Stanford Medical School threads the needle on how to teach infectious disease. Even better – you can take their course.

Vetter

 

Medicine has an image problem. As Malcolm Gladwell told Medscape’s Eric Topol, MD, “One thing that has always motivated me in writing about healthcare is that the world of healthcare does a very bad job of storytelling about itself. It represents itself to the public very poorly. The gap between the reality of medicine and the way the public thinks about medicine is growing, not shrinking.” Dr. Topol agreed: “Storytelling is a big deal, and it isn’t done enough in medicine or science.”

The Stanford University School of Medicine wants to change that. As part of their Re-imagining Medical Education initiative, they’re offering an open online 6-week course on infectious disease to the public called “Stories of Infection.” It “introduces learners to a variety of infectious diseases using a patient-centered, story-based approach. Through illustrated, short videos, learners will follow the course of each patient’s illness, from initial presentation to resolution.”

To get a sense of the course, here’s a partial transcript from the case presentation of the first patient you meet, David Vetter (above photo), whose story you may be familiar with:

“… To understand the importance of the immune system, we’re going to look at the case of a boy who made medical history by surviving for 12 years without a functioning immune system. In the process, David Phillip Vetter talked the medical world not only about his immune deficiency disorder. But also about the ethical dilemmas doctors can face when a temporary medical solution ends up becoming up a permanent one. On September 21st, 1971, David was delivered by Caesarean section at the Texas Medical Center in Houston. And within seconds, he was transferred into a sterile plastic bubble that would become his home for the next 12 years. David suffered from a rare genetic condition called Severe Combined Immunodeficiency, or SCID, that left him without a functioning immune system. The Vetters had lost their first son to an overwhelming infection that resulted from the same disorder. Because SCID is linked to the X chromosome, the Vetters knew there was a 50% chance their second son, David, would also have the disorder. But the prospect of a bone marrow transplant from David’s sister, Catherine, offered hope. Catherine would have been a perfect match for bone marrow transplant in the Vetter’s first son if he had survived long enough to undergo the procedure. So the family and physicians on David’s team saw the potential for a cure, if in fact, David carried the faulty X chromosome …

Three days after David Vetter was born, his diagnosis of SCID was confirmed, meaning that he would be just susceptible to severe infections as his brother. Having lost one child to the disease less than a year before, David’s mother was fearful of reaching into the bubble to touch David using the integrated rubber gloves that hung at regular intervals along the walls of the sterile chamber. She said in an interview, I felt if I could stay distant from him, then if the worst happened, I could handle it better. So I was hesitant to reach into the glove and touch him. But once I did, I was hooked for life.

She soon took on the challenges of caring for her baby boy along with his team of physicians who were confident they could cure him. David’s diapers, clothes and food had to be sterilized and inserted into the bubble through a system of air locks. But Baby David appeared to be thriving and growing in this sterile environment. No one had anticipated that David’s sister would not be a match for bone marrow transplant. And that David would somehow become trapped in the bubble that had been built to temporarily protect him.

As David grew, his awareness of his circumstances did too. And a story that had once held the promise of ending as a medical miracle slowly became an ethical nightmare.

During his years in the isolator, many studies were performed on David’s immune system. At the age of four, he was found trying to poke holes in the bubble. And doctors were forced to explain to him the very real risks that faced him if any microbes were allowed into the sterile environment. Psychologists who worked with David encouraged him to escape the bubble using his imagination. And his mother remembers taking many make believe trips into outer space with David in those early years. Teachers delivered lessons through the plastic walls of the bubble and David turned out to be an exceptionally bright boy. In 1975, engineers at NASA designed a spacesuit that would allow David to leave the hospital. But David was very anxious about being exposed to pathogens outside of his regular environment, so the suit was only worn six times. All of these worries and challenges of living inside the bubble took a took a toll on David’s emotional state as he grew. The isolator was moved from the hospital to David’s home when he was nine years old. And his mother remembers him watching other boys playing outside through a window in their home. And she noticed the downturn in her son.

David became increasingly withdrawn. As the family’s desperation grew in the years that followed, more research from Boston offered some hope. Physicians there had managed to perform form a successful bone marrow transplant using a non-matching donor. Though the procedure was still in its experimental stages, David, who was now 12 years old, received a bone marrow transplant from his sister. At first, the transplant appeared to have been successful. But then several weeks later, and still living inside the isolater, David spiked a fever and developed an intestinal hemorrhage. On February 22nd, 1984, David was removed from his sterile chamber and wheeled into a hospital room where his mother stroked his skin for the first and last time. Like many children who realize they’re going to die, David wanted to know if it was going to hurt and if his loved ones would be there with him. Once he was reassured on those two counts, he courageously faced death as he had faced life, and he passed away …

 

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Stanford also says “We will … examine the relationship between socioeconomic conditions and infectious disease” – and they aren’t kidding. For example, in Santi’s case, a 3-year old boy who contracted a virulent strain of E. coli by eating a hamburger from a fast food restaurant, the clinical presentation included these pointed words:

Like many commercially produced food products, the hamburger that Santi ate contained meat from many different animals raised in confined animal feeding operations, or CAFOs. Lakes of animal manure frequently surround these factory farms and during slaughter, underpaid workers are all too often forced to rapidly separate the useable meat from waste. Spillage of intestinal content is common in slaughter houses like these and if the resulting meat isn’t completely cooked, dangerous pathogens can be transmitted to humans through food.

 

The course by no means lacks intellectual rigor, hinted at in an email you receive after you sign up: “… these intimate and moving stories … are part of our medical students’ required course on microbiology and immunology.” So for instance, the clinical presentation of MRSA through the story of a 20-year old college football player includes this little nugget:

Methicillin-Resistant Staph Aureus is an example of how bacteria can evolve in the presence of antibiotics to develop resistance. Penicillin and others antibiotics of the beta-lactam family work by binding to penicillin binding proteins, bacterial proteins, which are essential for maintaining the bacterial cell wall. But these bacterial proteins can evolve their structure, so that they are no longer efficiently bound by beta-lactam antibiotics. In the case of MRSA, a gene called mecA encodes a particular form of penicillin-binding protein, PBP2A, which allows the bacteria to grow and divide in the presence of most beta-lactam antibiotics. mecA isn’t located on the bacterial chromosome. It’s located on a mobile genetic element called the staphylococcal chromosome cassette, or SCCmec. This cassette can be passed directly from one bacterium to another through horizontal gene transfer, which allows the population of bacteria to develop antibiotic resistance even more rapidly.

 

Don’t let that scare you. The genetics component of the course is not at all front and center; a graphic that accompanied this case presentation explained it quite nicely, and even better, it was not on the test that followed!

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When Malcolm Gladwell said we need to use stories to close the gap between the reality of medicine and the public’s perception of it, I assumed he meant something like the usual tale of heroic medical intervention. Where the public remains on the outside looking in, and the feeling can sometimes be akin to voyeurism.

But Stanford had a better idea: they’ve brought us into the medical world and they’ve made us part of the story. Real cases are presented. You really do care about the patient. And that emotion follows you as you work through the relevant biology to make sure this doesn’t happen on your watch – which of course cannot be strictly true. We’re not in it for the M.D. But that’s the whole point – it feels as if we are – and so the difficulties of study almost fade into the background. It leaves you wondering why they’d teach medicine any other way.

 

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