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Latest Posts

Considering A Non-Fatal Patient’s Quality Of Life

Why is it easier to talk about quality of life with patients who are dying? Why don’t we factor these considerations into the decision-making for patients with conditions that aren’t fatal?

The presence of a terminal illness serves to focus everyone’s attentions. Widespread cancer metastases? Concerns about tight blood glucose control fade away. End-stage liver disease? Blood pressure control doesn’t matter so much any more. Bony pain from prostate cancer? Narcotic and sleeping pill addiction doesn’t even occur to anyone. I find it far more problematic to deal with patients with debilitating but non-fatal conditions when treatment options are perceived as limited because of co-existing diseases that produce so-called contraindications to certain medications.

I have a patient in his mid-70s with severe pain from osteoarthritis. Several fractures and a couple of unsuccessful joint replacement surgeries haven’t helped matters. Several years ago he found that a little drug called Vioxx worked extremely well for him, reducing his pain considerably and allowing him to do pretty much watever he wanted. As we all know, however, that drug was pulled from the market because of an unacceptable increased risk of heart attacks and other untoward cardiovascular events. Interestingly, Read more »

*This blog post was originally published at Musings of a Dinosaur*

Will Doctors Actually Change Their Recommendations Given The New Cancer Screening Guidelines?

Cancer. Just the word is scary. Actually, that’s the problem. Once you say that word, the average American will do anything — ANYTHING! — to just get it out of my body!!! Whether or not they have it, whatever the actual numerical chances of their ever developing it, no chance for detecting or treating it should ever be neglected. EVER! Ask any Med-mal lawyer. Better, ask any twelve average people off the street (i.e., the ones who are going to wind up on a jury). “The doctor didn’t do every possible test/procedure, and now the patient has CANCER? String him up!”

Hence we have the new guidelines for PSA testing. (Given that many patients with prostate cancer have normal PSAs and lots of patients with high PSAs don’t have prostate cancer, it doesn’t seem semantically correct to call it “prostate cancer screening”.) Surprise! Turns out that not only does PSA testing not save lives, but that urologists don’t really care. Certainly not enough to stop recommending PSAs to just about everyone they can get their hands on.

Nor do breast surgeons have any intention of modifying their recommendations, not only in light of new understandings of the limitations of mammography, but even as Read more »

*This blog post was originally published at Musings of a Dinosaur*

When A Cancer Patient Might Be Better Off Choosing Hospice Care

Cancer is a dreadful disease. Just dreadful.  Make no mistake: I have tremendous respect for the awesome doctors who treat patients afflicted with it day after day. Still, paradoxically, I can’t help but notice that some of them have just as hard a time as do other doctors with caring for patients at the end of their lives. I believe a large part of their difficulty stems from the ridiculously dysfunctional either/or approach to palliative care and hospice we’re stuck with in this benighted country.

The problem is that in order to qualify for hospice, patients must not only have a certified life expectancy of less than six months, but they must also not be undergoing any active treatment for their malignancy. When you stop to think about it, though, this is actually quite discriminatory. We don’t require people on hospice with other diagnoses to discontinue their life sustaining medications. Patients with COPD are allowed to continue their bronchodilators; CHF patients don’t have to stop their ACE inhibitors and digoxin. But if a cancer patient wants to qualify for hospice, they have to forgo curative treatments like chemotherapy.

So what if the oncologists call it “palliative” chemo instead? Read more »

*This blog post was originally published at Musings of a Dinosaur*

Family Physician Makes The Switch Back To The White Coat

I have not worn a white coat since I opened my own practice more than twenty years ago.

Not that I had anything against white coats in principle. I wore my short white one in med school with pride, and the longer one in residency too; their pockets filled to bursting with the 4 x 6 inch six-ring binder emblazoned with my name in gold, courtesy of Burroughs-Wellcome, the long-defunct pharma giant, which had presented one to each medical student in the US for many years, as well as assorted pens, note cards, alcohol wipes, hemoccult cards, and so forth. I even had a tiny teddy bear pinned to my lapel, my own way of personalizing the impersonal.

When I went out on my own, though, I made the conscious decision not to wear one. I confess that all these years later, I don’t completely recall my thought processes on the subject. It seemed Read more »

*This blog post was originally published at Musings of a Dinosaur*

Research Shows That Supplements Can Be Dangerous

Hallelujah. At last there is an actual, published paper (full text behind subscription firewall, unfortunately) objectively documenting not only a lack of longevity benefit for several commonly consumed dietary supplements, but a numerical association indicating potential harm. Finally!

Investigators looked at nearly 39,000 women (in scientific terms: a lot) over 19 years of follow up (in scientific terms: a long time) and found increased risk of death in women who took supplemental iron (strongest association), copper, zinc, magnesium, Vitamin B6, and multi-vitamins.

Wow.

If nothing else, that should at least give one pause when considering whether or not to take supplements at all, especially in the demographic studied (the “older female”). But are they overstating their case? Scare-mongering? Not at all. In fact, the following caution was explicitly added by the researchers: Read more »

*This blog post was originally published at Musings of a Dinosaur*

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

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How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

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Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

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The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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