Wednesday, July 1, 2015

NYTimes: The Real Problem With Medical Internships

APROXIMATELY 26,000 newly minted doctors across the United States will begin their internships today. For many, this legendarily grueling year will be the most trying time of their professional lives. Most will spend it in a state of perpetual exhaustion, as near ascetics with regard to family, friends and other pleasures. I was an intern nearly 20 years ago, but I still remember it the way soldiers remember war.
Fortunately for today's interns, regulations have since reduced some of the misery. Most interns now are not permitted to work shifts longer than 16 hours. They are also encouraged to nap while on overnight duty.
At first glance, such reforms make sense. Studies have found that doctors who got no sleep during a night on call scored lower on tests of simple reasoning, response time, concentration and recall. Indeed, a single night of continuous sleep deprivation has been shown to be roughly equivalent to having a blood alcohol level of 0.10 percent — that is, being drunk.
But there is a downside to these regulations. Limits on work hours lead to frequent patient handoffs, which are susceptible to breakdowns in communication between doctors, thus potentially creating errors. In aviation, most crashes occur on takeoff and landing, and in medicine, too, most mistakes happen during transitions.

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Sunday, June 28, 2015

A Sea Change in Treating Heart Attacks - The New York Times

Yvette Samuels was listening to jazz late one night when she felt a stabbing pain down her left shoulder. She suspected a heart attack — she had heard about the symptoms from watching a Rosie O'Donnell standup routine on television — and managed to scratch on the door that connected her single room to her neighbor's. He found her collapsed on the floor.

Paramedics arrived minutes later and slapped electrocardiogram leads on her chest, transmitting the telltale pattern of a heart attack to Our Lady of Lourdes Medical Center here.

As the ambulance raced through the streets, lights swirling, sirens screaming, Ms. Samuels, who took phone orders for a company that delivers milk, asked the paramedic, "Can this kill me?" He murmured yes, then told the driver, "Step on it!" She thought to herself, "This will be my last view of the world, the last time I will see the night sky."

Instead, she survived, her heart undamaged, the beneficiary of the changing face of heart attack care. With no new medical discoveries, no new technologies, no payment incentives — and little public notice — hospitals in recent years have slashed the time it takes to clear a blockage in a patient's arteries and get blood flowing again to the heart.

The changes have been driven by a detailed analysis of the holdups in treating patients and a nationwide campaign led by the American College of Cardiology, a professional society for specialists in heart disease, and the American Heart Association. Hospitals across the country have adopted common-sense steps that include having paramedics transmit electrocardiogram readings directly from ambulances to emergency rooms and summoning medical teams with a single call that sets off all beepers at once.

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Monday, June 22, 2015

How Doctors Die - Zócalo Public Square

Years ago, Charlie, a highly respected orthopedist and a mentor of mine, found a lump in his stomach. He had a surgeon explore the area, and the diagnosis was pancreatic cancer. This surgeon was one of the best in the country. He had even invented a new procedure for this exact cancer that could triple a patient's five-year-survival odds–from 5 percent to 15 percent–albeit with a poor quality of life. Charlie was uninterested. He went home the next day, closed his practice, and never set foot in a hospital again. He focused on spending time with family and feeling as good as possible. Several months later, he died at home. He got no chemotherapy, radiation, or surgical treatment. Medicare didn't spend much on him.

It's not a frequent topic of discussion, but doctors die, too. And they don't die like the rest of us. What's unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.

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Friday, June 12, 2015

See Images From the ‘Instagram for Doctors’ -- Science of Us

In 1786, a lengthy caravan of mules journeyed from Florence to Vienna carrying a thousand or so anatomical wax models, among them a recumbent "Medical Venus." Possessing a mermaid's head of golden hair, the sorry goddess had been sliced from sternum to stomach, yet still wore her pearls. She and her colleagues were exhibited for the education of medical students as well as the gawking of a prurient public. The models had been a special commission for the Italian sculptor Clemente Susini, later praised for "the beauty he gave to the most revolting things."

And so it is with Figure 1, a free medical photo-sharing app — "Instagram for doctors." Who knew a portrait of an #ingrown-toenail removal could be so gorgeously gory: the tender alabaster big toe, bloody and raw where half the nail has been sliced off, the remaining half with its shimmering silvery chipped polish worn down to nearly nothing, and a few unkempt hairs puncturing the glamour.

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Wednesday, June 10, 2015

Common heartburn medications linked to greater risk of heart attack - The Washington Post

A novel data-mining project reveals evidence that a common group of heartburn medications taken by more than 100 million people every year is associated with a greater risk of heart attacks, Stanford University researchers reported Wednesday.

After combing through 16 million electronic records of 2.9 million patients in two separate databases, the researchers found that people who take the medication to suppress the release of stomach acid are 16 percent to 21 percent more likely to suffer myocardial infarction, commonly known as heart attack.

Because of its design, the study could not show cause and effect, but the researchers did claim that if their technology had been available, "such pharmacovigilance algorithms could have flagged this risk as early as the year 2000."


Sunday, June 7, 2015

Painkillers Resist Abuse, but Experts Still Worry -

Anthony DiTullio would pop a painkiller in his mouth but not just swallow it, as intended. He would chew it for 30 minutes, grinding through its protective coating and waxy unpleasantness, because the only pain he was treating was addiction.

The pill was OxyContin, a painkiller that its manufacturer, Purdue Pharma, says deters abuse by being difficult to chew or liquefy into forms that give addicts stronger highs, orally or through injection. Since adding these features to its original and widely abused OxyContin in 2010, the company has likened the pill to a virtual seatbelt to restrain the nation's epidemic of prescription drug abuse.

But as thousands of addicts still find ways to abuse OxyContin and similar painkillers, called abuse-deterrent formulations, some experts caution that the protections are misunderstood and could mislead both users and prescribers into thinking that the underlying medications are less addictive.

Because abuse-deterrent formulations are relatively new, preliminary data on their public-health implications is limited. Several studies, somesponsored by Purdue, have found that abuse of OxyContin specifically has decreased after its protections were added. Other reports confirmed those findings but also found that many abusers simply moved on to other opioids, as well as heroin, leaving the overall effect on drug abuse open for debate.

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Tuesday, June 2, 2015

Study: Nearly third of teens changed health habits based on online search - The Washington Post

Some good news about teens and the Internet: Many switch to healthier habits after consulting the Web.

In the first national study in more than a decade to look at how adolescents use digital tools for health information, nearly one-third of teenagers said they used online data to improve behavior — such as cutting back on drinking soda, using exercise to combat depression and trying healthier recipes — according to a study to be released Tuesday by researchers at Northwestern University.

Although it's common to hear about "all the negative things kids are doing online," the study highlights the importance of making sure there is accurate, appropriate and easily accessible information available to teens, "because it's used and acted upon," said Ellen Wartella, director of Northwestern's Center on Media and Human Development and lead author of the report.

Researchers also found that nearly one-quarter of teens were going online to look for information about health conditions affecting family or friends. While most teens rely on digital resources to learn more about puberty, drugs, sex and depression, among other issues, a surprising 88 percent said they did not feel comfortable sharing their health concerns with friends on Facebook or on other social networking sites.

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Cancer trial to begin targeting tumors by mutations, not location - The Washington Post

The National Cancer Institute's announcement Monday that it will soon begin a nationwide trial to test treatments based on the genetic mutations in patients' tumors, rather than on where the tumors occur in the body, highlights a profound shift taking place in the development of cancer drugs.

Researchers increasingly are using DNA sequencing, which has become far faster and cheaper over time, to identify molecular abnormalities in cancers. That technology is allowing them to develop drugs they hope will prove more effective in specific sets of patients and to design clinical trials that get the most promising drugs to market more quickly. 

"We are truly in a paradigm change," James H. Doroshow, director of the division of cancer treatment and diagnosis at the NCI, said in announcing the initiative Monday. He called the project "the largest and most rigorous precision oncology trial that's ever been attempted."

Traditionally, drug trials have focused on cancers in specific organs, such as the lungs or prostate. But that model is being upended by newer approaches such as basket trials, which group together patients with similar genetic mutations, regardless of the location of their cancers.

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Monday, June 1, 2015

Top Oncologist To Convention Of Doctors, Pharma Execs: New Cancer Treatments Cost Too Damn Much - Forbes

Will anything ever curb the runaway growth in the cost of breakthrough cancer drugs?

Eleven years ago, I wrote about a Memorial Sloan Kettering oncologist named Leonard Saltz who, after helping to develop some of the most important drugs for colon cancer, had gotten a bad case of sticker shock. The new breakthroughs were simply too expensive, he insisted. "Sooner or later the bubble is going to pop," he told me.

He was dead wrong. As 29% of my life so far passed by, two things changed: the new cancer medicines got more promising, and they got way more expensive. So there I was yesterday listening to him give a blistering talk on high cancer drug prices to thousands of oncologists at the annual meeting of the American Society of Clinical Oncology.

The prices will make your nose bleed. Take the exciting new medicines that unleash the immune system against tumors. A combination of two Bristol-Myers Squibb BMY +2.91%drugs dramatically shrank melanoma. By Saltz's calculations, that will cost $295,566 for the average patient. Merck 's immune system drug Keytruda showed promise in colorectal, gastric, and esophageal tumors. But if doctors adopted the 10-milligram-per-kilogram dose of Keytruda used in several New England Journal of Medicine papers, it would cost $1,000,000 to treat a 165-pound patient.

Saltz is an evangelist, and it's possible to take issue with his numbers. He uses an average selling price for the Bristol drugs; using their list prices gives a figure closer to $280,000, and we could discount it as much as 30% because so many patients have to stop the treatments because of side effects. (In one demonstration of how great these drugs are, many of those patients still get a benefit as their immune systems continue to attack their cancer.)

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Saturday, May 30, 2015

NYTimes: Smuggling a Beer for My Hospital Patient

My pager went off late one afternoon with a message from the oncology service at my hospital, asking me to see a 70-year-old man with metastatic cancer and trouble breathing. I wasn't hopeful. I had chosen to train in pulmonary and critical care medicine because I wanted to be someone who saved lives. But, it turned out, there was so much sickness I couldn't fix.
The patient had worked as a mechanic. Vague pain led to a diagnosis of colon cancer that had traveled to his liver and lungs. Now, he was short of breath and might have pneumonia. His team was asking me to arrange a procedure, called a bronchoscopy, in which we insert a small tube with a camera at the end down the throat in order to look inside the lungs and suck out a deep sample to help find out what's going wrong.
"We'll get him on the schedule for tomorrow," I sighed, suspecting that nothing I did would make him better. "No food or drink after midnight."
In the waiting area outside the procedure suite the next morning, I went through the usual consent forms. He would be asleep for the procedure, thanks to sedative drugs we would run through the intravenous line. We would make him feel pretty good, but he would remember none of it. "Just imagine a really good martini – or two or three," I joked.
It was the first time I had noticed my patient smile. "You know, I'm more of a Guinness man myself," he said.

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