Archive for the 'A Country Doctor Reads' Category

A Country Doctor Reads: June 1, 2019

Thought Provoking Titles and Concepts

This week I read some articles whose titles or first few words grabbed my attention and opened my mind to issues I had thought about only casually in recent months. These pieces put their concepts in the forefront of my thinking as a physician. The last item seemed thought provoking enough as it promised to tell the story of how human adipose tissue became a hot commodity a couple of hundred years ago, but the story gets better, or, rather, worse – much worse.

ARRIVAL FALLACY – NYT

Thursday’s The New York Times has an article titled “You Accomplished Something Great. So Now What?” It describes the phenomenon of striving for something you expect to make you happy, but once you achieve it, you just feel empty. This introduced me to the term “Arrival Fallacy”.

“Arrival fallacy is this illusion that once we make it, once we attain our goal or reach our destination, we will reach lasting happiness,” said Tal Ben-Shahar, the Harvard-trained positive psychology expert who is credited with coining the term.

Dr. Ben-Shahar said arrival fallacy is the reason some Hollywood stars struggle with mental health issues and substance abuse later in life.

“These individuals start out unhappy, but they say to themselves, ‘It’s O.K. because when I make it, then I’ll be happy,’” he said. But then they make it, and while they may feel briefly fulfilled, the feeling doesn’t last. “This time, they’re unhappy, but more than that they’re unhappy without hope,” he explained. “Because before they lived under the illusion — well, the false hope — that once they make it, then they’ll be happy.”

The article offers this advice on how to avoid Arrival Fallacy:

“We need to have goals,” Dr. Ben-Shahar said. “We need to think about the future.” And, he noted, we are also a “future-oriented” species. In fact, studies have shown that the mortality rate rises by 2 percent among men who retire right when they become eligible to collect Social Security, and that retiring early may lead to early death, even among those who are healthy when they do so. Purpose and meaning can generate satisfaction, which is part of the happiness equation, Dr. Gruman said.

https://www.nytimes.com/2019/05/28/smarter-living/you-accomplished-something-great-so-now-what.html?smprod=nytcore-ipad&smid=nytcore-ipad-share

LANGUAGE OF TOUCH – NYT

Another piece in Thursday’s The New York Times with the title “Your Surgeon’s Childhood Hobbies May Affect Your Health” introduced me to the concept of “The Language of Touch”, similar to a language you learn as a young child as opposed to in college or graduate school.

Medical schools are noticing a decline in students’ dexterity, possibly from spending time swiping screens rather than developing fine motor skills through woodworking and sewing.

“There is a language of touch that is easy to overlook or ignore,” said Dr. Roger Kneebone, professor of surgical education at Imperial College London. “You know if someone has learned French or Chinese because it’s very obvious, but the language of touch is harder to recognize.” And just like verbal language, he thinks it’s easier to acquire when you’re young: “It’s much more difficult to get it when you’re 24, 25 or 26 than when you’re 4, 5 or 6.”

Dr. Robert Spetzler, former president and chief executive of the Barrow Neurological Institute in Phoenix, agreed. “Think about the difference between someone who has learned to ski when they were a little kid and someone who spent a long time, perhaps even the same amount of time, skiing as an adult,” he said. “That elegance that you learn when very young, doing that sport, can never be equaled by an adult learning how to ski.”

Dr. Spetzler earned a reputation as a virtuosic brain surgeon during his more than 40 years operating. He said he developed his dexterity as a child by playing the piano. And he began performing surgery in high school — on gerbils. All of them survived.

“The sooner you begin doing a physical, repetitive task, the more ingrained and instinctive that motor skill becomes,” Dr. Spetzler said. “What makes a great surgeon is unrelenting practice.”

https://www.nytimes.com/2019/05/30/well/live/surgeons-hobbies-dexterity.html?smprod=nytcore-ipad&smid=nytcore-ipad-share

DIAGNOSTIC OVERSHADOWING – NEJM

I have often thought of this phenomenon, but never heard this term for it: When someone has an important or severe diagnosis, we tend to blame it for everything else that ever happens to them and thus run the risk of missing new diagnoses in such patients.

So here is my speculation about Michael’s diagnostic delay. His providers saw a patient with complete quadriplegia, paralyzed below his neck. When he developed new symptoms, perhaps they succumbed to “diagnostic overshadowing” — the erroneous attribution of all new symptoms to an underlying health condition, especially in patients with disability. After all, maybe extreme MS-related constipation caused Michael’s distended abdomen; wheelchair users commonly have lower extremity edema; and breathing difficulties occur in late-stage MS. Perhaps they thought Michael’s PPMS was at its end stage.

https://www.nejm.org/doi/full/10.1056/NEJMp1903078?query=featured_home

SPONTANEOUS HUMAN COMBUSTION – The Atlantic

The Atlantic has a story about human fat that opens with a case of a corpulent woman who burst into flames, presumably a victim of what we now call Spontaneous Human Combustion.

The Lucrative Black Market in Human Fat

In 16th- and 17th-century Europe, physicians, butchers, and executioners alike hawked the salutary effects of Axungia hominis.

One night in 1731, Cornelia di Bandi burst into flames. When the 62-year-old Italian countess was found the next morning, her head and torso had been reduced to ash and grease.

https://www.theatlantic.com/health/archive/2019/05/human-fat-was-once-medicine-black-market/590164/

I had never heard of this phenomenon, but it has been described many times:

Though the term “spontaneous human combustion” is of fairly recent vintage, it was a rare-but-real concern to many in the 1800s. In fact, there are nearly a dozen references to people bursting into flames in pre-1900 fiction. The most famous example is Charles Dickens’s 1853 novel “Bleak House,” in which a character explodes into fire, though the phenomenon can also be found in the works of Mark Twain, Herman Melville, Washington Irving and others. In modern times, SHC has appeared in movies and on television shows, including “The X-Files,” and it’s even, sort of, the super-power of Johnny Storm, the Human Torch, in “Fantastic Four” comic books.

https://www.livescience.com/42080-spontaneous-human-combustion.html

A Country Doctor Reads: May 19, 2019

“The physician–patient encounter is health care’s choke point” -NEJM

This week’s Journal has a very profound article about why healthcare has not evolved through its technology the way other sectors of society have.

My take, and extrapolation, is that there are three reasons why healthcare has failed to evolve in usefulness of both our product (the care we deliver) and our technology (our EMRs), our customer centeredness and the value/cost relationship of the services we provide.

1) Healthcare is not at all customer centered. Even the required operational framework for Patient Centered Medical Home recognition is completely top-down. We are being crushed by mandated screenings for everything from obesity to domestic abuse (see my postBrief is Good”). The whole notion of Quality is arbitrary and paternalistic. Cash practices are appearing and evolving to meet patients’ needs without the mandates of Medicare and the private insurance industry, but are in essence duplicating cost and effort because of Obamacare’s insurance mandate.

2) Our technology was not created with the purpose of speeding up or simplifying documentation so that clinicians can deliver better care. Instead, there was a dual focus of maximizing billing and controlling the “Quality” in clinician performance. Since we basically don’t have a clue, let alone agreement, about what Quality really is (see my 2009 postQuality or Conformity?”), any effort to promote or require Quality through templates and “hard stops” becomes cumbersome and potentially meaningless.

3) Healthcare is still practiced as if we were all solo practitioners without technology, seeing one patient at a time, in person, in the office, which is marginally more efficient than housecalls. So far, we have no incentives to do anything different. A silly example: A patient with perfect blood pressure at home on their internet connected sphygmomanometer doesn’t help my Quality ratings one iota, since my “grade” for the year is the last blood pressure recorded in the office for the calendar year (see my postDon’t Do Chronic Care in December”). And, as the NEJM article points out, there are no financial incentives to have nurses or other non-providers manage routine problems like hypertension in our current system.

Here is an eloquent section of the article by Asch, Nicholson and Berger:

“Information technology is changing medicine, but electronic health records (EHRs) are mostly demonized by clinicians, and the promised customer efficiencies seen in the retail, financial, entertainment, and travel industries have been largely absent in health care.

These approaches will improve with time. It’s worth noting, however, that the transformations seen in other industries have followed a different path. In these cases, aligned financial incentives, better customer centricity, and technology have been motivating and enabling forces for change, but the transformations themselves came from operational changes that enhanced productivity — mostly by finding ways to use fewer people.

The movement from bank tellers to automated teller machines to cashless digital transactions has reduced effort all around. Because of easy-to-use software, fewer people now use travel agents. Yet despite increased use of EHRs by clinicians and smartphones and wireless technology by patients, the fundamental approaches to managing hypertension, diabetes, and chronic lung disease have remained the same for 50 years. The drugs are better, but the way patients engage with doctors during office visits and hospital stays is unchanged.

The physician–patient encounter is health care’s choke point. So long as we continue to think of health care as a service that happens when patients connect with doctors, we shackle ourselves to a system in which increased patient needs must be met with more doctors. Other industries overcame similar constraints in various ways — McDonald’s pioneered a production-line approach to fast food, for example — but more recent transformations have come from facilitated self-service. Taxpayers abandoned tax preparers when TurboTax created a new pathway to what they wanted. Until we invent the TurboTax of health care, we won’t achieve the kind of productivity gains needed for transformative change in quality, access, or cost.”

https://www.nejm.org/doi/full/10.1056/NEJMp1817104

A Country Doctor Reads: May 11, 2019

Soulful Medical Writings

This morning I read a touching essay in The New York Times by an ENT resident at Harvard, Alessandra Colaianni:

https://www.nytimes.com/2019/05/10/well/live/skin-medical-ethics.html?smprod=nytcore-ipad&smid=nytcore-ipad-share

Looking for more of her writings I found a Canadian Journal I will now be checking out on a regular basis:

Ars Medica is a literary journal that explores the interface between the arts and healing, and examines what makes medicine an art.
— Read on ars-medica.ca/index.php/journal/issue/view/29

And then, of course, there is Bellevue Literary Review, edited by a frequent NYT contributor, Danielle Ofri , MD:

Read on blr.med.nyu.edu/content/editors-picks

The Guardian once published a thoughtful piece on the importance of doctors writing about not just diseases but about the human beings who are affected by them:

In the heyday of modernism, doctors lionised specialisation, but patients have now turned to holistic approaches that combine oncology, psychiatry, cardiology, neurology and a variety of alternative treatments. After a long period when we focused primarily on depth of knowledge, we have returned to the importance of breadth of knowledge. In telling the stories of illness, we need to tell the stories of the lives within which illness is embedded. Neither humanism nor medicine can explain much without the other.

A rising literature attempts to reconcile these modes of thought. Voltaire complained, “Doctors are men who prescribe medicines of which they know little, to cure diseases of which they know less, in human beings of whom they know nothing.” But a new run of books attempts to address the last clause of Voltaire’s challenge. Such writings may not be remarkable as either medical information or writing, but they rightly insist that coherence sits at the intersection of science and art.

https://www.theguardian.com/books/2016/apr/22/literature-about-medicine-may-be-all-that-can-save-us

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.

A Country Doctor Reads: April 27, 2019

Hypertension Hot Potato — Anatomy of the Angiotensin-Receptor Blocker Recalls | NEJM

I had not seen any numbers on the magnitude of the cancer risk in the angiotensin receptor blocker recall avalanche. A couple of days ago the New England Journal of Medicine published the number – one new case of cancer per 8000 users of maximum doses for four years:

Although not all products containing valsartan, irbesartan, or losartan that are marketed in the United States have been recalled, the scope of the exposure, the scale of the 20 recalls, and their impact on patient care are substantial (see timeline). FDA officials believe that U.S. patients have been ingesting ARBs containing carcinogenic impurities for approximately 4 years; they estimate that for every 8000 patients taking the highest dose of an affected product for the full 4 years, one new cancer above the background incidence would be expected.
— Read on http://www.nejm.org/doi/full/10.1056/NEJMp1901657

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What we need to talk about when we talk about health – The Lancet

What is it then that we need to talk about when we talk about health? We need to talk about health as a public good, and recognise that health, like all public goods, is inseparable from politics. The reason we have libraries, public parks, a system of public education, and other such goods is because we elected leaders who made political choices to create and maintain these institutions. Public goods were once the centre of political gravity in the USA. Programmes like the New Deal and the Great Society were attempts to leverage a spirit of collective investment into a network of polices and institutions that promote wellbeing at every level of American life. In recent decades, however, the legacy of these programmes have come under attack by a political philosophy that prizes unfettered individualism above all else, even health. This philosophy, which notably informed the Reagan and Thatcher era and has now been eagerly embraced by US President Donald Trump, sees government as a largely harmful influence, and led to a campaign of roll-back and privatisation that has been good for corporations and unfriendly to the policies and institutions that promote health. In the USA, for example, the current administration has, in the name of freeing up the markets, pursued an aggressive dismantling of environmental standards, placing profits over health. It has undermined collective investment in areas like public housing, which it has sought to keep from people in need, and education, which it has worked to privatise. At nearly every turn, it has embraced an ethos of “you’re on your own”, rather than “we’re all in this together”. While the latter may sound idealistic, even utopian, it is nothing of the kind. In fact, it is the only way we can organise ourselves, as a society, if we wish to be healthy. This is especially true at a time of nationalist retrenchment, Brexit, and building walls. When we reject collective effort in favour of ever-deeper divides, we open the door to sickness and shut it to health. More…

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Pills or public health? – The BMJ

Once again, the Brits seem to show a more balanced view on how to treat lifestyle related chronic disease:

How best to tackle the rising tide of non-communicable disease linked to lifestyle, or, more accurately, linked to the environments in which people live? With pills or with traditional public health interventions: healthier food and cleaner air?

The push for pills is strong. As reported by the Science Media Centre, the expert response to NICE’s draft guideline on hypertension has been glowing (http://bit.ly/2IjMEgD). NICE wants to lower the threshold for starting treatment for mild hypertension. All six experts (of whom two declare industry ties and three give no statement of interests at all) welcome the draft guidance. One expert, also quoted in our own news report (doi:10.1136/bmj.l1105), suggests the guidance doesn’t go far enough.
— Read on www.bmj.com/content/365/bmj.l1791

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Rate of Fentanyl Positivity Among Urine Drug Test Results Positive for Cocaine or Methamphetamine. | Substance Use and Addiction | JAMA Network Open |

It is well known that heroin is often spiked with fentanyl, sometimes of great potency, causing overdose deaths. But I have also seen fentanyl in urine drug screens done on patients who admit using cocaine and are very upfront about that. Spiking cocaine with fentanyl exposes opioid naive patients to serious risks. One patient, new to our Suboxone clinic was confronted with such a test result and said, indignantly, “I guess you can’t even trust your drug dealer anymore”.

An increasing number of UDT results positive for cocaine or methamphetamine were also positive for nonprescribed fentanyl. This provides additional insight into recently reported increases in cocaine- and methamphetamine-related overdoses. Stimulant users who may be opioid naive are at a heightened risk of overdose when exposed to fentanyl. Clinicians need to be aware that patients presenting for treatment of suspected drug overdose or substance use disorder may have been exposed, knowingly or unknowingly, to multiple substances, including the combination of stimulants and opioids.
— Read on jamanetwork.com/journals/jamanetworkopen/fullarticle/2731684

A Country Doctor Reads: April 20, 2019

Suppressing The Inward Eye Roll

The Canadian RuralMed listserv, which I was invited to join, had a comment today, inspired by my post “If You Are a Doctor, Act Like One“, Dr. Yogi Sehgal reflected on how seemingly trivial concerns can be very appropriate if you try to understand the context:

“[Dr. Duvefelt’s] post reminds of one of my little practice tips that I have learned over the years to reduce frustration in the ER.

When a patient presents to the ER or the office with a very minor complaint, and the nurse says to you, “OMG, I can’t believe they came to the ER/office with this,” followed by an eyeroll, it’s easy to get jaded or cynical. I find the simple question, “Was there something specific you were worried about?” or “What was it about this that worried you?” is the gist of the “FIFE” questions that we were taught in medical school and do so poorly except on exams. It opens up the discussion about what the real issue is and gives you a chance to educate (doctor, from the Latin “docere”, meaning “to teach”) and feel less cynical or jaded.

Real cases recently:

Patient with a tiny little scratch on their finger which probably doesn’t need a bandaid. “I have a cut I’d like to get checked out.”

You (suppressing inward eyeroll): “Was there something specific you were worried about?”

Patient: “My grandmother died of tetanus from a minor cut like this, my mother died of sepsis from blood infection from a wound like this, I’m worried I’m going to die of this too.”

You: (Aha, now I get it!) “Ok, it sounds like the issue is not your finger so much but your family history. When was your last Td? Screen for anxiety… etc.”

Teenage patient comes to ER (with Mom) with a sore foot that comes and goes for the past week, not an athlete, pain-free now: “I sometimes have a sore foot.”

You (suppressing inward eyeroll): “Was there something specific you were worried about?”

Patient and Mom: “We were worried it had something to do with her congenital hip dysplasia.”

You (Aha, now I get it!): “Ok, sounds like we need to know a bit more about the hip and mechanics of what’s going on.” (Turns out that indeed it likely was partly related to her hip in this case, and she needed to do some PT at home which she had not been doing.)”

(yogi sehgal)

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Sore knee? Maybe You Have a Fabella

The BBC has an interesting little piece about a small extra (sesamoid) bone that seems to be more common now than even just a hundred years ago, even though other sesamoid bones elsewhere in the body are not becoming more common.

The fabella (“little bean” in Latin) can be the cause of knee pain and perineal nerve palsy.

“Between 1918 and 2018, reports of the fabella bone’s existence in the knee increased to the extent that it is now thought to be three times as common as 100 years ago.
The scientists’ analysis showed that in 1918, fabellae were present in 11% of the world population, and by 2018, they were present in 39%.”

https://www.bbc.co.uk/news/health-47950258

The BBC originally picked this item up from a Wiley publication

“Hou (2016) recently investigated the effects of the fabella on posterolateral pain and palsy of common peroneal nerve following total knee arthroplasty. During trials, fabellae were excised from some patients but left in others. Post‐surgery, posterolateral pain and palsy of common peroneal nerve were only observed in patients who still had fabellae. Accordingly, Hou recommended removing the fabella when knee replacement surgery is performed.”

https://onlinelibrary.wiley.com/doi/full/10.1111/joa.12994

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Vaccination is Not Really Just a Personal Decision: People Don’t Understand Herd Immunity -NEJM

I may survive an infectious disease just fine, but what about vulnerable people I come in contact with? The less of it there is going around, the less risk for morbidity and mortality for everyone.

The New England Journal of Medicine editorialized about this:

Exposure to measles in the community certainly represents a danger to high-risk persons during a local outbreak; however, nosocomial transmission may pose an even greater threat and has been reported throughout the world. For example, during a measles outbreak in Shanghai in 2015, a single child with measles in a pediatric oncology clinic infected 23 other children, more than 50% of whom ended up with severe complications, and the case fatality rate was 21%.5 When the umbrella of herd immunity is compromised, such populations are highly vulnerable.
— Read on www.nejm.org/doi/full/10.1056/NEJMp1905099

A Country Doctor Reads: April 13, 2019

Vitamin D as Cancer Therapy? Insights From 2 New Trials – JAMA Network

All right, I’ve been less than enthusiastic, even downright acerbic, about the widespread interest in Vitamin D. I’ve written many times about it. Then I started taking Functional Medicine courses….

This is from this week’s JAMA:

It may be tempting to interpret the preliminary findings regarding recurrence- and progression-free survival as specific antineoplastic effects of vitamin D3 supplementation. However, higher vitamin D levels have been associated with substantially decreased mortality and morbidity among hospitalized patients with a range of nonneoplastic diseases as well as with cancer.14-16 Thus, the findings of the 2 trials may reflect relatively broad biological effects of vitamin D.

In summary, the SUNSHINE and AMATERASU clinical trials reported in this issue of JAMA provide new information regarding the potential use of vitamin D among patients with colorectal cancer and other luminal gastrointestinal malignancies. Confirmatory trials are needed to evaluate these preliminary findings, ideally with longer follow-up to obtain better estimates of effects on survival as well as biological measurements to clarify underlying mechanisms.

— Read on jamanetwork.com/journals/jama/fullarticle/2730095

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Billion dollar Medicare Fraud depends on doctors signing papers without reading – The New York Times

In this day of electronic medical records, we still get a lot of paper to sign, and we really never have time to read much of it. Home Health nursing orders require a signature on every single spaced page, for example.

This week, the New York Times wrote about the billion dollar market for fraudulent prescriptions for a back braces etc. I get these often, always return faxed with the comment “MEDICARE FRAUD!”, and I also get prescriptions “needing” my signature for compounded enormously expensive pain creams.

www.nytimes.com/2019/04/09/us/billion-dollar-medicare-scam.html

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Leonardo da Vinci – The Lancet

We may laugh or shrug at the Brits, but when it comes to their medical journals, I am always impressed by their depth, from both a humanistic and historical perspective. Last week’s The Lancet has a nice article about Leonardo da Vinci:

“It is a sobering thought”, said the satirist Tom Lehrer, “that when Mozart was my age he had been dead for 2 years”. Leonardo di ser Piero da Vinci lived almost twice as long as Wolfgang Amadeus Mozart, but his life and work provoke an even deeper sense of hopeless awe. Leonardo made three of the most influential and most parodied artworks in history—the Mona Lisa, The Last Supper, and his sketch of Vitruvian Man. Throughout his life, he kept notebooks, works of art in themselves, crammed with crisp observations and lists of questions from every field of life. No-one, wrote Giorgio Vasari in his gossipy biography of the Renaissance masters, was ever his peer in “vivacity, excellence, beauty and grace”. What can we do but throw up our hands and call him a genius?

More snippets from this wonderful article:

“the four universal conditions of man”—joy, weeping, fighting, and labour..

… he began the Mona Lisa and the Salvator Mundi, and became the subject of intense jealousy from the young Michelangelo…

True to form, he left behind a mess: unfinished paintings, flaking murals, and a heap of manuscripts that took centuries to sort—a fitting memorial for what the art historian Kenneth Clark called “the most relentlessly curious man in history”. But the “disciple of experience”, as he once signed himself, also left a humanist paradise in paint and ink, revealing the world as it might have wished to depict itself.

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Stress related disorders and risk of cardiovascular disease: population based, sibling controlled cohort study – The BMJ

This population based, sibling controlled analysis showed a clear association between clinically confirmed stress related disorders and a higher subsequent risk of cardiovascular disease, particularly during the months after diagnosis of a stress related disorder, in the Swedish population. This association applies equally to men and women and is independent of familial factors, history of somatic/psychiatric diseases, and psychiatric comorbidities. These findings call for enhanced clinical awareness and, if verified, monitoring or early intervention among patients with recently diagnosed stress related disorders.
— Read on www.bmj.com/content/365/bmj.l1255

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Writing the body – The Lancet

The Lancet offers free access to some of its articles by just signing up. This week has an interesting book review:

Ned Beauman argues for the utility of the appendix, arguing in favour of the theory that in less hygienic times it served as a reservoir for helpful bacteria, ready to repopulate our insides after infection had purged us. Appendicitis, he says, is the mark of an immune system “deranged by tedium”.
— Read on www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)30801-3/fulltext


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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