cannot, even if they wish it, take any but a formal attitude to their clients, in this respect they are not different from the peasant who slaughters sheep and calves in the backyard, and does not notice the blood”
–Anton Chekhov in Ward No. # 6.

His storytelling, fabled to have been inherited from his storytelling mother, Yevgeniya, is powerful, evocative, and thought-provoking to say the least. His works merit a spot on a physician’s reading list, even if he did write of medicine practiced centuries ago.

Sources:
Chekhov, A. P. (2002). Ward No. 6 and other stories, 1892-1895. London ; New York: Penguin.
Coulehan, J. (2003). Chekhov’s doctors: a collection of Chekhov’s medical tales. Kent, Ohio: Kent State University Press.
Teuber, A. (n.d.). Anton Chekhov Biography. Retrieved June 24, 2014, from http://people.brandeis.edu/~teuber/chekhovbio.html#Biography%20Part%20I

Pathognomonic Signs and Metaphors of the Gynecologic Exam

By Damiana Andonova

Here we share memorable metaphors and pathognomonic signs, some of which are fruit and cheese metaphors in their own right. This is not mean to be an exhaustive list, but rather a reminder of the many interesting observations that can be made during a physical exam.

We begin with the peau d’orange appearance of breast cancer; the cervical petechiae that resemble the strawberry cervix of Trichomoniasis and the rather cottage cheese-like discharge of Candidiasis.

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© 2007 Terese Winslow, U.S. Govt. has certain rights.

During a properly performed examination, a physician could further note cervical motion tenderness for pelvic peritonitis or perhaps pelvic inflammatory disease (PID). Of particular interest is the “Chandelier sign”, as the gynecologic patient would jump up and cling to the chandelier in utter pain.

Uterine size measured during a pelvic exam can also be likened to fruits: the non-pregnant or five weeks pregnant small pear, the three-month grapefruit (Margulies & Miller 2001).

Additionally, the physician could observe the esoteric grainy, sandy patches of schistosomiasis (of which S. haematobium is the etiological agent), the sulfur granules associated with pelvic actinomycosis, or utero-sacral nodularity, which is pathognomonic for endometriosis.

If a recto-vaginal exam is indicated and performed, a descending soft mass observed between the vaginal and rectal finger upon the Valsalva maneuver is pathognomonic for a rectocele. Similarly, the descent of a soft mass in the anterior vagina during the Valsalva maneuver noted in the bimanual portion of the pelvic exam can also be pathognomonic for a cystocele.

On the matter of observing discharge, some argue the color and consistency are pathognomonic for certain infections, including a frothy discharge for trichomoniasis and a thin fishy gray discharge associated with bacterial vaginosis.

Medical phraseology and the common every day language that can sometimes take over conversation can be fun to explore. And yet, while pathognomonic signs and metaphors can be fun to think about, they can also help us remember how useful the physical exam can be in the clinical encounter!

Can you think of more? Let us know!

Special thanks to Emmet Hirsch (Clinical Professor of Obstetrics and Gynecology at the Pritzker School of Medicine of the University of Chicago) and Paula Hillard (Professor of Obstetrics and Gynecology and Associate Char for Medical Student Education at Stanford University) for helping me in creating this article.

Cultural Competence at the Bedside

By Damiana Andonova

A clinician will encounter patients from all socio-economic strata, who speak foreign tongues and understand disease in ways that stand apart from the clinician’s own conceptions of disease etiology.

Perhaps they might encounter a Hmong elderly who complains of a heavy heart. What physical exam does one perform? Their spiritual understanding of disease etiology is linked to their soul, as Anne Fadiman eloquently explains in her text, “The Spirit Catches You and You Fall Down”. The proper course of action may not be just a diagnostic test but perhaps a concert of medicine and spiritual tradition.

Perhaps a 20-something Bulgarian mother demands she feeds you bread and honey before being discharged with her newborn after an emergency Cesarean.

Or consider the scenario that I experienced as a young medical observer:
A Chinese woman experiences post-partum depression after completing a traditional post-partum zuo yuezi, or period of confinement after her pregnancy; an Asian practice that is becoming popular in United States as well.

Abraham

For clinicians it may be difficult to negotiate the culture shock that can take place in the doctor’s office. Yet, the academic community’s response to teaching less technical competencies at the bedside usually results in the creation of many inaccessible, didactic texts that, while aimed at helping students learn, actually bring the student farther away from the bedside and leave the student confounded.

To shy away from academic reviews of the literature and copious reading lists that can be offered to shed light on this issue, we share a quick lesson of cultural competence at the bedside.

Harvey Cushing is perhaps, the greatest neurosurgeon of the 20th century. You may recall many eponyms including Cushing’s clip, law, and symphalangism; Cushing’s syndromes I, II, and III; Cushing’s triad, and some other hyphenated syndromes such as Bailey-Cushing syndrome. Of his many accomplishments, a singular quote on the obligations of physicians is memorable,

“A physician is obligated to consider more than a diseased organ, more even than the whole man — he must view the man in his world.”

This is an extremely fallible yet certainly achievable task. If you’ve listened to Dr. Abraham Verghese’s memorable anecdote about the linoleum factory worker (link), you’ll note Sir Joseph Bell performed his obligations to a sound degree.

Cultural competence is very useful tool to gauge how to approach a physical exam and what practical advice to offer to a patient.

Consider this case:
“The Hand Injury”
An uninsured, yet documented immigrant housekeeper visits Cook County Hospital after a serious injury to her hand while cutting an avocado. “The Hand Injury” received proper care and surgery, and is a single parent whose earnings rely on her ability to iron clothes, to wash the dishes by hand, and to vacuum.

Considering her job security is almost zero (private domestic workers can be fired at any time; they receive no mandatory paid or unpaid sick leave), how might treating and advising her as a hand surgery patient be different if she were a high school math teacher? Would it be any different if she were a freelance jewelry artist?

A long review of the literature will simply show that the discussion of cultural competency and sensitivity at the bedside includes awareness of socio-cultural diversity and the social production of disease as well as its implications at the bedside. An article might recommend a semester course in medical anthropology, too. Understanding her background can provide clues as to how to approach her care, and personalize it so that her care is effective, and as the industry prefers, efficient. Being culturally competent will also render “the hand injury” a useless synonym for her name.

The Stanford 25 bedside sessions as well as the Bedside 5 Minute Moment attempts to bring students closer to real patients and help them gauge differences between caring for the textbook patient and a real patient. Working at the bedside, then, brings students closer to the actual patient, and like Cushing says, gives residents a chance to “view the man in his world”.