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Stanford Medcast: Hidden and Here Mini-Series - Part 2

Learning Objective
Develop strategies to engage caregivers in the decision-making process and customize care for each individual patient
0.75 Credit CME

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Audio Transcript

Dr Ruth Adewuya: Hello, you're listening to Stanford Medcast, Stanford CME's podcast, where we bring you insights from the world's leading physicians and scientists. If you're new here, consider subscribing to listen to more free episodes coming your way. I am your host, Dr Ruth Adewuya. We are back with part two of our mini-series called Hidden and Here, presented in collaboration with Stanford Presence, a Stanford Medicine Center and the Stanford Department of Psychiatry.

Before the pandemic, 53 million people were known caregivers of adults or children with medical or mental health conditions. It is estimated that the unpaid care of caregivers is close to $500 billion, rivaling the revenues of Fortune 100 companies like Facebook at 512 billion, ExxonMobil at 343 billion and Walmart at 296 billion. Shelter-in-place recommendations have confined cohabitating caregivers with their family without external support, or prohibited caregivers from visiting family who live separately or are in nursing homes. These caregivers are hiding in plain sight, taking care of those who cannot care for themselves, often neglecting their own care and needs in the process. In this episode, Dr Ranak Trivedi will lead a discussion on caregivers and caregiving in the world of COVID. She is joined by Sonoo Thadaney Israni from the Stanford Presence Center and Dr Sheila Lahijani and Ryan Matlow.

Ranak Trivedi, PhD: So welcome, Ryan, Sheila, and Sonoo to this virtual fireside chat about the mental health of family.

Ryan Matlow, PhD: Thank you, Ranak. It's pleasure to be here.

Sheila Lahijani, MD: Thanks, Ranak. Looking forward to our discussion.

Sonoo Thadaney Israni, MD: Same here, Ranak. Thanks a lot.

RT: I'm really excited to have you all here. So what do we mean by family. Family are family members or friends who support loved ones with mental health or medical conditions. We all have heard and experienced the stress that the pandemic has placed on all of us. I had the opportunity to speak with Dr Peter Poullos, a radiologist and clinical associate professor at Stanford. He's the founder and Executive Director of the Stanford Medicine Abilities Coalition, and is currently co-hosting a series for the influential podcast DocsWithDisabilities. Dr Poullos has unique insights into how caregiving has shifted during the pandemic. I'd like to share his story in his own words, and then we will chat. Welcome to this podcast, Peter, and thank you so much for sharing your experiences with us today.

Peter Poullos, MD: Thanks for the invitation, Ranak. It's my pleasure to be here.

RT: Let me start by asking you to share a bit about your career arc, especially around the injury that has required the caregiving that we are focusing on today.

PP: Sure. So in 2003, I was a GI fellow at UC San Francisco. So I've done three years of residency in internal medicine and I was 6 months into the fellowship. And I was out one afternoon for what I thought was going to be a short bike ride, but had a severe accident and ended up being paralyzed from the neck down. And I was hospitalized there in San Francisco and taken care of by my colleagues, and then eventually, transferred down to Santa Clara Valley Rehab to begin my process of what ended up being a fairly significant recovery. So I was initially not able to move my arms or legs, but eventually, regained the ability to walk and to use my hands. I still have a very significant residual disability, but it's not as bad as it could have been.

PP: So my experience with caregiving started on that day and has continued every day until the present. I didn't actually know the terminology around caregiving and caretaking and caring and all of these different words. They had slightly different connotations to me, but the idea that I would need somebody to facilitate my life was apparent very early on as I wasn't even able to feed myself or even scratch my own nose after the injury. But over time, came to… Well, in the beginning, I had nothing on my mind, but a complete recovery. So I was doing everything I could in the hospital and then even after the hospital and outpatient rehab and at home just exercising and trying to become as independent as possible. And I got pretty far, I got to the point actually, where I could shower myself and get dressed, but it was so taxing physically and took so long that it just wasn't practical.

And so I explored this idea of what would it mean for me to be working full-time as a doctor, but still requiring caregiving. And this whole concept of outsourcing the unnecessary was shared with me that is like, I have a unique ability because of my education and training and that's to take care of patients and to be a doctor. And not everybody has that ability, whereas I used to have abilities like tying my own shoes and shaving my own face, but anybody can do those things. And so you can outsource this stuff that anybody can do in favor of saving your energy for the things that only I can do. So I eventually plateaued in my recovery probably about 10 months after the injury, when no amount of additional rehabilitation was providing any results. And so decided that I was going to hire caregivers or use family caregivers in lieu of trying to do everything on my own. And so over the years, I've finally settled into the pattern which I now have, which is paid care 7 days a week.

There's a lot of, for me, at least guilt and asking my wife to help me with things because I want to minimize the impact of my injury on her. She realized when she met me that I wasn't fully independent. So it's not really driven by her so much as my own insecurities and fears after losing my first wife to burnout from caregiving, in part to burn out from caregiving. I'm just extremely sensitive about the issue and just hyper aware of asking for things. And she always tells me, don't worry about it. Don't worry about it. It's fine, we're a team, but at the same time, you just, I don't know, it's 18 years and I still haven't gotten over, feeling a little bit bad asking for things, but now with the baby, I'm able to help her take care of the baby, which I think she wasn't so much expecting at the beginning.

RT: Fast forward through the years, it's been a partner then friends, another partner. And there's been this changing dynamic of caregiving, which I think is overlooked a lot. When people think about caregiving, it's seen as a static thing that somebody is a caregiver and then that's just how it is, and somebody is a care recipient, that's just how it is. How's your paid caregiver changed during the pandemic or has it been the same person prior to and during? How has your care shifted during the pandemic, I guess?

PP: Oh, it's the exact same team. I have two women who helped me. One of them is 6 days and 6 evenings a week. And the second person does one weekend day and one weekday evening. And so between the two of them, we have most of the day covered. Luckily, no, we haven't had to find new caregivers. Well, I take that back. Actually, we did have a night nanny for the first couple months after Dean was born. And she actually her daughter also used to fill in for her at times. So we had the night nanny and her daughter, and then we had my two caregivers. And it made us, especially my wife nervous because every person that walks through the door is a potential exposure to COVID. And I know we had asked them to please be careful and they professed that they were being careful, but you really never know. And we talked about it, do we have them more masks or not wear masks? Do we all wear masks?

PP: Ultimately, we decided that nobody's going to wear masks because it's just impossible to do for eight hours a day, although try telling that to the medical doctors who are doing that every day, but it's rough, not easy. It would not be easy to find a new caregiver if one of them should become ill. I was acutely aware in the beginning that my disability put me at risk in a couple of different ways. So it became apparent that I was not going to be working at the hospital even before anyone knew it had a shelter in place or it was. I had emailed my boss and said, if I catch this COVID and pneumonia, I can barely breathe that baseline. It's not going to be good for me. And they said, “No, you should work from home."

And then it became a moot point because within like 5 to 7 days, everybody began working from home. So there was that danger of being exposed to COVID as a provider. And then there was the exposure risk of COVID as a care recipient in my own home, which was amplified as was it with all people with disabilities by the comings and goings of people through the door.

RT: And I think also each situation is unique where you are able to get paid care, other people may not be as able to get paid care either because of resources or just availability in rural areas is just different than urban areas. So I think there's definitely uniqueness to certain caregiving situations, but I think you're touching on a lot of things that are going to be common across caregiving and caregivers or care recipient. And I think that's important to see both sides. And it's been so great to hear your insight and your experiences on this. Any last words for our listeners?

PP: Yes. I have a few last words. The first of my last words is that I realize, as you just alluded to, that I am coming from a place of privilege. I have long-term care insurance. And so I both make a good salary and don't have to pay for the majority of my care. So that's huge. And so for somebody who's disabled and maybe even lost their job during the pandemic and doesn't have insurance, maybe this interview might come off almost as obnoxious because it would be so far removed from their experience. And I always try to give this caveat when talking about this stuff, because I don't want people to get the idea that my situation is typical and that, oh, well, if he can go out and be a doctor, anybody should be able to overcome their disability and do whatever they want. Whereas as you know, people's situations are much more complicated and people with disabilities are disproportionately poor, and underrepresented minority communities have disproportionate rates of disability and therefore poverty. And so these issues really don't circulate very commonly in our rarefied medical media, if you will. So just to acknowledge that.

RT: Excellent, those are great. And I just want to amplify what you said about the people who have disabilities. And that's a pretty broad group of folks, and there might be people who have disability due to some injury after they're well on their way of accomplishing the goals they set out to do. And there's others who are not in that situation at all. And I just want to echo what you said, that there are people who may not see themselves in your experience. And yet, I'm also struck by how so many of your experiences and insights echo what we hear from people from all walks of life, who are in both caregiving and care receiving situations. Thank you so much, Peter, for those thoughts. And thank you so much for joining me today. I really appreciate the generosity of your time.

PP: Thank you, Ranak, is my pleasure. Thanks for having me.

RT: Sheila, one of the unique challenges for caregivers is that they can't accompany patients to their clinic visits or visit their loved ones who may be in inpatient hospitals or nursing homes. What are you hearing from caregivers and patients when it comes to these issues? What are some challenges people are sharing?

SR: Ranak, you asked such an important question. Simply stated, there is a lot of anxiety. People are fearing that case scenarios and outcomes, they're feeling threatened. Many people are feeling less secure about some of their decision-making or their ability to go through a hospitalization or a clinic visit or an appointment without the presence of their caregiver. There's anxiety all around. And for very understandable reasons, these can be real possibilities. And yet having said that, a lot of it is associated with people feeling guilty, feeling guilty that they can't necessarily participate or fulfill a role or a duty that they have to their loved one or to the person whom they're providing care for. And that's tough.

And in many circumstances, the caregiver is a husband, the caregiver is a father or a daughter or a sibling. And then with the enmeshment of the roles that could also affect how that person feels in terms of that dynamic as well. So it's very tough. We really try to engage everybody in these discussions with these policies, because it's, of course, all about safety. There are circumstances where it's particularly tough. I've had many patients and their caregivers reach out to me as recently as this past week.

One other point I'd like to make is something that I've observed is, in circumstances where people do not have caregivers, when they're attending an appointment or getting prepared for a hospitalization and that policy is stated or communicated, I've had people tell me, well, that's a trigger for me. It's making me feel even more lonely and more isolated, knowing that I don't have anyone taking care of me, I don't have anyone that I have to tell not to come with me. So there are many nuances to this. And by and large, it's affected the whole community of patients and it also affects the clinicians. So I think it's important for us to just continue the dialogue about what the consequences of this are, not just in the immediate term, but also in the longterm.

RT: Sonoo, you hear stories from both within Stanford and from your various roles within the community, what could we be missing by restricting the role of caregivers in this way? Some other things that I've been thinking about is advocacy or relying only patient self-report and so forth. What are some things that you've been observing or hearing from others?

SI: I think what I'll start off by pointing out is that there isn't one average caregiving experience or caregiver experience. There is so much diversity in our world and it shows up with the cruelty of COVID and the range of cruelty in caregiving as well. There are, for instance, caregivers and caregiving situations with a great deal of privilege, where they're flying to other cities and countries to get the vaccines. Meanwhile, family caregivers, who are often under the age of 65, currently don't qualify for vaccines. And if they don't have the privilege of, the willingness and the ability to jump the line in a way, they continue to do caregiving today with no vaccine inside and petrified that they're going to end up harming the people, often parents or family members that they're caring for.

On the bright side, I will say that when it comes to families that have children or family members with disabilities, including mental health disabilities, I know some states including the County of San Mateo, where I live, have prioritized vaccines, for instance, for both the adult children with mental and physical disabilities, but also the parents who are living caregivers. So there is some [inaudible 00:19:25] that has been put into those situations. So the stories when yours are about the range of the lack of privilege and how people are using that privilege to either up their caregiving world or sitting at a loss in it.

RT: One of the things that we've been hearing a lot, and there's a lot of attention and advocacy around is allowing caregivers to accompany patients to their clinic visits or certainly visit them in their inpatient facilities, whether it's hospitals or nursing homes. I'm wondering Ryan, when you think of caregivers and patients in that situation where their team is basically torn apart, because now only patients go to clinic visits and the caregivers don't, what are some things that you think might come up for the patients or their caregivers from their mental health or wellbeing perspective?

RM: When I think about the restrictions on the presence of caregivers, one thing that comes to mind is this concept of co-regulation. This idea that, we refer to a lot in psychology, and then there's a big focus about in parent child relationships, but really relates to all of us in any of our relationships that are psychological and our physiological state is really based on the state of those that around us. We co-regulate with the people around us, and particularly so for folks that we have a close connection with. So clearly, a caregiver and a patient with a disability, there's a close connection in their psychological and physiological states. They play off one another. And that provides opportunity to have foundation for stabilization. And obviously, going to a hospital visit, being in the hospital is a very stressful situation in many ways. And it's really important to have all the resources, as many resources as possible at our fingertips. And one of those primary resources is the presence of someone that we feel a close connection with. That's how we co-regulate.

And so this underlies the entire patient experience and there's this close interdependence or close relationship between a caregiver and individual with a disability. And so if we are restricting opportunities for that co-regulation, then this is going to heighten anxiety, heighten stress in the experience in a medical setting or in a hospital setting, that is going to impact all the things that you've mentioned that we started talking about, right? The ability of the individual to advocate for themselves, the ability of the individual, of the patient to report on what's happening, the increased sense of isolation.

And so I think it's easy to overlook or it's too often that we overlook the critical role of the caregiver in providing that kind of stabilization and that foundation for co-regulation that helps really with stress management. And it's, back to this core principle or idea that we're regulated when we feel seen and heard and understood by people around us, and caregivers are often the best people to do this.

RT: You really surfaced a really important point that hasn't received enough attention, which is this idea of co-regulation, how people's emotional state depend on one another. And when they really feel like they're part of the same team, attending visits together, hearing the trajectory of care decisions, all of that together, it's just a fundamentally different experience. So thank you for raising that really important point. I think clinicians, especially, it would be really useful for them to keep that at the back of their mind and see what they could be doing to engage caregivers better. Sheila, you've been at the front lines, especially in the work you do in the cancer community, in cancer care. Thinking of what Ryan said, what are some things that clinicians could be doing to engage caregivers better in patient care, given the restrictions we have in place?

SR: Thanks, Ranak. First and foremost is including the caregivers. I think with these blanket policies that are being enforced to restrict visitors and to restrict people entering the appointments at clinic or to the hospital, it's really basically setting up a wall. And on many occasions, it's limiting the communication that's also taking place. So however which way the caregiver can remain part of the communication, part of the decision-making, part of the planning and the care coordination, that really can go a long way so as not to disrupt those relationships and not to disrupt those roles any further than they need to.

And in addition to communication, again, being innovative, how can we involve the caregivers over video, over FaceTime in ways that allows the patient receiving care to feel connected, to feel supported, to feel less threatened and less anxious. I see this a lot with the patients I take care of who are admitted for several weeks at a time to undergo bone marrow transplantation. They are very dependent on the presence of their caregivers. And to be isolated from them, and what's already an isolating experience during a pandemic, causes a lot more anxiety, threatens their own self-efficacy or how self-efficacious they believe they are. And sometimes it really affects the ways certain people are being advocated for. And so I think it's important for all of us clinicians to be mindful that these changes are very prominent. And while we're taking care of many, many patients, each patient is a person who is part of a community, and how can we continue to make it less disruptive and less threatening to them?

RM: I think piggybacking a little bit on one of the comments that Sheila was speaking to, I think it's all too often that caregivers are somewhat on the periphery of the treatment plan or the clinical care. And by that, I mean that their presence is often unnamed or assumed or in many ways taken for granted, especially when we're talking about informal caregivers, when there aren't official arrangements that have been made or that are in place. And so it feels like there may be a need or an opportunity to more actively and explicitly engage caregivers in treatment planning, in decision-making, and really being cautious about not taking their presence for granted and not just assuming that they're going to be there, but really that active engagement and involvement and being explicit around the significant role that they play.

RT: For patients who are getting their telehealth visits at home, we've been right now talking about inpatient versus leaving the caregivers out. But the flip of it is patients are attending their visits from home by phone or a video. And I'm wondering what are some challenges to engaging caregivers in those conversations? And what are some maybe silver linings to that context that might occur because now patients are being seen within their homes, where their family, their caregivers are around? Any thoughts on that, Ryan?

RM: There's an interesting dynamic that I think that we're seeing where there are new windows into people's lives and experience. And so in many ways, the current context, the current situation, the current way in which care is being delivered through telehealth, for example, provides an opportunity to see the reality of the real life situation at home and to see the real life environment. And it's a double-edged sword. In some ways that leads to increase vulnerability on the part of patients and families and their caregivers in terms of what's being disclosed, what's being seen by their medical team, less control their agency in that, but with that also comes perhaps a greater connection, a greater understanding for the individual, for the caregiver, for the dynamic at home.

SI: I think what I'd add to that is a growing body of knowledge, not research yet that is coming into play, which is about mental health services now being delivered over telehealth platforms, but you live in a home where you don't have any privacy at all, and the stresses for that, whether they're intimate partner violence or whether they are anxious and can't sleep, and you don't necessarily want to let your family members know and or you don't want to let your roommates know. And what are the implications of that ?

SR: I'd like to add to both what Sonoo as well as Ryan have shared. And on any given day, I see a number of patients and over the course of this past year, by using tele-health, I have met more and more caregivers and family members were oftentimes joining the visits, and in many ways, very helpful. And yet, there are times where I wonder about how to very tactfully disengage the caregivers as well, because the focus is really on the patient. And so there have been many circumstances where I've had to see patients who prefer to be seen alone in a car, parked in a parking lot, or they've chosen to walk somewhere else as a way of protecting some of the information they would otherwise be sharing with me alone in the clinic encounter.

And so I think we can look at this in multiple different ways, both how has this benefited the patients? How has this benefited the caregivers? How has it also made it hard for the patients as well as the caregivers who oftentimes feel like they have an added duty and an added responsibility, not just to follow through on their caregiving tasks, but perform also during the clinical encounters? And I have found that that increases the distress for a lot of people.

RT: Beyond the diversity, the way we think about it, people are just different. And one of the things that occurs to me as we're talking is, perhaps we should ask, perhaps it would be important as clinicians to ask patients what their preferences are, who was invited into the visits, and ask it in a way that they can be candid with us to say, this is the person I want, and maybe partner with them to make that experience as supportive and helpful for the patient as possible.

SR: I've learned to ask what portion of this visit would you like X to be a part of? And oftentimes, I defer to the patient to share that with me, but I also invite the caregiver to be part of the encounter. And that's most especially important when we're seeing patients who have some level of cognitive impairment, have difficulty with language, or for whatever reason, are having a very hard time with the technology. And so I often approach it as an invitation, but I also provide some instruction so that it's coming from me and not necessarily from the patient that I'm seeing as a way of not disrupting the relationship too much, but it is hard. It requires a lot of finesse. And like we've all said, every encounter is different because we are exchanging with different humans.

SI: A lot of things to what Sheila said earlier, which is this idea of being a caregiver. And now, the family wasn't at home when you were doing caregiving in the past, but not everyone's doing school from home, meetings from home, work from home. So suddenly, there's a great deal of scrutiny constantly on the caregiver in terms of what they're doing and what they're not doing or how they're doing it. And the impact on the wellness of the caregiver community while they're on this 724 microscope.

RT: Yes. Sonoo, that's an excellent point, that it's not just the patients who are under scrutiny in these virtual visits, but the caregivers themselves. So up till now, we've been really talking about family, so family members and friends who are providing unpaid care, but there's another part of the workforce, which is people who provide home-based care like nurses and nursing aides and are paid. And we heard from Peter how they've decided that the paid caregiver was essential during the pandemic for their families functioning. A lot of people are struggling with this right now, should the family continue getting paid care? And what are the implications of that for the informal caregiver if they decide against it?

One of the challenges being paid caregivers go from home to home and therefore, there's a greater risk of spreading COVID, but without the paid caregiver there, that means somebody else is taking on some pretty intensive caregiving roles frequently around activities of daily living. So this is a tension that people are navigating right now. Ryan, as you think about some cognitive behavioral techniques or something from the psychotherapy background, what are some strategies or techniques caregivers could use to help navigate that to come to a decision that they can feel comfortable with?

RM: First, it's important to acknowledge that this is clearly a difficult decision as you've described, and there's not a one size fits all solution, but maybe most important is thoughtfully and intentionally engaging in this process, where you're really breaking down this decision. And so this is looking at the decisional balance, so to speak, and really taking care and time. And this is something that we do in therapy sometimes is looking at the options and really listing all the pros and cons of the different decision options, carefully thinking about the costs and benefits of selecting a certain path or certain avenue for caregiving. This fits into a larger skill or scheme of problem solving, where we often suggest that folks start by clearly stating the problem that we're looking to solve. In this case, it may be just specifically stating that, I need XYZ sorts of care in my home and not sure the best way to get it or the best way to achieve this care.

So we want to specifically state the problem. And then we want to openly brainstorm all the possible solutions and really put everything on the table. Be creative in this process, no bad ideas at this stage of the process, put them all out there. And then we can start to break down and do this decisional balance, look at the pros and cons, examine the good and bad of each of these options that we brainstormed. From there, after looking at the pros and cons, we pick one solution and go with that and we see if it works. What's most important is to have this intentional space, to have a conversation with everyone who is impacted, to engage them and give them a seat at the table and really thinking broadly about who's going to be impacted by the decisions that we make, by the arrangements that we make around caregiving in our home or in our family or in our community.

SI: I would add that they should be intentionality on the impact on the caregiver about the choices that are made, because these are people who would not get paid if a family chose not to keep them and yet, they need to pay their bills too.

RT: I think the pandemic has definitely highlighted how many institutions and social systems are really cogs in a big machinery, moving one lever, move the other lever, which then moves yet another lever. Ryan, you said something that I really think it's important for us to just amplify. And I want to make sure we capture that, which is this process will be iterative, that for caregivers and for other people at the table, as you so beautifully put it, the first solution they come up with may not be the best or the most optimal solution and as the context shifts, the need to reevaluate may also shift. So there's two aspects. One is that the first solution itself didn't work out. So let's get back to the drawing board. And the other is the set of issues we were dealing with in March or April, maybe different in December, which are now different in the current times

I want to just go around and if people can come up with one or two key takeaways, one for caregivers who might be listening, and one for clinicians who might be listening, what is something that you feel that caregivers need to know? And what is one thing that a clinician needs to know who might be listening right now? I'll start with you, Sonoo.

SI: I think for both communities, I would say, you recognize it's not a one size fits all, customizing for the last mile and for the individual is important. And I'll add a second piece, picking a page out of Ryan's recommendation earlier, which is, it's not one and done, rethink, reevaluate, redo, reassess, and then do it again.

RT: Thank you, Sonoo. Sheila.

SR: I just would like to acknowledge that this is hard. This is hard for everyone. And I think that caregivers need to know that they need to be kind to themselves as they make very difficult decisions during these very trying times, and likewise for the clinicians. For the most part, if not all the time, everyone has good intentions and we are all dealing with all series of difficult circumstances and everyone is trying to make the best choices. So extending self-compassion and leaning in on others to help with some of the decision-making as well as the communication can go a really long way.

RT: Great point, Sheila. Ryan.

RM: My thoughts and comments echo a little bit what Sheila mentioned. My message to caregivers, similarly is acknowledging that this is an incredibly difficult time given the care that they're providing, whether it's informally for a family or it's part of their profession, there is an increased risk and increased vulnerability in this role that the pandemic has caused. And so I think it's important that we acknowledge and appreciate that and express gratitude for the ongoing efforts to provide care. And similarly, I think that flows right into the kind of recommendation or consideration for clinicians and providers, just a particularly critical time to be attentive to the role that caregivers play as we are clinicians and professionals coming into contact with them in a clinical care with the patients that work together as a community supporting.

RT: Thank you, Ryan and Sonoo and Sheila, I echo all those recommendations. The two unique things that I would want to add is for the clinicians to ask patients and the caregivers what they need in those times frequently, and making sure that they are not just replicating the clinic visits the way they used to, but using this new normal to come up with better ways of engaging and supporting caregivers. And for the caregivers, I think it's important for them to know that they can and should speak up when they're not getting their needs met, when they need either the health care system to help or if they need other people to help them. These are trying times, but for caregivers, it's always been trying times.

Thank you everybody for this amazing discussion and for this opportunity to talk about this topic with all of you. And a special thank you to Stanford Medcast for the privilege of hosting this episode.

Dr Ruth Adewuya: Thanks for tuning in. This podcast was brought to you by Stanford CME. To claim CME for listening to this episode, click on the Claim CME button below or visit medcast.stanford.edu. Check back for new episodes by subscribing to Stanford Medcast wherever you listen to podcasts.

Audio Information

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The content of this activity is protected by U.S. and International copyright laws. Reproduction and distribution of its content without written permission of its creator(s) is prohibited.

Accreditation: In support of improving patient care, Stanford Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the health care team.

Credit Designation Statement: American Medical Association (AMA)

Stanford Medicine designates this Enduring Material for a maximum of 0.75 AMA PRA Category 1 Credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Financial Support Disclosure: This CME Activity is supported in part by educational grants from Novartis.

Authors:

The Stanford University School of Medicine adheres to ACCME Criteria, Standards and Policies regarding industry support of continuing medical education.

There are no relevant financial relationships with ACCME-defined commercial interests for anyone who was in control of the content of this activity.

Ruth Adewuya, MD

Managing Director, CME

Stanford University School of Medicine

Course Director

Nothing to disclose

Sheila Chitsaz Lahijani, MD

Stanford Health Care

Planner Nothing to disclose

Ryan B Matlow, PhD

Stanford University

Planner

Nothing to disclose

Peter Dean Poullos, MD

Clinical Associate Professor, Radiology and Founder, SMAC

Stanford University School of Medicine

Planner

Nothing to disclose

Sonoo Thadaney Israni, MBA

Executive Director, Presence and Program in Bedside Medicine

Stanford University School of Medicine

Planner

Nothing to disclose

Ranak B Trivedi, PhD

Assistant Professor of Psychiatry and Behavioral Sciences, Public Mental Health and Population Sciences

Stanford University

Planner

Nothing to disclose

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