A Country Doctor Reads: May 4, 2019

Delays in B-12 deficiency diagnosis -WSJ

This was interesting. The Wall Street Journal ran an article about the difficulties and delays in getting diagnosed with B-12 deficiency. It often takes years:

www.wsj.com/articles/vitamin-b-12-deficiency-the-serious-health-problem-thats-easy-to-miss-11556589900

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Review article: metoclopramide and tardive dyskinesia – RAO – 2010 – Alimentary Pharmacology & Therapeutics – Wiley Online Library

All of a sudden, I am reading a lot about tardive dyskinesia. I’ve been thinking about it in the context of being a side effect of metoclopramide.

Gastroparesis is frustrating to treat. Metoclopramide has been around since 1979, and I have certainly prescribed it often. But now there are all these warnings about Tardive Dyskinesia. Erythromycin is an option, not always well tolerated, and now the price of it has gone from $4 to $600 per month. Over the years, one motility drug after another has entered the market and been withdrawn due to side effects. There has also been Domperidone, not available in this country but in Canada (I have a Border License), but now I hear that it isn’t available there either.

So I wanted to get a handle on how prevalent Tardive Dykinesia from metoclopramide really is. I found a ten year old piece that said 1-15%. Guess how many cases I have seen over the years. Answer: Not a single one.

In the past 5 years, guidelines from two national organizations on the treatment of gastroparesis suggested that the frequency of TD with metoclopramide use is 1–15%.3, 4 However, clinical experience suggests that the risk of TD is much less. There are several potential explanations for the discrepancy between the stated prevalence and clinical experience: First, TD may not be encountered by gastroenterologists because it is actually rarer than the minimum 1% frequency. Second, gastroenterologists may miss the complication. Third, the patient may seek advice from another physician such as a neurologist.

— Read on onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2036.2009.04189.x

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The Empty Promise of Suicide Prevention – The New York Times

Last Sunday’s NYT had a thought provoking piece by Dr. Amy Barnhorst at UC Davis. She suggests that real suicide prevention would be bettering people’s social circumstances and decreasing access to lethal means. She also quotes statistics that 50% of suicides are impulsive actions and 25% of people who kill themselves contemplate their decision for less than five minutes.

According to a 2016 study, almost half of people who try to kill themselves do so impulsively. One 2001 study that interviewed survivors of near-lethal attempts (defined as any attempt that would have been fatal without emergent medical intervention, or any attempt involving a gun) found that roughly a quarter considered their actions for less than five minutes. This doesn’t give anyone much time to notice something is wrong and step in.

Nonetheless, mental health providers perpetuate the narrative that suicide is preventable, if patients and family members just follow the right steps. Suicide prevention campaigns encourage people to overcome stigma, tell someone or call a hotline. The implication is that the help is there, just waiting to be sought out.

But it is not that easy. Good outpatient psychiatric care is hard to find, hard to get into and hard to pay for. Inpatient care is reserved for the most extreme cases, and even for them, there are not enough beds. Initiatives like crisis hotlines and anti-stigma campaigns focus on opening more portals into mental health services, but this is like cutting doorways into an empty building.

And yet there are things we can do to prevent suicide. One of the few tried-and-true strategies is reducing people’s access to lethal tools, so that if they do sink into hopelessness, any attempt they make most likely won’t be fatal. If my first patient had had a gun in her house, she wouldn’t have made it to me. If my second patient had grabbed acetaminophen instead of ibuprofen, she might not have either. Averting death in that impulsive moment of despair is crucial to reducing suicide rates. Contrary to popular opinion, only a small fraction of people who survive one serious suicide attempt go on to die by another.

www.nytimes.com/2019/04/26/opinion/sunday/suicide-prevention.html

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Am I Smarter than Geisinger and The Harvard Business Review?

I subscribe to HBR, even though many issues don’t apply a whole lot to what I do. But the March issue seemed irresistible: Transforming Health Care…

A big article about Geisinger looked especially promising:

But, their physician interim CEO is another one of those HUDDLE HIJACKERS who thinks that mucking up primary care providers’ fifteen minute visits with spotting care gaps is going to be the solution for improving health care. He, like many other pundits, must never have heard of computer reminders, Constant Contact and Mailchimp.

Another article looked interesting:

But it only depressed me. What kind of system is Employer Provided Health Care when it only provides for half the population? Seems like a no-brainer to me (a Swede who left that country’s version of Socialized Medicine, mind you) that this system has got to go away.

I think we need to really reinvent health insurance in this country. My recent experience with Martins Point and other managed Medicare plans is echoing in my mind (and now the CMO of Martins Point wants to talk to me….I wonder what that is all about).

The American health insurance system is perverse, that’s all there is to it. If you are insured by your employer, your plan offers a free physical (deemed a worthless thing to do by most clinical experts) and free random bloodwork ordered as part of that physical, but if you feel a lump in your breast or testicle, copays and deductibles apply. If you have Managed Medicare, you get free gym memberships and other flashy extras but God help you if you need a CT or MRI to look for cancer.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

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