Wednesday, September 18, 2019

The Heart of a Swimmer vs. the Heart of a Runner - The New York Times

Do world-class swimmers' hearts function differently than the hearts of elite runners?

A new study finds that the answer may be yes, and the differences, although slight, could be telling and consequential, even for those of us who swim or run at a much less lofty level.

Cardiologists and exercise scientists already know that regular exercise changes the look and workings of the human heart. The left ventricle, in particular, alters with exercise. This chamber of the heart receives oxygen-rich blood from the lungs and pumps it out to the rest of the body, using a rather strenuous twisting and unspooling motion, as if the ventricle were a sponge being wrung out before springing back into shape.

Exercise, especially aerobic exercise, requires that considerable oxygen be delivered to working muscles, placing high demands on the left ventricle. In response, this part of the heart in athletes typically becomes larger and stronger than in sedentary people and functions more efficiently, filling with blood a little earlier and more fully and untwisting with each heartbeat a bit more rapidly, allowing the heart to pump more blood more quickly.

While almost any exercise can prompt remodeling of the left ventricle over time, different types of exercise often produce subtly different effects. A 2015 study found, for instance, that competitive rowers, whose sport combines endurance and power, had greater muscle mass in their left ventricles than runners, making their hearts strong but potentially less nimble during the twisting that pumps blood to muscles.

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https://www.nytimes.com/2019/04/03/well/move/heart-health-swimming-running-exercise.html?

Monday, September 9, 2019

As ER Wait Times Grow, More Patients Leave Against Medical Advice | Kaiser Health News

Emergency room patients increasingly leave California hospitals against medical advice, and experts say crowded ERs are likely to blame.

About 352,000 California ER visits in 2017 ended when patients left after seeing a doctor but before their medical care was complete. That's up by 57%, or 128,000 incidents, from 2012, according to data from the Office of Statewide Health Planning and Development.

Another 322,000 would-be patients left the emergency room without seeing a doctor, up from 315,000 such episodes in 2012.

Several hospital administrators said overcrowding is a likely culprit for the trend. California emergency room trips grew by almost 20%, or 2.4 million, from 2012 to 2017.

Moreover, ER wait times also increased for many during that time period: In 2017, the median ER wait time for patients before admission as inpatients to California hospitals was 336 minutes — or more than 5½ hours. That is up 15 minutes from 2012, according to the federal Centers for Medicare & Medicaid Services. The median wait time for those discharged without admission to the hospital dropped 12 minutes over that period, but still clocked in at more than 2½ hours in 2017.

California wait times remain higher than the national average. In 2017, the median length of a stay in the ER before inpatient admission nationwide was 80 minutes shorter than the median stay in California. Four states — Maryland, New York, New Jersey and Delaware — had even longer median wait times.

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https://khn.org/news/as-er-wait-times-grow-more-patients-leave-against-medical-advice/

Walking on Eggshells in Medical Schools - The New York Times

I trained to be a doctor in the bad old days — not the worst old days, but the bad old days. Humiliation was part of the deal, sometimes deliberately inflicted by certain grandstanding, sadistic attending physicians, sometimes more casually, because everyone could see that you didn't know something you should have known.

Now we are aware of the consequences of harassment and unconscious bias, and we are trying to give medical students room to learn and grow — but many medical students and residents continue to experience harassment and discrimination and bullying. At the same time, some faculty members worry that they cannot discuss difficult subjects, or give negative feedback of any kind, for fear of upsetting students. In other words, though the training environment now looks much gentler to those of us who trained in the bad old days, we still don't seem to be consistently getting it right.

In August, a commentary in JAMA Pediatrics addressed the intrinsic complication that medical training inevitably makes people uncomfortable: "Walking on Eggshells With Trainees in the Clinical Learning Environment — Avoiding the Eggshells Is Not the Answer." You can't avoid the eggshells, they argue, because medicine is going to bring you up against difficult situations and tricky conversations, and also because part of the responsibility of those who train doctors is to tell them when they're messing up.

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https://www.nytimes.com/2019/09/09/well/family/walking-on-eggshells-in-medical-schools.html

Wednesday, August 28, 2019

Why Doctors Still Offer Treatments That May Not Help - The New York Times

When your doctor gives you health advice, and your insurer pays for the recommended treatment, you probably presume it's based on solid evidence. But a great deal of clinical practice that's covered by private insurers and public programs isn't.

The British Medical Journal sifted through the evidence for thousands of medical treatments to assess which are beneficial and which aren't. According to the analysis, there is evidence of some benefit for just over 40 percent of them. Only 3 percent are ineffective or harmful; a further 6 percent are unlikely to be helpful. But a whopping 50 percent are of unknown effectiveness. We haven't done the studies.

Sometimes uncertain and experimental treatments are warranted; patients may even welcome them. When there is no known cure for a fatal or severely debilitating health condition, trying something uncertain — as evidence is gathered — is a reasonable approach, provided the patient is informed and consents.

"We have lots of effective treatments, many of which were originally experimental," said Dr. Jason H. Wasfy, an assistant professor of medicine at Harvard Medical School and a cardiologist at Massachusetts General Hospital. "But not every experimental treatment ends up effective, and many aren't better than existing alternatives. It's important to collect and analyze the evidence so we can stop doing things that don't work to minimize patient harm."

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https://www.nytimes.com/2019/08/26/upshot/why-doctors-still-offer-treatments-that-may-not-help.html?

Monday, August 26, 2019

This Daily Pill Cut Heart Attacks by Half. Why Isn’t Everyone Getting It? - The New York Times

Giving people an inexpensive pill containing generic drugs that prevent heart attacks — an idea first proposed 20 years ago but rarely tested — worked quite well in a new study, slashing the rate of heart attacks by more than half among those who regularly took the pills.

If other studies now underway find similar results, such multidrug cocktails — sometimes called "polypills" — given to vast numbers of older people could radically change the way cardiologists fight the soaring rates of heart disease and strokes in poor and middle-income countries

Even if the concept is ultimately adopted, there will be battles over the ingredients. The pill in the study, which involved the participation of 6,800 rural villagers aged 50 to 75 in Iran, contained a cholesterol-lowering statin, two blood-pressure drugs and a low-dose aspirin.

But the study, called PolyIran and published Thursday by The Lancet, was designed 14 years ago. More recent research in wealthy countries has questioned the wisdom of giving some drugs — particularly aspirin — to older people with no history of disease.

The stakes are high. As more residents of poor countries survive childhood into middle age and beyond — and as rising incomes contribute to their adoption of cigarette smoking and diets high in sugar and fat — a polypill offers a way to help millions lead longer, healthier lives.

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https://www.nytimes.com/2019/08/22/health/heart-disease-iran-study.html

Sunday, July 28, 2019

What Happens When Lyme Disease Becomes an Identity?

Polly Murray, in the 1960s and '70s, was a mother of four with an old house on several acres in Lyme, Connecticut. In the summer, her kids built forts in the woods; they ice-skated on frozen cow ponds in the winter. The Murrays had an idyllic life in the country. They also had enormous rashes, strange joint swellings, and recurrent fevers.

One son wound up in the infirmary at boarding school, unable to lift his leg. Another had to have the fluid drained from his knee. Murray was constantly taking herself or her husband or one of her kids to a doctor — but none of the doctors ever had answers, nor did they seem especially interested in finding any. So Murray took the search upon herself. In The Widening Circle, her 1996 memoir, she reproduces extracts from her diary ("Monday, July 28: Todd had a fever of 100 again for two days and a severe jaw ache; he said it hurt to open his mouth … The attack lasted for five days"). The record Murray gathered is a testament to both the relentlessness of the symptoms and her own relentlessness in tracking them. Her husband compares her to "the lonely hero of a Hitchcock movie": isolated, embattled, and disbelieved.

Soon, though, Murray started to hear other stories like hers. Her area, it appeared, had a cluster of juvenile-rheumatoid-arthritis cases. She called the state's health department and met with Dr. Allen Steere, a rheumatologist doing a fellowship at Yale. He pored over her pages of notes. On the car ride home, Murray wept with joy: Steere didn't have any answers, but he had listened. He wanted to find out what was wrong. By 1976, the condition Murray had observed had become known as Lyme disease.

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https://www.thecut.com/2019/07/what-happens-when-lyme-disease-becomes-an-identity.html?

Saturday, July 27, 2019

Physician burnout and medical breakthroughs: a patient's story - STAT

I entered my doctor's exam room worried about my health. I exited worried about his.

A lack of pressure when he placed the stethoscope over my heart. His ghost-eyed look when I spoke. His nearly inaudible voice. All of this registered as the most severe depletion of spirit — or what is sometimes and inadequately referred to as burnout — I'd seen in one of my doctors. And I've seen a lot of doctors over the years.

When I was 32, I was diagnosed with ovarian cancer. Lucky enough to survive, I spent several years housebound as I grappled with the fallout from chemotherapy. Tanking blood pressure levels. Hours spent lying on my hardwood floor to avert blacking out instead of legging it out the door to work. Innumerable texts to family and friends that started with "V sorry to cancel."

Trying to identify why my pre-cancer health had not returned and how to get it back, I gunned it to doctors' offices with an I'll-do-anything-to-get-better mindset.

I believe that the diagnoses and treatments I ultimately and thankfully received would have been made years earlier had my doctors been empowered to dedicate themselves to my case with a singular focus instead of being pulled in disparate directions. In a nutshell, I was unable to get well while my doctors' wells were empty.

Although faced with what three primary care physicians described in a recent First Opinion as "the corporatization and bureaucratization of medical practice, which impinges on our professional autonomy, leaving us less flexibility to do what needs to be done for each patient," most of the doctors I saw have done what Dr. Danielle Ofri referred to in her nerve-hitting New York Times op-ed last month: "An overwhelming majority do the right thing for their patients, even at a high personal cost."

More ….


https://www.statnews.com/2019/07/26/physician-burnout-and-medical-breakthroughs-a-patients-story/

This college dropout was bedridden for 11 years. Then he invented a surgery and cured himself - CNN

Doug Lindsay was 21 and starting his senior year at Rockhurst University, a Jesuit college in Kansas City, Missouri, when his world imploded.

After his first day of classes, the biology major collapsed at home on the dining room table, the room spinning around him.

It was 1999. The symptoms soon became intense and untreatable. His heart would race, he felt weak and he frequently got dizzy. Lindsay could walk only about 50 feet at a time and couldn't stand for more than a few minutes.

"Even lying on the floor didn't feel like it was low enough," he said.

The former high school track athlete had dreamed of becoming a biochemistry professor or maybe a writer for "The Simpsons."

Instead, he would spend the next 11 years mostly confined to a hospital bed in his living room in St. Louis, hamstrung by a mysterious ailment.

Doctors were baffled. Treatments didn't help. And Lindsay eventually realized that if he wanted his life back, he would have to do it himself.

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https://www.cnn.com/2019/07/27/health/doug-lindsay-invented-surgery-trnd/

Thursday, July 25, 2019

American Medical Students Less Likely To Choose To Become Primary Care Doctors | Kaiser Health News

Despite hospital systems and health officials calling out the need for more primary care doctors, graduates of U.S. medical schools are becoming less likely to choose to specialize in one of those fields.

A record-high number of primary care positions was offered in the 2019 National Resident Matching Program — known to doctors as "the Match." It determines where a medical student will study in their chosen specialty after graduation. But this year, the percentage of primary care positions filled by fourth-year medical students was the lowest on record.

"I think part of it has to do with income," said Mona Signer, the CEO of the Match. "Primary care specialties are not the highest paying." She suggested that where a student gets a degree also influences the choice. "Many medical schools are part of academic medical centers where research and specialization is a priority," she said.

The three key primary care fields are internal medicine, family medicine and pediatrics. According to the 2019 Match report, 8,116 internal medicine positions were offered, the highest number on record and the most positions offered within any specialty, but only 41.5% were filled by seniors pursuing their M.D.s from U.S. medical schools. Similar trends were seen this year in family medicine and pediatrics.

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https://khn.org/news/american-medical-students-less-likely-to-choose-to-become-primary-care-doctors/

Monday, July 8, 2019

The Challenge of Caring for a Stroke Patient - The New York Times

Kelly Baxter was 36 years old and had just moved to Illinois with her 41-year-old husband, Ted, when he suffered a disabling stroke that derailed his high-powered career in international finance. It derailed her life as well.

"It was a terrible shock, especially in such a young, healthy, athletic man," she told me. "Initially I was in denial. He's this amazing guy, so determined. He's going to get over this," she thought.

But when she took him home six weeks later, the grim reality quickly set in. "Seeing him not able to speak or remember or even understand what I said to him — it was a very scary, lonely, uncertain time. What happened to my life? I had to make big decisions without Ted's input. We had been in the process of selling our house in New Jersey, and now I also had to put our Illinois house on the market and sell two cars."

But those logistical problems were minor in comparison to the steep learning curve she endured trying to figure out how to cope with an adult she loved whose brain had suddenly become completely scrambled. He could not talk, struggled to understand what was said to him, and for a long time had limited use of the right side of his body.

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https://www.nytimes.com/2019/07/08/well/live/stroke-patient-caregiver.html