Reflecting on Presence: One Year Later

When we last checked in on Presence, a Stanford center founded by Abraham Verghese, MD, the Linda R. Meier and Joan F. Lane Provostial Professor of Medicine, and managed by Executive Director Sonoo Thadaney, MBA, the center had just opened with the goal of “fostering research, dialogue, and multidisciplinary collaboration to produce measurable and meaningful change in health care.”

This is a lofty goal, and perhaps a deceptively simple one, because it can mean many things to many people. But in its first full academic year, Presence has made great strides.

Creativity in medicine

The center’s initiatives are growing and expanding, fostered by knowledge that could only be gained by practice. Presence hopes to remind us all that, as important as technology is, the practice of medicine is an art as well as a science.

The center is described as an “incubator,” engaging with many problems and various ways of arriving at possible solutions. Verghese observes: “We have precision in understanding biological systems, precision in data science and population health. But we need the same precision in understanding the human experience of illness.” It’s also a truly interdisciplinary effort, involving faculty, scholars and students from all seven of Stanford’s schools as well as CASBS, a behavioral science center, and IDEO, a design firm, to name a few.

The Crown Jewel: The Stanford Presence 5   

Presence has many initiatives, but only one is what Thadaney refers to as the first “crown jewel”: the Stanford Presence 5. This initiative asks a broad question: what are the 5 (or potentially more than five) things that a clinician needs to do in order to optimize the very first connection with the patient and his or her family? That seminal moment often predicates everything that follows. Positively affecting that moment is an ambitious goal, but one that recently has gotten a boost from the Gordon & Betty Moore Foundation, which provided a $1.3 million grant to the Stanford Presence 5 initiative.

Under the co-leadership of Donna Zulman, MD, assistant professor of medicine, as well as Verghese, Presence has assembled a multidisciplinary team of researchers from diverse fields including medicine, communications, anthropology, linguistics, and design. “The current pace and climate in medicine can make it difficult to fully understand the experiences and circumstances that shape a patient’s health and wellbeing,” says Zulman. “Our goal is to design an intervention that helps clinicians be fully present and engaged during patient encounters.” Verghese and Zulman believe that enhancing clinician presence will not only promote safer and more effective care, but will also enhance clinician well-being.

The four-pronged approach

So how do you go about answering such a big question? The Stanford Presence 5 team has embarked on a four-pronged approach.           

First, they are conducting a systematic review of the literature. The team is looking for evidence that shows one or more elements of presence in a scientific study with outcomes for patients, physicians, cost, or scalability. They began by reading the abstracts of 20,000+ articles that fit the criteria, which they’ve now narrowed down to a few hundred.

The second prong is an observational study. Stanford Presence 5 researchers are observing clinicians in outpatient encounters to see how they practice at four diverse locations: Stanford Primary Care, the Palo Alto VA Hospital, the Ravenswood Clinic in East Palo Alto, and Highland Hospital in Oakland. The diversity of locations was a deliberate choice: “We are very clear that we cannot produce solutions that only work for those of us that have privilege. We must be able to create solutions that are globally scalable,” Thadaney explains.

The third prong is what the design thinking world calls “analogous interviews.” The researchers are interviewing professionals in relational fields to explore how and what they do when they’re expected to be present with a client. They will interview a wide range of professionals, from teachers and social workers to community police officers and nurses. 

Finally, the fourth prong - synthesis. Once all the evidence is gathered, the Stanford Presence 5 researchers will assemble a preliminary list of the Stanford Presence 5, which will then be presented to a Delphi panel of experts in various fields in order to get feedback. The team will then collaborate with design partners to develop an intervention that incorporates the final list of presence components.        

Beyond Stanford Presence 5

Stanford Presence 5 is the first crown jewel, but it’s not the only initiative Presence is focused on. This September, for the third year in a row, Stanford hosted the Stanford 25 Bedside Medicine Symposium, which brought together 100+ physician educators from around the country and the world who want to re-emphasize the importance of bedside medicine and teach it to younger physicians and residents.

Presence has also incubated and helped launch a nonprofit called the Society of Bedside Medicine, which aims to “bring in the ability to scale and test across the globe.” John Kugler, MD, clinical associate professor of medicine, co-chair of the annual Symposium and co-president of the new Society of Bedside Medicine adds: “Each year we are blown away by the excitement and passion that our attendees bring to the symposium. Speakers and attendees alike leave reinvigorated in their passion for bedside medical education. It is this passion which helped create the Society of Bedside Medicine with the goal to support bedside educators around the globe.”

Presence is also involved with Stanford 25. Errol Ozdalga, MD, clinical associate professor of medicine and director of Stanford Medicine 25, explains: “The Stanford Medicine 25 began as an initiative to promote bedside medicine to our residents and students. It has grown into both a local and online program with a worldwide reach that has served as the foundation of our successes, with total website visits at nearly 5 million and over 4 million YouTube views with over 12 million total minutes watched.”

Merging high tech with high touch

Other major projects in development focus on how artificial intelligence (AI) can be best designed and deployed in medicine. Presence seeks to avoid the pitfalls that other industries have fallen into with AI. They recognize that technology is critical to the future of health care, but wish to have it anchored in the high-touch care of humans. So Presence is seeking a way forward that embraces both, working in tandem. In their eyes, successful health services will provide care that isn’t MD versus AI, but MD plus AI. To start, they intend to explore issues surrounding disparities in health access and outcomes; soon, their interest in AI will extend into the realm of diagnostics.

To that end, Presence is planning to host two symposia: one focused on diagnostics and AI, and a second specifically to address AI and health disparities and ensure equity in a tech-driven healthcare ecosystem. The latter will focus on closing the healthcare gap for those who lack access and privilege; improving diversity in the evidence base of race, age, and gender; countering the algorithm bias; and exploring the technology of preventive care, not just curative care. Presence asks: “How do we proactively address and operationalize high-touch practices in a high-tech world of care?”

To seek solutions to these challenges, and to prevent problems before they arise, Presence funds two fellowships: one is a Presence-CASBS Fellow and a second is the Presence-Ontology Fellow, working with Mark Musen, MD, professor of biomedical informatics research and biomedical data science. Presence works with colleagues in biomedical informatics, ethics and philosophy, computer science, business, behavioral science, as well as colleagues outside the university at IDEO and thinkers at nonprofit and for-profit companies.

Presence is, ultimately, the study of the human experience of illness and a place to ask questions and think creatively about solutions.  And a year in, its members’ dedication and passion show no signs of slowing down.