Taylor Dunstan ’15, Stanford University School of Medicine

Day One

Walking into the Child and Adolescent Psychiatry building on a brilliant, Californian winter day seemed to reflect my feelings for the day: bright and optimistic. I had definitely been enjoying my winter break, but I couldn’t wait to begin myPrinceternship with Dr. Kiki Chang ’88, the Director of the Pediatric Bipolar Disorders Program who is also an Associate Professor at Stanford University School of Medicine, a child psychiatrist, and administers clinical research. 

Evaline, the other Princetern, and myself had contacted Dr. Chang in the weeks leading up to the Princeternship, which helped us choose the best times and dates for all of us. We arrived in the lobby of the psychiatry building in the morning and waited for Dr. Chang to meet us there – unfortunately, his son had to be picked up sick from school. Instead, one of his clinical research coordinators, Rosie, happily met us in the lobby and brought us upstairs to her office and the “headquarters” of some of Dr. Chang’s research. While Rosie prepared for the upcoming “case-ad”, an interview with one of the subjects from a study, she enthusiastically answered our questions and provided us with a great background on what we would be sitting in on for the morning. We would be observing the longitudinal part of one of Dr. Chang’s studies, “Identification of Genetic and Neurobiological Risk Factors for the Development of Early-Onset Bipolar Disorder” with a healthy control subject. Although the study focuses on discovering the possible factors of neurochemistry, genetic markers, and brain activations patterns that contribute to the onset of bipolar disorder, we learned that it is important to have healthy control subjects (those who do not have ADHD or mood problems or a parent with bipolar disorder) in order to compare results and claim significance.

Rosie took us to Meghan Howe’s office, who is one of the Clinical Research Managers, where Dr. Chang quickly welcomed us and introduced himself to us before Meghan began the “case-ad” with the healthy control subject. The case-ad, in which Meghan interviewed the healthy subject about possible symptoms for mood disorder, lasted about a half hour. Afterwards, we accompanied Rosie and the healthy control subject while Rosie administered a few follow-up tests. Rosie administered the Affect Recognition, or the NEPSY test, which is used to evaluate a child’s neuropsychological development through testing basic and complex aspects of cognition. We also observed the healthy control subject take the “MultiMorph” test, which uses a computer to morph a picture of a face from one mood to another (i.e., an angry face to a happy face).

When the healthy control subject left, we met Dr. Chang in the lobby where he brought us outside to the “Nom Nom Truck” (http://nomnomtruck.com/) for a delicious Vietnamese meal to-go. While waiting for our food, Dr. Chang was enthusiastic about getting familiar with our interests, our passions, and our goals, and we found that many of our interests overlapped. Dr. Chang and I found out that we even share the same residential building, Joline! We brought our lunch to a communal meeting with many prestigious psychiatrists, analysts, researchers, and mentors who discussed current research, ways to better research, and ways to better collaborate. The meeting brought together some of the brightest minds and experts in pediatric mood disorders. Straight from the meeting, Dr. Chang brought us to his office for another meeting with Rex Huang, the Chief Fellow of Child and Adolescent Psychiatry at Stanford Hospital and Clinics. Dr. Chang and Dr. Huang discussed recent patients, any dosage or medication changes, and any updates. It was really interesting to get a glimpse of Dr. Chang’s overarching role in the clinic and to hear snapshots of Dr. Huang’s individual and direct work with his patients.

Following that meeting, we rushed to a meeting with Alan Reiss, one of Dr. Chang’s mentors and head of the neuroimaging lab, for a consultation on the findings of one of Dr. Chang’s more recent studies. Amy Garrett, a Research Scientist and Neuroimaging Manager, Ryan Kelley and Spencer Boucher, neuroimaging research assistants, were also there to discuss the findings and the best possible way to present and publish them. From what I could understand, the study, CAFENE, used MRI to evaluate the neurological response to viewing images of a fear face, a calm face, or a neutral face. It was a great collaborative effort and the meeting worked as a conversation, with each person providing insight and asking further questions to better the understanding of the findings.

Afterwards, Amy Garrett and Victoria Cosgrove met us in Dr. Chang’s office before heading off to another meeting. Dr. Chang drove us to the “Lucille-Packard Foundation” donor presentation, which we all thought would be a small meeting. We were all surprised when we walked into a room full of business suits, but Dr. Chang nonchalantly and humbly began his presentation. He opened the presentation with the importance of funding for Bipolar Disorder, especially in accordance with its “de-stigmatizing”. Listening to Dr. Chang speak, I realized that, despite his success, he must overcome much adversity in order to receive recognition or donations for his research. The social stigma of Bipolar Disorder discourages many people from donating, especially when there are people out there who still believe that Bipolar Disorder doesn’t exist or is simply an exaggeration of teenage “temper tantrums.”  Dr. Chang went on to present a summary of his work, discussing comorbidity factors, the difficulty of applying adult findings to children and adolescents, and how it affects a child’s education. In the end, the meeting came together to brainstorm ideas on how to raise money for Dr. Chang’s incredible work.

When Dr. Chang dropped us back off at 401 Quarry Road, I walked away with an immense amount of knowledge. Not only did all of my background research come together and apply to each of my experiences from today, I had learned so much about Dr. Chang’s career and the careers of his colleagues. Everyone I had met was very enthusiastic and welcoming, but more importantly, they were all very down-to-earth. Dr. Chang was incredibly personable, friendly, and humble. It was definitely refreshing to see Dr. Chang, a man so modest with his success, in this business environment because his likability was impossible to deny. Looking back, I realized Dr. Chang’s personality is evident in all of his relations with his colleagues we observed today, making for a very successful, upbeat atmosphere. Today I learned a lot about pediatric bipolar disorder, its research, and psychiatry, but I also learned the importance of personality in the workplace. I can’t wait to start another day with Dr. Chang tomorrow!

Day Two

Taylor, fellow Princetern Evaline, and Dr. Chang

Evaline and I met Dr. Chang in the lobby and quickly went to his office where we had a “debriefing session”. Dr. Chang first discussed mindfulness, the art of being aware of ourselves, and controlling our emotions and how this is involved in his future work. He then discussed the grant writing process that accompanies any research. He filled us in on the differences between mutltiple grant proposals he is writing. We were pretty intrigued by the approval process and review panel, which seems to exist very subjectively. From what I understand, a grant can be approved or turned down based on the opinion of one person, which makes for a pretty competitive system. Furthermore, Dr. Chang shared with us the pathway that brought him to his profession. I found his experiences relatable and enlightening, opening up my eyes to options I hadn’t considered yet. He is a strong advocate for engaging in whatever makes one happy, “you won’t be successful unless you enjoy what you are doing,” he told us. I found these to be powerful words, especially from such a successful man who really contemplated the steps he took to get him to where he is now. His job embodies what he loves to do: he has a balance of research, of clinic involvement, or academia, of teaching, of pediatrics, and of travel. Dr. Chang was interested in our lives, as well, and we shared our experiences and hopes with him in return. We all seemed to harbor the “social conscious” that brought Dr. Chang to medicine.

After our debriefing session, Evaline and I went to lunch at the nearby Stanford Shopping Center and ordered sandwiches from La Baguette – a great, cute café. Over lunch, we were able to reflect on our experience so far and share our excitement for the upcoming plans Dr. Chang had for us. We met up with Dr. Chang at the clinical mood disorder meeting with other psychiatrists, psychologists, and therapists who work in the clinic.  The group discussed intakes, patients’ updates, and Dr. Chang ended the meeting by teaching the group about clinical trials. He went over interventions and whether it be medication, therapy, education, CBT, DBT, or mindfulness. He then taught about the efficacy of trials, whether a subject is in remission or recovery, and the different measures of deciding these labels. The importance of NNT (number needed to treat) and NNH (number needed to harm) in clinical trials and medications was then discussed, teaching us that a medication with a low NNT and a high NNH is the most productive.

Afterwards, we had the opportunity to shadow Dr. Chang in the clinic. We sat in on four appointments, each with a girl in her teenage years. The patients had mood disorders from depression to bipolar disorder, from anxiety to schizophrenia. Often, Dr. Chang would first converse individually with a patient before bringing her parents in. The meeting served primarily to discuss dosage, but in order to discern which dosage would be appropriate, Dr. Chang needed behavioral updates from the individual and her family, as well as any updates on side effects. Dr. Chang filled us in on the background history of each patient, who all seemed to be doing well with treatment and experiencing improvements.  Seeing Dr. Chang work in the clinic allowed me to understand what it would be like to be a practicing psychiatrist, the types of illness and issues a psychiatrist might deal with, and the ways in which a psychiatrist can directly and indirectly help a patient. Once again, I walked away with an incredible amount of new information and an invaluable experience that will certainly leave an impression on which medical pathway I’d like to take.

Day Three

Today, Evaline and I had the great opportunity to meet with Amy, Spencer and Ryan again in Alan Reiss’s neuroimaging lab. We first met with Amy, who evaluates the neurology of eating disorders, mood disorders, and memory in elderly,  to discuss the neuroimaging fMRI. She explained to us the physics and statistics of fMRI and explained to us the functional contrasts that we see in a brain scan. Furthermore, we learned about the traditional vs. original design of task-oriented scans, lowering the percent of unusable scans, and the variability that must be considered when evaluation a scan. For instance, you must understand and consider the comorbidity factors, the medication, and environmental factors when evaluating a scan. She also went on to lament the difficulties in recruitment for research and acknowledged that the likability Dr. Chang exhibited is extremely helpful not only for funding and for grants, but for recruitment as well. We then spent time with Spencer, who intelligently explained to us the program “FreeSurfer”, which traces parts of the brain and discerns between white matter and grey matter. He spoke more about structural imaging, normalization, and the corrections that must be done with scans. Spencer showed us some of the faces used during the CAFENE study we heard about during a meeting on Monday, which were amusing and gave us all a good laugh. In addition, he talked about the simulation subjects must undergo before getting a real fMRI scan. They usually place a subject in a simulated fMRI scan with a video of Spongebob or a popular television show playing. If the subject moves, the video stops for four seconds in hopes of training the subject to stay still. With Spencer, we also talked about his major, cognitive science, and how he ended up where he is. I found this to be really helpful because it gave me a great sense of what someone can do with a degree or major and how I can use my abilities in the neuroimaging field.

Our final stop in the neuroimaging lab was with Ryan, one of the lab’s favorite employees. Ryan was working on finalizing the CAFENE study paper we discussed in the meeting on Monday and helpfully went over the paper with us – by the end of our meeting with Ryan, we really understood all the scientific and complicated terms from the original CAFENE meeting. Ryan told us that CAFENE stood for CAlmFEarfulNEutral and explained that the calm face was used as the baseline because bipolar kids had a neurological response to the neutral face. We first went over the primary analysis, the establishment of whether or not bipolar kids have more activation in certain parts of their brain, in this case, the amygdala. We then went over the post hoc analysis, evaluating the genetic implications of the study. This dealt with the SERT allele, which was taken from a blood sample or a saliva test. We learned about the importance and power of integrating brain, behavior, and genes in a study for the integration provides the best answers to the questions. Ryan also told us about the difficulty of the research and the change from undergraduate writing to scientific writing, which tends to be short and simple, full of limitations. The morning in the neuroimaging lab taught me a lot about a field that I am finding very interesting and would like to explore more. The experience also showed the collaboration between medicine and technology, something I am also very interested in.

Evaline and I had lunch at the café downstairs and went to the cubicles upstairs for a little downtime and some work.  We had been so busy the past two days that it was nice to relax for a while and reflect on what we had learned so far. Everyone we ran into while we were upstairs was so welcoming, engaging, and nice – it was a great environment to be in. After our break, we met back up with Dr. Chang and his colleagues, many of whom we already worked with, for a lab meeting. Recruitment, updates, announcements, and bonding options were all discussed during the meeting. Once again, it was great to see how many people are involved with Dr. Chang’s work and each of their individual and group roles.

Afterwards, we were able to see one of the patient’s from Dr. Chang’s clinical trials, which he had taught his colleagues about in the meeting from yesterday.  He had to interview the patient on her comprehensive history symptoms of bipolar disorder and discuss medication with her parents. The interview was upbeat and Dr. Chang created a great atmosphere for the patient, making her feel comfortable during the process.

Unfortunately, the end of the interview signaled our last moments of the Princeternship. I am definitely sad to leave Stanford and the experience with Dr. Chang, but I am so glad I got the opportunity to learn so much. I would definitely recommend this Princeternship to students interested in psychology, neuroscience, or medicine. My time at Stanford affirmed my interest in helping those around me and exploring medical school. I’m extremely grateful to Dr. Chang for the opportunity to learn more about his area of expertise, his career, and his path to success. It was an invaluable experience for which I will always be appreciative.

Evaline Cheng ’14, Stanford University School of Medicine

Day 1: January 9, 2012

Today marks the start of my 3-day Princeternship at the Stanford University Medical School, and what a beautiful day (California sun is glorious! I almost forgot what it felt like to sweat…)! This morning Taylor, the other Princetern, and I met Dr. Kiki Chang ’88, a child psychiatrist and clinical researcher. Dr. Chang is the Director of the Pediatric Bipolar Disorders Program and Associate Professor at the Stanford School of Medicine. He also played ultimate frisbee at Princeton— shout out to Clockwork! After introductions, Taylor and I met with Rosie Shoemaker and Sherrie Li, the clinical research coordinators. Several clinical research projects are ongoing under Dr. Chang’s direction, and we were able to watch Meghan Howe, clinical research manager, conduct an interview with a normal teenager who was a control patient in a 5-year longitudinal study following control and children with bipolar disorder.  As part of the interview, the patient was asked a series of personal questions. I was surprised to see that the research assistants had such strong relationships with the patients to the extent that the children were even comfortable sharing private details about their lives. Afterwards, we observed the patient complete face recognition and face morphing tasks that tested for things such as the ability to identify emotions and theory of mind.

In the afternoon, we attended a mood disorders meeting with Dr. Chang and other researchers and physicians working in related fields. There is certainly a spirit of collaboration amongst researchers. Part of the meeting focused on genetics and the search for a genetic link to several of these mood disorders. We left the meeting early to meet Dr. Rex Huang, the child and adolescent psychiatry Chief Fellow. Dr. Chang and Dr. Huang discussed updates about several patients (what was going on in their lives, if any changes in medicine dosage were necessary). Although many patients were diagnosed with the same mood disorders, every patient was different— each patient faces different environments and families that influence their moods. I had never realized that there was such diversity in the onset of bipolar disorder or depression and other mood disorders.

To end our first day as Princeterns, Taylor and I accompanied Dr. Chang to the Lucile Packard Foundation, an organization that helps fundraise for child health programs. We walked into an impressive boardroom with an enormous table surrounded by the people who would potentially help secure donors Dr. Chang gave a presentation outlining his clinical research and the importance of grants or philanthropy to really keep the research going. While conditions such as autism have gained a larger presence in the public eye (and a subsequent increase in donations), the persisting stigma surrounding bipolar disorder has made it difficult to secure donations from private donors.

Day 2: January 10, 2012

Fellow Princetern Taylor, Evaline, and Dr. Chang

Today was my favorite day of the Princeternship as it is Dr. Chang’s “clinical day,” where he sees patients for private consultations. Taylor and I began the day with a debriefing session in Dr. Chang’s office, during which we discussed our goals and experiences at Princeton so far as well as his life path and how he ended up where he is now. After Princeton, Dr. Chang went straight to medical school, but still paused and took time to pursue his interest in music and to really think about whether medical school was what he wanted to do. To hear this from someone who is so accomplished in his field and career was definitely a surprise. People always say that “you have time to figure out what you want to do” or that “you should explore your passions and interests.” But when push comes to shove, I always feel pressure (from parents, peers, and maybe just “society” in general) to really buckle down and commit myself to a concrete path towards a reputable profession. As a student looking up at these accomplished and happy individuals who are business owners or professionals or doing amazing things in the world, I seemed to always picture them as having known what they wanted to do from the get-go; they were the special ones who didn’t have to struggle with figuring things out, and that’s how they ended up at the top of their fields. To hear such candid and sincere stories from Dr. Chang about his own questioning was unexpected, but more importantly both comforting and inspiring. When everyone around you seems to be very go-go-go (as is the case at Princeton), it’s scary to admit to yourself that you may not even know where to go, and it’s even scarier to dig your heels in the ground and stop— to take time to figure out what you want to do. This talk with Dr. Chang was more reassurance that even if I walk away from this Princeternship not knowing what career I want to pursue or what type of medicine to practice or whether or not to go into psychiatry, it’s all okay— as long as I do something that I love and enjoy, I will (most likely) be great and accomplished in that field (fingers crossed and knock on wood). Dr. Chang also discussed with us the reality of his career and the balance of research, clinical practice, and academia. Being involved in academia requires a lot of traveling to conferences (often to Hawaii!), teaching, and (unpaid) mentoring. Being involved in research requires dealing with the process of writing and applying for grants when you could be spending that time doing much more productive things. However, that’s simply the nature of scientific research.

In the afternoon, we shadowed Dr. Chang in his clinic mode and observed several patients during their visits. There were children (with accompanying parents) who were diagnosed with bipolar disorder, depression, ADHD, anxiety, or schizophrenia. At first, I didn’t know what to expect; I had never witnessed a child who has a mood disorder, and I wasn’t sure how I would react if the situation became intense. Fortunately, I ended up not having too much to worry about. During each visit, Dr. Chang and the patient first discussed updates on his or her emotional state, family situation, and life in the past weeks in general. These updates allowed Dr. Chang to decide if the patient was making progress and if medication dosage changes were required. It seemed like Dr. Chang and his patients had really close relationships, and that aspect of psychiatry is appealing to me. I was also drawn into each patient’s story; each patient has his or her own quirks and personality, and each exhibited the mood disorder in different ways.

Day 3: January 11, 2012

This morning, Taylor and I spent time learning about the neuroscience aspect of Dr. Chang’s research. First, Dr. Amy Garrett, a research scientist and the neuroimaging manager, gave us an overview of neuroimaging with fMRI. We learned about the physics and science behind how fMRI works, the common types of tasks used, and the difficulty with recruiting patients and managing variability between patients and their brains. Next, Spencer Boucher, a neuroimaging research assistant, showed us the structural aspects of neuroimaging. Although the technology has made remarkable progress, Spencer uses a program called FreeSurfer to make touch-ups on the structural brain images including normalizing the images with a “standard” brain. Finally, Ryan Kelley, another neuroimaging research assistant, walked us through the statistical analysis of the data in one of the ongoing projects. One interesting thing that he mentioned was that there is a change in how we approach science from when we’re an undergraduate to when we’re actually conducting research. In reality, science isn’t as absolute as it appears in textbooks; there are actually a lot of assumptions and limitations in research.

Later in the afternoon, we attended a lab meeting with Dr. Chang, his research assistants, and colleagues, where they discussed updates with ongoing research projects. Although everyone is busy with specific tasks or parts of projects, they still get together to discuss the research holistically, which is pretty great. After the lab meeting, we joined Dr. Chang in his office to observe a patient who is participating in a clinical trial. Although similar to the private consultations from yesterday, this patient was being paid to participate in clinical research involving medication that could help with managing bipolar disorder.

At the end of this Princeternship, I am extremely thankful for such a wonderful opportunity and an amazing experience. Everyone was gracious and willing to show us aspects of their research projects and clinical work. I enjoyed this insider’s peek into the daily work life of Dr. Chang. With my only impressions of the daily work life of a doctor coming from watching “House,” I was surprised to see that Dr. Chang was involved in so much more than seeing patients— it was amazing to see how diverse a career in medicine can be. All in all, this was a wonderful Princeternship!