Tuesday, November 27, 2018

Implant Files - AP

Led by the International Consortium of Investigative Journalists, reporters from more than 50 news organizations, including The Associated Press, examined how medical devices are developed, approved and monitored. One universal truth: patients are often the last to know when there's a problem.


Thursday, November 15, 2018

A Patient Complained About The Cost Of Her Medical Care. Here's How Her Doctor Responded - Forbes

The oncologist had prescribed Xgeva hoping it would strengthen her bones while also delaying the progression of Angela Kahn's breast cancer. But Kahn (a pseudonym) couldn't get over the price of the drug. Before the oncologist had a chance to ask how she was feeling, she blurted out that the medication cost "$15,000 a shot." "That's crazy," the oncologist replied, continuing by saying the price "fits right in with the rest of the insanity" of U.S. healthcare pricing. At that price, Kahn concluded, "I don't think I should get it."

The oncologist assured her "You're getting it," and they both laughed.

Not that either thought Xgeva's price was a laughing matter. In fact, like many medications, Xgeva costs much more in the U.S. than in any other developed countries, with a single injection costing more than $2,000.

There's too many reasons for these high prices to delve into them in the space of a short essay. Instead, I want to show how the insanity of American healthcare prices played out in this one, real oncology appointment. (Note: The appointment was recorded by a marketing company, Verilogue Inc., with the permission of the doctor and patient. I gained access to an anonymized transcript of the appointment for a research project approved by the Duke University IRB.)

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Saturday, November 10, 2018

Laura Levis died outside a Boston-area ER. The doors were locked. Why? - The Boston Globe

SEPTEMBER 16, 2016, 4:23:59 A.M.

911 operator: "This line is recorded. Where is your emergency?"

Laura: "I'm at Somerville Hospital."

911 operator: "I'm sorry. Where are you?"

Laura: "Somerville Hospital."

911 operator: "OK, what's the emergency?"

Laura: "I'm having an asthma attack. I'm dying."

911 operator: "Whereabouts are you at the hospital?"

Laura: "Emergency room."

911 operator: "OK."

Laura: "I can't get in."

911 operator: "Let me get you into Somerville. You're outside?"

Laura: "Mm-hm."

911 operator: "Are you in the parking lot?"

Laura: "Yeah."

911 operator: "Are you in a vehicle?"

Laura: "No. I'm just outside it."

911 operator: "At the door?"

Laura: "Asthma. Asthma."

911 operator: "Are you at the door?"

Laura: "Yeah."

911 operator: "Yes?"

Laura: "Yes, I'm just at the door. I feel like I'm dying."

* * *

MY NAME IS Peter DeMarco, and I am Laura's husband. And I didn't know any of this.

When I finally arrived at the emergency room that morning, I was told that Laura never made it there. That she collapsed on a street leading to CHA Somerville Hospital, or possibly in a parking lot on the outskirts of the property. No one in the emergency room could tell me the full story, as there had been a shift change at 7 a.m., and everyone who'd treated her was gone. All they knew was that my wife had called 911 just after 4 a.m., before she lost consciousness, but she wasn't able to give her exact location.

It took emergency responders a long time to find her, they told me.

"She was in the last place they looked," someone in the emergency room said.

Some 10 minutes passed between the time Laura called 911 and the time she was found, in cardiac arrest following a devastating asthma attack. Those 10 minutes meant her life.

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Wednesday, November 7, 2018

What if the Placebo Effect Isn’t a Trick? - The New York Times

The Chain of Office of the Dutch city of Leiden is a broad and colorful ceremonial necklace that, draped around the shoulders of Mayor Henri Lenferink, lends a magisterial air to official proceedings in this ancient university town. But whatever gravitas it provided Lenferink as he welcomed a group of researchers to his city, he was quick to undercut it. "I am just a humble historian," he told the 300 members of the Society for Interdisciplinary Placebo Studies who had gathered in Leiden's ornate municipal concert hall, "so I don't know anything about your topic." He was being a little disingenuous. He knew enough about the topic that these psychologists and neuroscientists and physicians and anthropologists and philosophers had come to his city to talk about — the placebo effect, the phenomenon whereby suffering people get better from treatments that have no discernible reason to work — to call it "fake medicine," and to add that it probably works because "people like to be cheated." He took a beat. "But in the end, I believe that honesty will prevail."

Lenferink might not have been so glib had he attended the previous day's meeting on the other side of town, at which two dozen of the leading lights of placebo science spent a preconference day agonizing over their reputation — as purveyors of sham medicine who prey on the desperate and, if they are lucky, fool people into feeling better — and strategizing about how to improve it. It's an urgent subject for them, and only in part because, like all apostate professionals, they crave mainstream acceptance. More important, they are motivated by a conviction that the placebo is a powerful medical treatment that is ignored by doctors only at their patients' expense.

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Sunday, October 21, 2018

All His Symptoms Pointed Toward the Flu. But the Test Was Negative. - The New York Times

"I think I'm losing this battle," the 58-year-old man told his wife one Saturday night nearly a year ago. While she was at the theater — they'd bought the tickets months earlier — he had to crawl up the stairs on his hands and knees to get to bed. Terrible bone-shaking chills racked him, despite the thick layer of blankets. The chills were followed by sudden blasts of internal heat and drenching sweats that made him kick off the covers — only to haul them back up as the cycle repeated itself.

"I need to go to the E.R.," he told his wife. He'd been there three times already. They'd give him intravenous fluids and send him home with the diagnosis of a viral syndrome. He would start to feel better soon, he was told. But he didn't.

This all began nine days before. That first day he called in sick to his job as a physical therapist. He felt feverish and achy, as if he had the flu. He decided to drink plenty of fluids, take it easy and go back to work the next day. But the next day he felt even worse. That's when the fever and chills really kicked in. He was alternating between acetaminophen and ibuprofen, but the fever never let up. He'd started sleeping in the guest room because his sweat was soaking the sheets, and his chills shook the bed, waking his wife.

After three days of this, he made his first visit to the Yale New Haven Hospital emergency room. He was already taking antibiotics. Several weekends earlier, he developed a red, swollen elbow and went to an urgent-care center, where he was started on one antibiotic for a presumed infection. He took it for 10 days, but his elbow was still killing him. He went back to urgent care, where he was started on a broader-spectrum drug, which he had nearly finished. Now his elbow was fine. It was the rest of his body that ached as if he had the flu.

But at the hospital, his flu swab was negative. So was his chest X-ray. It was probably just a virus, he was told. He should take it easy until it passed. And come back if he got any worse.

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Thursday, October 18, 2018

About Tissue Chip | National Center for Advancing Translational Sciences

Approximately 30 percent of promising medications have failed in human clinical trials because they are found to be toxic despite promising pre-clinical studies in animal models. About 60 percent of candidate drugs fail due to lack of efficacy.

To address this problem, NCATS, through its Tissue Chip for Drug Screening program, along with other NIH Institutes and Centers, the Defense Advanced Research Projects Agency (DARPA) and the Food and Drug Administration (FDA), leads the development of 3-D platforms engineered to support living human tissues and cells, called tissue chips or organs-on-chips.

Tissue chip devices are designed as accurate models of the structure and function of human organs, such as the lung, liver and heart. Once developed and integrated, researchers can use these models to predict whether a candidate drug, vaccine or biologic agent is safe or toxic in humans in a faster and more effective way than current methods.

The ultimate goal of the program is to accelerate the translation of basic discoveries into the clinic. By creating an integrated human body-on-a-chip, researchers can test the varied potential effects of a substance like a drug across the entire body before any testing in humans.

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Wednesday, October 17, 2018

For Doctors, Delving Deeper as a Way to Avoid Burnout - The New York Times

The anatomy laboratory was always freezing. This was our first course as medical students, and we had split ourselves into groups — four students to every cluster. Each of us carried a copy of "Netter's Anatomy"; by the end of three months in the lab, the volume would become chemically yellowed by formaldehyde, and to leaf through the tawny, crackling pages would be to feel your fingers becoming slowly embalmed. Our group had three men — me, S. and B. — and a woman, G. We "shared" a 60-something female cadaver whose name we knew by only her initials: M.C. She had died, we were told, of metastatic breast cancer. Eventually, as we dissected her body, we would find misshapen deposits of that cancer in her brain, liver and bones.

We met twice a week in the chilly anatomy lab and had lectures, twice a week, in an auditorium downstairs (each of us was also given a real human skull, in a lacquered mahogany box, to take home to study. "A Gift of Dr. Goldberger, M.D.," mine said, although I didn't know whether he had merely purchased the box or donated his cranium). There's the old, apocryphal story about the law-school professor who announces: "Look to your left and look to your right. One of you is going to flunk out of this school." But in medicine, we would soon learn, the danger wasn't flunking out of school. It was a phenomenon called burnout — being propelled to leave the profession after years, or even decades, of training and practice. "Look to your left and look to your right," the anatomy instructor might have said one morning. "One of you is going to flunk out of your medical life."

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Tuesday, October 9, 2018

Primary care doctors aren't so important to millenials - The Washington Post

Calvin Brown doesn't have a primary care doctor — and the peripatetic 23-year-old doesn't want one.

Since his graduation last year from the University of San Diego, Brown has held a series of jobs that have taken him to several California cities. "As a young person in a nomadic state," Brown said, he prefers finding a walk-in clinic on the rare occasions when he's sick.

"The whole 'going to the doctor' phenomenon is something that's fading away from our generation," said Brown, who now lives in Daly City outside San Francisco. "It means getting in a car [and] going to a waiting room." In his view urgent care, which costs him about $40 per visit, is more convenient "like speed dating. Services are rendered in a quick manner."

Brown's views appear to be shared by many millennials, the 83 million Americans born between 1981 and 1996, who constitute the nation's biggest generation. Their preferences — for convenience, fast service, connectivity and price transparency — are upending the time-honored model of office-based primary care.

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Friday, October 5, 2018

Brain Scans Can Detect Who Has Better Skills - WSJ

To gain new insight into how highly specialized workers learn skills or react to stressful situations, researchers are leveraging advanced scanning technologies to look at what's happening inside the brain.

In the latest findings, a team of researchers studied surgeons as they performed surgical simulations and found they could identify novice from experienced surgeons by analyzing brain scans taken as the physicians worked.

The researchers, who described their findings Wednesday in the journal Science Advances, said that the part of the brain involved in planning complex behaviors was more active in the novices. Skilled surgeons had more activity in the motor cortex, which is important for movement. The researchers, who developed a machine-learning system to analyze the scans, also showed that training resulted in a shift toward higher activity in the motor cortex.

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Doctors are surprisingly bad at reading lab results. It’s putting us all at risk. - The Washington Post

The man was 66 when he came to the hospital with a serious skin infection. He had a fever and low blood pressure, as well as a headache. His doctors gave him a brain scan just to be safe. They found a very small bulge in one of his cranial arteries, which probably had nothing to do with his headache or the infection. Nevertheless, doctors ordered an angiogram to get images of brain blood vessels. This test, in which doctors insert a plastic tube into a patient's arteries and inject dye, found no evidence of any blood vessel problems. But the dye injection caused multiple strokes, leading to permanent issues with the man's speech and memory.

That case, recounted in JAMA Internal Medicine three years ago, is no surprise. As a doctor in a large urban hospital, I know how much modern medicine has come to rely on tests and scans. I review about 10 cases per day and order and interpret more than 150 tests for patients. Every year, doctors in this country order more than 4 billion tests in total. They've gotten more sophisticated and easier to execute as technology has advanced, and they're essential to helping doctors understand what might be wrong with their patients.

But my research has found that many physicians misunderstand test results or think tests are more accurate than they are. Doctors especially fail to grasp how false positives work, which means they make crucial medical decisions — sometimes life-or-death calls — based on incorrect assumptions that patients have ailments that they probably don't. When we do this without understanding the science of risk and probability, we unacceptably increase the chances of making the wrong choice. In the worst cases, as with the man whose angiogram caused otherwise avoidable strokes, we increase the odds of unnecessarily putting patients in danger.

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Thursday, October 4, 2018

The Risk of Alternative Cancer Treatments - The New York Times

A diagnosis of cancer, even an early-stage, highly curable cancer, can prompt some people to feel as if they've suddenly lost control of their future and that they must do whatever they can to regain it.

They may seek guidance from the internet, friends and acquaintances, some of whom may be quick to relate tales of miraculous cures from alternative remedies that claim to spare patients the challenges of established cancer treatments like surgery, radiation and chemotherapy.

One web-based group, Integrative Cancer Answers, states that as many as 83 percent of cancer patients choose to use one or more forms of alternative medicine, ranging from acupuncture and herbs to vitamins and yoga, most often in conjunction with therapies clinically proven to be effective.

However, a small but significant number of cancer patients reject the treatments offered by mainstream oncologists and seek instead alternative remedies that may sound wonderful to a layperson but lack the support of scientifically valid research. Their reasons range from wanting to feel empowered by making their own treatment decisions to avoiding toxic side effects by selecting remedies they consider harmless.

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Monday, September 24, 2018

Trial by Fire: Critics Demand That a Huge Sepsis Study Be Stopped - The New York Times

A large government trial comparing treatments for a life-threatening condition called sepsis is putting participants at risk of organ failure and even death, critics charge, and should be immediately shut down.

A detailed analysis of the trial design prepared by senior investigators at the National Institutes of Health Clinical Center in Bethesda, Md., concluded that the study "places seriously ill patients at risk without the possibility of gaining information that can provide benefits either to the subjects or to future patients."

In a letter to the federal Office for Human Research Protection, representatives of Public Citizen's Health Research Group compared the study, called Clovers, to "an experiment that would be conducted on laboratory animals."

"The human subjects of the Clovers trial, as designed and currently conducted, are unwitting guinea pigs in a physiology experiment," Dr. Michael Carome and Dr. Sidney M. Wolfe wrote in their letter.

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Friday, September 14, 2018

Most Doctors Are Ill-Equipped to Deal With the Opioid Epidemic. Few Medical Schools Teach Addiction. - The New York Times

To the medical students, the patient was a conundrum.

According to his chart, he had residual pain from a leg injury sustained while working on a train track. Now he wanted an opioid stronger than the Percocet he'd been prescribed. So why did his urine test positive for two other drugs — cocaine and hydromorphone, a powerful opioid that doctors had not ordered?

It was up to Clark Yin, 29, to figure out what was really going on with Chris McQ, 58 — as seven other third-year medical students and two instructors watched.

"How are you going to have a conversation around the patient's positive tox screen results?" asked Dr. Lidya H. Wlasiuk, who teaches addiction awareness and interventions here at Boston University School of Medicine.

Mr. Yin threw up his hands. "I have no idea," he admitted.

Chris McQ is a fictional case study created by Dr. Wlasiuk, brought to life for this class by Ric Mauré, a keyboard player who also works as a standardized patient — trained to represent a real patient, to help medical students practice diagnostic and communication skills. The assignment today: grappling with the delicate art and science of managing a chronic pain patient who might be tipping into a substance use disorder.

How can a doctor win over a patient who fears being judged? How to determine whether the patient's demand for opioids is a response to dependence or pain?

Addressing these quandaries might seem fundamental in medical training — such patients appear in just about every field, from internal medicine to orthopedics to cardiology. The need for front-line intervention is dire: primary care providers like Dr. Wlasiuk, who practices family medicine in a Boston community clinic, routinely encounter these patients but often lack the expertise to prevent, diagnose and treat addiction.

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Wednesday, September 5, 2018

Narrative Medicine: Every Patient Has a Story

Every patient has a story that goes beyond the symptoms they bring into the doctor's office.

Those stories can illuminate how a person became ill, the tipping point that compelled them to seek help, and, perhaps most importantly, the social challenges they face in getting better. Stories can offer the kind of contextual richness that promotes and nourishes empathy, prompting a provider to switch from asking "How can I treat this disease?" to "How can I help my patient?" The difference may seem subtle at first, but knowing how to get patients to share their stories can be transformative in improving patient care, say proponents of this approach called "narrative medicine."

Indu Voruganti, MS, now a third-year medical student at Brown University Warren Alpert Medical School, had just that type of realization. Voruganti had originally planned to head straight to medical school after completing her bachelor's studies in biology. After taking an undergraduate creative writing class, however, she decided to take a slight detour.

"I immediately felt [creative writing] exercised a unique part of my brain that seemed to offer a different lens [with which] to view health care," said Voruganti. "Then I learned there's a whole world of physicians out there who are also writers."

That lightbulb moment led Voruganti to enroll in the Program in Narrative Medicine at Columbia University College of Physicians and Surgeons, an interdisciplinary master's program that seeks to improve clinical care through narratives. In a nutshell, narrative medicine draws on the study of art and literature to enhance students' listening and observation skills and to expand their view of patients to encompass more than just medical histories.

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Monday, August 20, 2018

I’m Coping With Cancer by Reporting On It - POLITICO Magazine

It's Wednesday morning. My boyfriend's mom is walking around the house, humming to herself, and my puppy is waiting for her to leave, sitting patiently by the door.

I'm also waiting for her to leave, just like I waited for my own mother to leave three days ago. And, after she leaves, I'll wait for my boyfriend to leave for work so that I can finally sit in silence for the first time since Friday.

I'm a relatively solitary person. I normally live alone. I work from home most days. And before I adopted a border terrier from the Humane Society last Monday, I could go days in a row before touching another living, breathing thing.

But that's not my life now, because I have cancer. It's in my left breast and perhaps in other areas of my body too: my armpit, my shoulder, maybe even my femur.

I found out last Friday at the vet, as my new hound, Lily, squealed during her rabies shot and my mom waited in the sitting area. The doctor called, and the vet and her tech probably thought I was rude to answer while Lily cried out on the cold, metal operating table. I didn't leave the room but tried to duck my head down near the seat of my chair, to better avoid their line of vision and, therefore, their judgment.

I was surprised, but the doctor wasn't. As he told me that the biopsy had come back positive, I hoped I hadn't been previously rude to him because I was irritated that he had been treating me like a cancer patient before I even got my results. I had privately bashed him for extorting me for unnecessary tests that already cost more than $600. This is the problem with health care, I told a nurse at the time. Expensive, unnecessary tests.

Talking to him, my head between my legs, trying to pay attention to the important things he was saying, I felt terrible for those comments. I suddenly felt grateful for all those expensive tests and for his serious, quiet demeanor; for his quick action.

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Medical students are skipping class, making lectures increasingly obsolete - STAT

The future doctors of America cut class. Not to gossip in the bathroom or flirt behind the bleachers. They skip to learn — at twice the speed.

Some medical students follow along with class remotely, watching sped-up recordings of their professors at home, in their pajamas. Others rarely tune in. At one school, attendance is so bad that a Nobel laureate recently lectured to mostly empty seats.

Nationally, nearly one-quarter of second-year medical students reported last year that they "almost never" attended class during their first two, preclinical years, a 5 percent increase from 2015.

The AWOL students highlight increasing dissatisfaction and anxiety that there's a mismatch between what they're taught in class during those years and what they're expected to know — or how they're tested — on national licensing exams. Despite paying nearly $60,000 a year in tuition, medical students are turning to unsanctioned online resources to prepare for Step 1, the make-or-break test typically taken at the end of the preclinical years.

These self-guided med students are akin to a group of American tourists wandering through Tokyo without a map. Like a tour guide hired on the street, the online learning tools — including memory aids, videos, and online quizzes — can enhance the educational journey, or send the students down a dead end.

Lawrence Wang, a third-year M.D.-Ph.D. student at the University of California, San Diego, and the National Institutes of Health, said he relied heavily on these resources during his first two years of medical school.

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A constant loud clicking or crunching noise in her head stumped stumped doctors - The Washington Post

Maryjane Behforouz's attempts to ignore the disturbing noise in her head always ended in failure, leaving her feeling increasingly desperate. No one seemed to know what was causing the nearly constant clicking — or sometimes crunching — sound that was so loud it would wake her in the middle of the night.

Behforouz, 48, who lives outside Indianapolis, had tried everything she could think of to make it stop.

She had seen three ear, nose and throat specialists, undergone painful steroid injections in her ear, tried acupuncture and changed her diet, all in a vain attempt to drown out the persistent auditory intrusion. When her doctors seemed unable to help, she scoured the Web, intensely focused on finding an expert who could.

Her husband, an ophthalmologist, was sympathetic, but at a loss to explain what sounded to Behforouz "like someone clicking their fingernails together, amplified by a megaphone."

It was only after the cause had been identified and eliminated more than a year later by an expert Behforouz had found that she realized "how much energy it took every day just to deal with it."

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Friday, August 17, 2018

If You Smell Things That Aren't Really There, You're Not Alone - Gizmodo

A small but very real percentage of people often smell odors that aren't actually there. About one in 15 Americans over the age of 40 regularly experience so-called phantom odors. But we have no idea why, according to a new study publishedThursday in JAMA Otolaryngology–Head & Neck Surgery.

The study, led by researchers from the National of Institutes of Health, is the largest to take a detailed look at the issue, said lead author Kathleen Bainbridge, a researcher at the National Institutes on Deafness and Other Communication Disorders (NICCD).

"We knew that phantom odor perception had been observed in medical clinics, but we did not know how common this condition was, nor what types of people are more commonly affected," she told Gizmodo via email.

Bainbridge and her team studied data from the National Health and Nutrition Examination Survey, an annual, nationally representative study of Americans' lifestyle habits and overall health. They specifically looked at more than 7,000 people over the age of 40 who had taken the survey from 2011 to 2014. Of these, 6.5 percent, or 534 people, answered yes to a question asking if they ever sometimes smelled "an unpleasant, bad, or burning odor when nothing is there."

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Wednesday, July 25, 2018

What Can Odd, Interesting Medical Case Studies Teach Us? - The New York Times

Late one evening in the medical library of the hospital where I work, I opened The Lancet, the medical journal, and came across a case report written by the neurologist-writer Oliver Sacks and colleagues. "In July 2011, a 52-year-old woman presented to our psychiatric outpatient clinic in The Hague with a lifelong history of seeing people's faces change into dragonlike faces."

Hooked, I continued: "She could perceive and recognize actual faces, but after several minutes, they turned black, grew long, pointy ears and a protruding snout and displayed a reptiloid skin and huge eyes in bright yellow, green, blue or red. She saw similar dragonlike faces drifting toward her many times a day from the walls, electrical sockets or the computer screen."

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Saturday, July 7, 2018

What it’s like to be sick with late-stage Lyme when no one believes you - Slate

On this week's episode of my podcast, I Have to Ask, I spoke to Porochista Khakpour, a novelist and writer whose new book is Sick: A Memoir. Khakpour, a 40-year-old Iranian-American writer, has struggled with health issues for much of her life. She begins the book by saying she has "never felt comfortable" in her own body, often feeling that something was wrong it; she had more serious symptoms—lethargy and dizziness, joint and muscle pain, as well as serious psychological symptoms, including insomnia—as she got older. Khakpour was eventually diagnosed as having late-stage Lyme disease. Below is an edited excerpt from the show. In it, we discuss why it took her so long to get diagnosed, why people with Lyme disease—especially women—are often doubted when they report their symptoms, and why people have so much trouble talking to, and understanding, their friends or relatives who are living with illness.

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Friday, June 29, 2018

Staying with one doctor may prolong your life, study finds - CBS News

Sticking with one primary care doctor may help you stay healthy and extend your life, according to a new British study. Researchers reviewed 22 studies from nine countries with different cultures and health systems. Of those, 18 concluded that staying with the same doctor over time significantly reduced early deaths, compared with switching doctors.

"Currently, arranging for a patient to see the doctor of their choice is considered a social convenience," said lead researcher Dr. Denis Pereira Gray. "Now it is clear that it is about improving the quality of medical practice with profound implications for all health systems."

Gray is an emeritus professor at the University of Exeter in England. He is also former president of the Royal College of General Practitioners and former chairman of the Academy of Medical Royal Colleges.

He said this study is the first systematic review of the relationship between continuity of doctor care and death rates.

Not only can seeing the same primary care doctor prolong life, but the same holds true for specialists such as surgeons and psychiatrists, Gray said.

"Patients talk more freely to doctors they know, and doctors can then understand them better and tailor advice and treatment better," he said.

Although technology has brought advances in medical care, Gray said, "this research shows that human factors like continuity of care remain important and are indeed a matter of life and death."

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Tuesday, June 26, 2018

Boundary-breaking neurologist treats patients other doctors give up on - STAT

Even beforehand — before the compulsive writing and the bipolar diagnosis, before the niche medical practice and the best-selling book — Dr. Alice Flaherty stuck out. She had grown up beside a duckweed-filled pond in rural New Jersey, and by the time she was a young adult, she'd become a neuroscientist in a family of engineers, a theorist among doers.

When she came home during breaks at Harvard, her father would rib her. "He'd say, 'Yo, you talk big about pure science now, but you're going to end up an engineer just like the rest of us,'" she recalled. "And when I went to med school, he was like, 'See? See?' And it's totally true. It's like tinkering. You tinker with the patients. It's so fun. I love fixing broken machines."

Her neurology work at Massachusetts General Hospital involves plenty of gadgetry — she heads up the deep brain stimulation unit, and sometimes uses electroconvulsive therapy to help patients with depression or mania — but these days, that's not the kind of tinkering that's at the front of her mind.

Instead, she has been toying with the boundaries of illness itself. She likes seeing patients other doctors have given up on. Many have faced questions about whether they're really as sick as they say. For all of them, getting the proper treatment — pills or infusions or electrical currents — depends on a kind of collaboration with Flaherty, a workshop in which motivations are re-examined, stories reshaped, turns of phrase redefined.

"These poor patients are typically seen as just not wanting to get better, and I got interested in that whole thing, like if you want to get better then you're sick, if you don't want to get better, then it's a vice," she said. "What was it about us — the caregivers, family members, and doctors — what was it that made us attribute willfulness to people who were obviously miserable?"

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Monday, June 18, 2018

Video Game Addiction Tries to Move From Basement to Doctor’s Office - The New York Times

Video games work hard to hook players. Designers use predictive algorithms and principles of behavioral economics to keep fans engaged. When new games are reviewed, the most flattering accolade might be "I can't put it down."

Now, the World Health Organization is saying players can actually become addicted.

On Monday, "gaming disorder" will appear in a new draft of the organization's International Classification of Diseases, the highly regarded compendium of medical conditions.

Concerns about the influence of video games are dovetailing with increasing scrutiny over the harmful aspects of technology, as consumers look for ways to scale back consumption of social media and online entertainment.

The W.H.O. designation may help legitimize worries about video game fans who neglect other parts of their lives. It could also make gamers more willing to seek treatment, encourage more therapists to provide it and increase the chances that insurance companies would cover it.
"It's going to untie our hands in terms of treatment, in that we'll be able to treat patients and get reimbursed," said Dr. Petros Levounis, the chairman of the psychiatry department at Rutgers New Jersey Medical School. "We won't have to go dancing around the issue, calling it depression or anxiety or some other consequence of the issue but not the issue itself."

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Thursday, May 31, 2018

Who Gets To Profit From Patients' Medical Data? : Shots - Health News : NPR

If you go to the hospital for medical treatment and scientists there decide to use your medical information to create a commercial product, are you owed anything as part of the bargain?

That's one of the questions that is emerging as researchers and product developers eagerly delve into digital data such as CT scans and electronic medical records, making artificial-intelligence products that are helping doctors to manage information and even to help them diagnose disease.

This issue cropped up in 2016, when Google DeepMind decided to test an app that measures kidney health by gathering 1.6 million records from patients at the Royal Free Hospital in London. The British authorities found this broke patient privacy laws in the United Kingdom and put a stop to it.

But the rules are different in the United States. The most notable cases have involved living tissue, but the legal arguments apply to medical data as well. One of the best examples dates back to 1976, when John Moore went to UCLA to be treated for hairy cell leukemia.

Prof. Leslie Wolf, director of the Center for Health, Law and Society at the Georgia State University College of Law, says Moore's doctors gave him good medical care, "but they also discovered there was something interesting about his cells and created a cell line from his cells without his knowledge," she says.

"And what complicated things even more is they asked Mr. Moore to travel down from his home in Seattle to L.A. multiple times, for seven years, to get additional cells without telling him they had this commercial interest in his cells."

Moore sued. In 1990, The California Supreme Court decided that he did not own his cells, but found his doctors had an obligation to inform him that his tissue was being used for commercial purposes and to give him a chance to object. Moore reached a settlement following his court battle, "but Mr. Moore certainly felt betrayed through the process," Wolf says.

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The Largest Health Disparity We Don’t Talk About - The New York Times

I didn't think our relationship would last, but neither did I think it would end so soon.

My patient had struggled with bipolar disorder his entire life, and his illness dominated our years together. He had, in a fit of hopelessness, tried to take his life with a fistful of pills. He had, in an episode of mania, driven his car into a tree. But the reason I now held his death certificate — his sister and mother in tears by his bed — was more pedestrian: a ruptured plaque in his coronary artery. A heart attack.

Americans with depression, bipolar disorder or other serious mental illnesses die 15 to 30 years younger than those without mental illness — a disparity larger than for race, ethnicity, geography or socioeconomic status. It's a gap, unlike many others, that has been growing, but it receives considerably less academic study or public attention. The extraordinary life expectancy gains of the past half-century have left these patients behind, with the result that Americans with serious mental illness live shorter lives than those in many of the world's poorest countries.

National conversations about better mental health care tend to follow a mass shooting or the suicide of a celebrity. These discussions obscure a more rampant killer of millions of Americans with mental illness: chronic disease.

We may assume that people with mental health problems die of "unnatural causes" like suicide, overdoses and accidents, but they're much more likely to die of the same things as everyone else: cancer, heart disease, stroke, diabetes and respiratory problems. Those with serious mental illness are more likely to struggle with homelessness, poverty and social isolation. They have higher rates of obesity, physical inactivity and tobacco use. Nearly half don't receive treatment, and for those who do, there's often a long delay.
When these patients do make it into our clinics and hospitals, it's clear that we could do better. A troubled mind can distract doctors from an ailing heart or a budding cancer.

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‘Unintended pregnancy’: Nearly 170,000 Allergan birth control packs recalled - The Washington Post

Pharmaceutical company Allergan issued a nationwide recall Tuesday for nearly 170,000 sample packs of the birth control Taytulla after a packaging error caused pills to be placed in the wrong order, a mistake that it said could lead to unintended pregnancies.

The botched packs have placebo pills where active pills should be, Allergan said in a statement. The 28-pill pack should have 24 pink pills with hormones followed by the four maroon capsules that don't have hormones, the company said. However, in the recalled packs, the placebos are at the beginning of the treatment. Taking placebos allow women to still experience period-like bleeding.

"The reversing of the order may not be apparent to either new users or previous users of the product, increasing the likelihood of taking the capsules out of order," the company's statement said. "If patients have concerns regarding the possibility of an unintended pregnancy they should consult their physician."

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BBC - Future - Pain bias: The health inequality rarely discussed

In 2009, my doctor told me that, like "a lot of women", I was paying too much attention to my body. Saying there wasn't an issue, he suggested I just relax and try to ignore the symptoms.

The decision seemed to run counter to what my records showed. A few weeks earlier, I had ended up in the emergency room with chest pains and a heart rate hitting 220 beats per minute. The ER crew told me it was a panic attack, gave me Xanax and told me to try to sleep.

I'd had panic attacks before. I knew this episode was not one. So I went to my doctor.

He put me on a heart monitor overnight. Bingo: I had another episode, this time recorded. It didn't matter. I still left his office thinking it was perhaps anxiety. And so, listening to the advice, I tried to ignore the pain.­­

Until it happened again. And again. First every month, then every week. Over the following nine years, I would complain about it and be told again that I was having panic attacks or anxiety, that women don't feel heart pain the way I was feeling it, and that maybe I was just confused.

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BBC - Future - 'Everybody was telling me there was nothing wrong'

Compared to many other diseases, diagnosing a brain tumour is fairly straightforward. Promptly detecting it comes down to being concerned enough about the early symptoms – which range from fatigue to seizures to personality change – to get an image of the brain. Either the tumour is there, or it isn't.

But in 2016, the Brain Tumour Charity released a report on the treatment of brain tumour patients in the United Kingdom. It found that almost one in three of them had visited a doctor more than five times before receiving their diagnosis. Nearly a quarter weren't diagnosed for more than a year.

Women, as well as low-income patients, experienced longer delays. They were more likely than men to see 10 or more months pass between their first visit to a doctor and diagnosis –and to have made more than five visits to a doctor prior to diagnosis.

One 39-year-old woman quoted in the report recalled: "One of the GPs I saw actually made fun of me, saying 'what did I think my headaches were, a brain tumour?' I had to request a referral to neurology. I went back repeated times to be given antidepressants, sleep charts, analgesia, etc. No one took me seriously."

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Monday, May 28, 2018

When is dentistry not medicine? When insurance is involved - CNN

I'm 61 years old, a San Francisco homeowner with an academic position at the University of California-Berkeley, which provides me with comprehensive health insurance. Yet, to afford the more than $50,000 in out-of-pocket expenses required for the restorative dental work I've needed in the past 20 years, I've had to rely on handouts -- from my mom.

This was how I learned all about the Great Divide between medicine and dentistry -- especially in how treatment is paid for, or mostly not paid for, by insurers. Many Americans with serious dental illness find out the same way: sticker shock.

For millions of Americans -- blessed in some measure with good genes and good luck -- dental insurance works pretty well, and they don't think much about it. But people like me learn the hard way that dental insurance isn't insurance at all -- not in the sense of providing significant protection against unexpected or unaffordable costs. My dental coverage from UC-Berkeley, where I have been on the public health and journalism faculties, tops out at $1,500 a year -- and that's considered a decent plan.

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Saturday, May 19, 2018

Opinion | Treat Addiction Like Cancer - The New York Times

Two years ago, I spent a week in Houston helping my stepbrother while he underwent treatment for Stage 4 lymphoma at the University of Texas MD Anderson Cancer Center. I sat with him while a nurse cleaned his chemo port and made records of her work, to keep his medical team updated. I accompanied him for the blood tests that determined his readiness for the next treatment. I stayed by his bed as his stem cells were harvested for a transplant, one of the cutting-edge, evidence-based therapies that ultimately saved his life.

Around the same time, I was helping my 22-year-old daughter, who struggled with alcohol and drug addiction. The contrast between the two experiences was stark. While my stepbrother received a doctor's diagnosis, underwent a clearly defined treatment protocol and had his expenses covered by insurance, there was no road map for my daughter. She had gone undiagnosed for several years, despite my reaching out to her health care providers, who either minimized my concerns or weren't sure what to do.

I had to hire an expensive interventionist — a professional who helps families find appropriate care and runs interventions — to find names of treatment centers. I spent weeks calling programs, asking questions and waiting to learn what insurance would cover. Finally, after my daughter agreed to treatment and we paid all costs up front, I sent her to a 45-day Arizona inpatient program, praying it would work.

Addiction, like cancer, is a complex disease that requires a multipronged approach. It also affects 1.5 times as many people as those with all cancers combined, and it was pivotal in causing some 64,000 overdose deaths in 2016 alone. It makes no sense that what is fast becoming our greatest health care crisis is still dealt with mostly outside the mainstream medical system.

According to a 2016 surgeon general's report, 10 percent of the 21 million Americans with substance-use disorders will receive treatment. This is in part because there are no national standards of care for treating addiction, and the $35 billion rehab industry is regulated piecemeal, state by state. While many treatment programs offer excellent care, others are motivated by profit and engage in practices such as patient brokering (in which hefty sums are paid to those who refer an addict to a program) and charging insurers exorbitant fees.

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Friday, May 18, 2018

New Drug Offers Hope to Millions With Severe Migraines - The New York Times

The first medicine designed to prevent migraines was approved by the Food and Drug Administration on Thursday, ushering in what many experts believe will be a new era in treatment for people who suffer the most severe form of these headaches.

The drug, Aimovig, made by Amgen and Novartis, is a monthly injection with a device similar to an insulin pen. The list price will be $6,900 a year, and Amgen said the drug will be available to patients within a week.

Aimovig blocks a protein fragment, CGRP, that instigates and perpetuates migraines. Three other companies — Lilly, Teva and Alder — have similar medicines in the final stages of study or awaiting F.D.A. approval.

"The drugs will have a huge impact," said Dr. Amaal Starling, a neurologist and migraine specialist at the Mayo Clinic in Phoenix. "This is really an amazing time for my patient population and for general neurologists treating patients with migraine."

Millions of people experience severe migraines so often that they are disabled and in despair. These drugs do not prevent all migraine attacks, but can make them less severe and can reduce their frequency by 50 percent or more.

As a recent editorial in the journal JAMA put it, they are "progress, but not a panacea."

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Thursday, May 17, 2018

This revolution in our understanding of depression will be life-transforming | The Guardian

Depression runs in families, we know. But it is only very recently, and after considerable controversy and frustration, that we are beginning to know how and why. The major scientific discoveries reported last week by the Psychiatric Genomics Consortium in Nature Genetics are a hard-won breakthrough in our understanding of this very common and potentially disabling disorder.

If your parents have been depressed, the chances that you have been or will be depressed are significantly increased. The background risk of depression in the general population is about one in four – each of us has a 25% chance of becoming depressed at some point in our lives. And if your parents have been depressed, your risk jumps by a factor of three.

However, controversy has long swirled around the question of nature or nurture. Is the depressed son of a depressed mother the victim of her inadequate parenting and the emotionally chilly, unloving environment she provided during the early years of his life? Or is he depressed because he inherited her depressive genes that biologically determined his emotional fate, regardless of her parenting skills? Is it nature or nurture, genetics or environment, which explain why depression runs in families?

In the 20th century, psychiatrists ingeniously teased out some answers to these questions. For example, it was found that pairs of identical twins, with 100% identical DNA, were more likely to have similar experiences of depression than were pairs of non-identical twins, with 50% identical DNA. This indicated clearly that depression is genetically heritable. But well into the 21st century, the precise identity of the "genes for depression" remained obscure. Since 2000, there has been a sustained international research effort to discover these genes, but the field has been bedevilled by false dawns and inconsistent results.

That is why the study published last week is such a significant milestone. For the first time, scientists around the world, with leading contributions from the UK's world-class centres of psychiatric genetics research largely funded by the Medical Research Council at the University of Cardiff University, University of Edinburgh University and King's College London, have been able to combine DNA data on a large enough sample to pinpoint which locations on the genome are associated with an increased risk of depression. So we now know, with a high degree of confidence, something important about depression that we didn't know this time last year. We know that there are at least 44 genes, out of the 20,000 genes comprising the human genome, which contribute to the transmission of risk for depression from one generation to the next.

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My Adventures With the Trip Doctors - The New York Times

My first psilocybin journey began around an altar in the middle of a second-story loft in a suburb of a small city on the Eastern Seaboard. On this adventure I would have a guide, a therapist who, like an unknown number of other therapists administering psychedelics in America today, must work underground because these drugs are illegal. Seated across the altar from me, Mary (who asked that I use a nickname because of the work she does) began by reciting, with her eyes closed, a long and elaborate prayer derived from various Native American traditions. My eyes were closed, too, but now and again I couldn't resist peeking out for a glance at my guide: a woman in her 60s with long blond hair parted in the middle and high cheekbones that I mention only because they would, in a few hours, figure in her miraculous transformation into a Mexican Indian.

I also stole a few glances at the scene: the squash-colored loft with its potted plants and symbols of fertility and female power; the embroidered purple fabric from Peru that covered the altar; and the collection of items arrayed across it, including an amethyst in the shape of a heart, a purple crystal holding a candle, a bowl containing a few squares of dark chocolate, the personal "sacred item" that Mary had asked me to bring (a little bronze Buddha a friend brought me from Tibet) and, set squarely before me, an antique plate holding the biggest psilocybin mushroom I had ever seen.

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How Tech Can Turn Doctors Into Clerical Workers - The New York Times

There are times when the diagnosis announces itself as the patient walks in, because the body is, among other things, a text. I'm thinking of the icy hand, coarse dry skin, hoarse voice, puffy face, sluggish demeanor and hourglass swelling in the neck — signs of a thyroid that's running out of gas. This afternoon the person before me in my office isn't a patient but a young physician; still, the clinical gaze doesn't turn off, and I diagnose existential despair.

Let's not call this intuition — an unfashionable term in our algorithmic world, although there is more to intuition than you think (or less than you think), because it is a subconscious application of a heuristic that can be surprisingly accurate. This physician, whose gender I withhold in the interest of anonymity and because the disease is gender-neutral, is burned out in what should be the honeymoon of a career. Over the years, I have come to recognize discrete passages in a medical life, not unlike in Shakespeare's "Seven Ages of Man" — we have our med-school equivalent of "the whining schoolboy with his satchel and shining morning face" and the associate professor "jealous in honor, sudden and quick in quarrel." But what I see in my colleague is disillusionment, and it has come too early, and I am seeing too much of it.

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Trying to Put a Value on the Doctor-Patient Relationship - The New York Times

In October 2014, my father was startled to receive a letter announcing the retirement, in a month's time, of our family physician. Both he and his doctor were in their late 60s by then, and their relationship went back about 30 years, to the early 1980s, after my father followed his father and paternal grandparents, all from the Midwest, to Southwest Florida. How they began seeing the doctor is beyond memory, but as my father's grandparents grew increasingly frail, his father frequently drove them to their doctor for checkups. At one of them, in the mid-'80s, the doctor suggested that it might be less strenuous for my great-grandparents if he met them in the parking lot. From then until they died, he came downstairs from his seventh-floor office with his black bag and climbed into the back seat of their yellow Oldsmobile 88 to give them their physicals.

More than a decade later, my grandfather, who was 78 by then and had chronic obstructive pulmonary disease, developed pneumonia. When he was admitted to the county hospital, it was the same doctor — now my doctor, too — who came to his room to describe his options: go on a ventilator and go home, where he would most likely remain bedridden for the remainder of his life (probably months), or let the illness run its course and die within a few days. My grandfather asked if the latter would hurt much. The doctor said no, he could make him comfortable. All right, then, my grandfather replied.

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Monday, May 14, 2018

Nine Rights Every Patient Should Demand - The New York Times

Ever since the American Hospital Association created its first Patient Bill of Rights in the early 1970s, medical centers, professional associations and states have been adapting it or creating their own. They are featured on websites and included in admissions packets, and adorn hospital walls.

But most of these documents are relics, responding to the concerns of a bygone era, like the right to "understandable information concerning diagnosis, treatment and prognosis" and to "a smoke-free environment." (Smoking has been forbidden in accredited hospitals for more than 25 years.)

If the cost of treatment is mentioned at all, it often squeaks in at the bottom. Consider how Johns Hopkins puts it: The patient has the right to "ask for an estimate of hospital charges before care is provided." Note: not to receive one.

Today patients' worries are financial as much as medical. Twenty percent of people with insurance say they have trouble paying their medical bills, a figure that rises to above 50 percent for the uninsured. In an era when patients are told to be better consumers of health care, they need a Financial Bill of Rights, too.

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Opinion | My Brief Trip to Cancerland - The New York Times

I knew, as soon as I heard the radiologist's voice on the phone, that the news wasn't good. "Is this an O.K. time to talk?" she asked. If everything was fine, she would have said that. Instead, she was saying, "I'm so sorry, but your biopsy came back positive for cancer."

Still in my pajamas, I scribbled down notes. "Will probably need lumpectomy and radiology. Find surgeon. Call this number." Of course, through the 10-minute conversation, the only word that really registered was "cancer."

What happened was this: A few months ago, I went for a mammogram. The doctors saw spots they didn't like. I wasn't concerned. Once you hit your late 40s, it's practically a rite of passage. You will see your mother's face when you look in the mirror. You will require a young child to fix your phone or explain a meme. And you, or a friend, or a sister, will get a call about her mammogram. Over the years, I've driven friends to get ultrasounds, and taken them home after needle biopsies. Everything always turned out fine, which reflects the statistics: Most women who have an abnormality on their mammograms will be O.K.

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The Burnout Crisis in American Medicine - The Atlantic

During a recent evening on call in the hospital, I was asked to see an elderly woman with a failing kidney. She'd come in feeling weak and short of breath and had been admitted to the cardiology service because it seemed her heart wasn't working right. Among other tests, she had been scheduled for a heart-imaging procedure the following morning; her doctors were worried that the vessels in her heart might be dangerously narrowed. But then they discovered that one of her kidneys wasn't working, either. The ureter, a tube that drains urine from the kidney to the bladder, was blocked, and relieving the blockage would require minor surgery. This presented a dilemma. Her planned heart-imaging test would require contrast dye, which could only be given if her kidney function was restored—but surgery with a damaged heart was risky.

I went to the patient's room, where I found her sitting alone in a reclining chair by the window, hands folded in her lap under a blanket. She smiled faintly when I walked in, but the creasing of her face was the only movement I detected. She didn't look like someone who could bounce back from even a small misstep in care. The risks of surgery, and by extension the timing of it, would need to be considered carefully.

I called the anesthesiologist in charge of the operating room schedule to ask about availability. If the cardiology department cleared her for surgery, he said, he could fit her in the following morning. I then called the on-call cardiologist to ask whether it would be safe to proceed. He hesitated. "I'm just covering," he said. "I don't know her well enough to say one way or the other." He offered to pass on the question to her regular cardiologist.

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Thursday, May 10, 2018

When Doctors Give Their Patients Gifts - The New York Times

When I was a medical student, I often found myself in the hospital gift shop. The gift shop was an oasis for me, not only because of the expansive candy selection that palliated my sugar cravings, but also because I could see gift-givers in cross-section. Loved ones came in and out, buying balloons for newborns and flowers for their parents or children. One would buy a newspaper for her spouse to read; another doting husband would buy a scarf for his wife to hide the scar from her recent surgery. Through their gifts, they were not only showing their love, but also their hope and yearning for health, for success, for life.

I found myself in the gift shop again on the day of my patient's planned discharge to home hospice. She was an elderly woman with metastatic cancer. She had been admitted for nearly a month.

As a third-year student, I had followed the course of her care throughout my time on the service. Every morning for that month, I walked into her room to ask how she was doing. I had watched her reach the limits of medicine; her disease was incurable. Perhaps it was just an instinct ingrained in me from my Italian-Jewish family, but I knew I could not leave the gift shop empty-handed. I settled on a stuffed animal, a black puppy.

Gift-giving to physicians is a relatively common practice, albeit a controversial one. One study in the British Medical Journal found that 20 percent of physicians in Britain had received a gift in the previous month. The study was conducted from May to July and therefore did not include the holiday months, when gift-giving may be even more frequent. Some doctors believe that patient gifts may predispose them to favoritism; others are willing to accept small gifts of low monetary value.

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Many People Taking Antidepressants Discover They Cannot Quit - The New York Times

Victoria Toline would hunch over the kitchen table, steady her hands and draw a bead of liquid from a vial with a small dropper. It was a delicate operation that had become a daily routine — extracting ever tinier doses of the antidepressant she had taken for three years, on and off, and was desperately trying to quit.

"Basically that's all I have been doing — dealing with the dizziness, the confusion, the fatigue, all the symptoms of withdrawal," said Ms. Toline, 27, of Tacoma, Wash. It took nine months to wean herself from the drug, Zoloft, by taking increasingly smaller doses.

"I couldn't finish my college degree," she said. "Only now am I feeling well enough to try to re-enter society and go back to work."

Long-term use of antidepressants is surging in the United States, according to a new analysis of federal data by The New York Times. Some 15.5 million Americans have been taking the medications for at least five years. The rate has almost doubled since 2010, and more than tripled since 2000.

Nearly 25 million adults, like Ms. Toline, have been on antidepressants for at least two years, a 60 percent increase since 2010.

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Wednesday, May 9, 2018

Surgical Checklists Save Lives — but Once in a While, They Don’t. Why? - The New York Times

Late last year, I witnessed an extraordinary surgical procedure at the Cleveland Clinic in Ohio. The patient was a middle-aged man who was born with a leaky valve at the root of his aorta, the wide-bored blood vessel that arcs out of the human heart and carries blood to the upper and lower reaches of the body. That faulty valve had been replaced several years ago but wasn't working properly and was leaking again. To fix the valve, the cardiac surgeon intended to remove the old tissue, resecting the ring-shaped wall of the aorta around it. He would then build a new vessel wall, crafted from the heart-lining of a cow, and stitch a new valve into that freshly built ring of aorta. It was the most exquisite form of human tailoring that I had ever seen.

The surgical suite ran with unobstructed, preternatural smoothness. Minutes before the incision was made, the charge nurse called a "time out." The patient's identity was confirmed by the name tag on his wrist. The surgeon reviewed the anatomy, while the nurses — six in all — took their positions around the bed and identified themselves by name. A large steel tray, with needles, sponges, gauze and scalpels, was placed in front of the head nurse. Each time a scalpel or sponge was removed from the tray, as I recall, the nurse checked off a box on a list; when it was returned, the box was checked off again. The old tray was not exchanged for a new one, I noted, until every item had been ticked off twice. It was a simple, effective method to stave off a devastating but avoidable human error: leaving a needle or sponge inside a patient's body.

In 2007, the surgeon and writer Atul Gawande began a study to determine whether a 19-item "checklist" might reduce human errors during surgery. The items on the list included many of the checks that I had seen in action in the operating room: the verification of a patient's name and the surgical site before incision; documentation of any previous allergic reactions; confirmation that blood and fluids would be at hand if needed; and, of course, a protocol to account for every needle and tool before and after a surgical procedure. Gawande's team applied this checklist to eight sites in eight cities across the globe, including hospitals in India, Canada, Tanzania and the United States, and measured the rate of death and complications before and after implementation.

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Saturday, May 5, 2018

A Simple Way to Improve a Billion Lives: Eyeglasses - The New York Times

PANIPAT, India — Shivam Kumar's failing eyesight was manageable at first. To better see the chalkboard, the 12-year-old moved to the front of the classroom, but in time, the indignities piled up.

Increasingly blurry vision forced him to give up flying kites and then cricket, after he was repeatedly whacked by balls he could no longer see. The constant squinting gave him headaches, and he came to dread walking home from school.

"Sometimes I don't see a motorbike until it's almost in my face," he said.

As his grades flagged, so did his dreams of becoming a pilot. "You can't fly a plane if you're blind," he noted glumly.

The fix for Shivam's declining vision, it turns out, was remarkably simple.

He needed glasses.

More than a billion people around the world need eyeglasses but don't have them, researchers say, an affliction long overlooked on lists of public health priorities. Some estimates put that figure closer to 2.5 billion people. They include thousands of nearsighted Nigerian truck drivers who strain to see pedestrians darting across the road and middle-aged coffee farmers in Bolivia whose inability to see objects up close makes it hard to spot ripe beans for harvest.

Then there the tens of millions of children like Shivam across the world whose families cannot afford an eye exam or the prescription eyeglasses that would help them excel in school.

"Many of these kids are classified as poor learners or just dumb and therefore don't progress at school," said Kovin Naidoo, global director of Our Children's Vision, an organization that provides free or inexpensive eyeglasses across Africa. "That just adds another hurdle to countries struggling to break the cycle of poverty."

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Thursday, May 3, 2018

I followed the federal dietary and exercise guidelines for a year. Here's what happened. - NBC News

Early in 2017, I started my year-long project to adhere to the federal Physical Activity Guidelines and Dietary Guidelines with the support of the Science & Research Team of the American Council on Exercise.

We mapped out a six-month incremental process of behavior change that allowed me to establish and then build upon new habits over the remaining six months. It was a year full of stops, starts, plateaus, struggles and triumphs. Through this process, I changed so many things about my life. I learned how to incorporate more physical activity into my daily routine (and I learned to enjoy it, or at least enjoy the way it made me feel). By making a series of small, manageable changes, I completely altered the way I eat and my overall relationship with food. I inspired my wife to get more active and helped a number of friends and family members make similar changes in their lives. I learned how to make changes that made me healthier without negatively impacting my overall quality of life.

In many ways, I still struggle with certain aspects of my new lifestyle and will admit to having gained a few pounds since my project "ended" a few months ago — though we all know that true lifestyle change never ends. In other words, it still is — and always will be — a work in progress. But I've learned how to live a healthy lifestyle, how to forgive myself for slip-ups and how to inspire myself to get back on track.

Of course, when people ask me how the project went, they don't want to hear some inspirational speech. They want numbers!

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Patients face expensive ER bills even when they don’t receive treatment - Vox

On October 19, 2016, Jessica Pell fainted and hit her head on a nearby table, cutting her ear. She went to the emergency room at Hoboken University Medical Center, where she was given an ice pack. She received no other treatment. She never received any diagnosis. But a bill arrived in the mail for $5,751.

"It's for the ice pack and the bandage," Pell said of the fee. "That is the only tangible thing they could bill me for."

Pell's experience is not unique. Submissions to Vox's ER database project found multiple examples of ERs charging patients hundreds or even thousands of dollars for walking through the door. Some never got past the waiting room. Some were triaged, but none received treatment from a doctor.

Pell left the ER when she discovered the plastic surgeon who would see her was out of network for her insurance. She decided to go to an in-network facility instead. She thought this was a smart way to avoid the costly fees that came with seeing a provider that wasn't included in her health plan.

"I decided to decline treatment because I can't really afford any surprise bills right now," she said. "The bill I'd probably incur would not be worth saving my ear, which was sad but a choice I had to make."

Pell's health insurance plan paid the hospital $862, what it deemed a "reasonable and appropriate" fee for the services the hospital paid. That left Pell with a $4,989 bill that she received on February 28.

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Saturday, April 28, 2018

Patient histories should tell personal stories too - The Washington Post

One of the fundamental skills we learn early in medicine is how to take a patient history. We are encouraged to tell a story. Yet these stories have a specific formula. They go something like this: "Mr. A is a 60-year-old man with high blood pressure and diabetes who presents with new left lower extremity weakness." We describe when the weakness started, what makes it better and what makes it worse, and any other accompanying symptoms.

Most often, we elicit a story of disease but not one of the patient who is experiencing an illness. The best stories are cut short. Mr. A's story may not communicate that he has been homeless for months because he lost his job. Or that his daughter is getting married in a few months and that he is most concerned that he will not be able to walk her down the aisle. Both of these stories — about the illness and about the patient — are important in different ways.

When we look at the medical chart, we can read multiple notes without learning any information that tells us who our patients really are. But what if we could sit down with our patients for an hour and learn about them as people?

So I was intrigued when I heard about the My Life, My Story program started in 2013 by Eileen Ahearn and Dean Krahn, psychiatrists at the Veterans Affairs hospital in Madison, Wis. With My Life, My Story, veterans have the opportunity to tell their story through interviews. These interviews are conducted by volunteers, social work interns, medical students and staff, and others.

Each story is approximately 1,000 words long and written in the first person. Suggested interview questions include: "What has been the most significant change you've seen in yourself? What is most important to you? What are you most grateful for? What do you want your health-care team to know that they don't already know?" There are no medical questions.

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Friday, April 27, 2018

The Body That Understands What Fullness Is – Unruly Bodies – Medium

The first weight-loss surgery was performed during the 10th century, on D. Sancho, the king of León, Spain. He was so fat that he lost his throne, so he was taken to Córdoba, where a doctor sewed his lips shut. Only able to drink through a straw, the former king lost enough weight after a time to return home and reclaim his kingdom.

The notion that thinness — and the attempt to force the fat body toward a state of culturally mandated discipline — begets great rewards is centuries old.

Modern weight-loss surgery began in the 1950s, when surgeons employing various techniques caused their patients fairly distressing problems, like severe diarrhea, dehydration, kidney stones, gallstones, and even death — but, generally, the patients lost weight. Surgeons have since refined their techniques, using a range of restriction or malabsorption methods to force the human body to lose weight. They have tried wiring patients' jaws shut to force weight loss through liquid diets. They have stapled stomachs into smaller pouches to restrict caloric intake. They have developed gastric bands and balloons to restrict the amount of food that can enter the stomach. But it was the first laparoscopic gastric bypass—in which the gastrointestinal tract is routed around a person's stomach—performed in 1994, that enabled bariatric surgery to go more mainstream by way of minimal invasion.

Some of these interventions have succeeded for people, and some have failed, because not even surgical intervention can overcome the reasons why many people gain and then struggle to lose weight. Some bodies and minds simply cannot be brought to heel.

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Thursday, April 26, 2018

‘Desperation Oncology’: When Patients Are Dying, Some Cancer Doctors Turn to Immunotherapy - The New York Times

Dr. Oliver Sartor has a provocative question for patients who are running out of time.

Most are dying of prostate cancer. They have tried every standard treatment, to no avail. New immunotherapy drugs, which can work miracles against a few types of cancer, are not known to work for this kind.

Still, Dr. Sartor, assistant dean for oncology at Tulane Medical School, asks a diplomatic version of this: Do you want to try an immunotherapy drug before you die?

The chance such a drug will help is vanishingly small — but not zero. "Under rules of desperation oncology, you engage in a different kind of oncology than the rational guideline thought," Dr. Sartor said.

The promise of immunotherapy has drawn cancer specialists into a conundrum. When the drugs work, a cancer may seem to melt away overnight. But little is known about which patients might benefit, and from which drugs.

Some oncologists choose not to mention immunotherapy to dying patients, arguing that scientists first must gather rigorous evidence about the benefits and pitfalls, and that treating patients experimentally outside a clinical trial is perilous business.

But others, like Dr. Sartor, are offering the drugs to some terminal patients as a roll of the dice. If the patient is dying and there's a remote chance the drug will help, then why not?

"Immunotherapy is a particularly nuanced problem," said Dr. Paul Helft, an ethicist and oncologist at Indiana University School of Medicine.

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Wednesday, April 25, 2018

Ovarian cancer vaccine helped increase survival rates in early trial - The Washington Post

In early research that involved marshaling the body's own immune system, a personalized vaccine helped patients with ovarian cancer mount a stronger defense against their tumors than standard therapy and substantially improved their survival rate.

The vaccine was tested in a preliminary clinical trial and used with standard chemotherapy and an immune-boosting agent. The experimental therapy, described recently in the journal Science Translational Medicine, weaves together a number of approaches that are collectively driving innovations in cancer treatment.

Because the treatment uses the patient's immune cells as a sort of T-cell training force, it is an immunotherapy. Because it uses the distinctive proteins on a patient's own tumor as homing beacons, it is a targeted therapy. And because a patient's cells are harvested and returned to her, it is personalized therapy.

Rather than round up a patient's T cells and re-engineer them in a lab to find cancer, this treatment harvests a class of immune "helpers" called dendritic cells. Using ground-up cells from a patient's tumor, researchers trained the dendritic cells to recognize and attack that specific malignancy. When these fortified cells were reintroduced into the patient, they passed on their training to the immune system's army of killer T cells and sent them into battle.

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Doctors are scrambling to deal with a new world of telemedicine - The Washington Post

For years, doctors have been told to look at the patient — not the computer — when providing medical care. What we haven't been told is what to do when there's only a computer.

Telemedicine is perhaps the most rapidly evolving area in health care. About 15 million Americans receive some form of remote medical care every year. Investment in on-demand health-care services is estimated at $1 billion annually, according to Accenture Consulting. Kaiser Permanente, the nation's largest integrated delivery system, provides more visits virtually than it does in person.

All of which raises an important but overlooked question: Do doctors know how to use telemedicine?

As is often the case with technological change, our capacity to generate innovation has exceeded our capacity to understand its implications. With telemedicine, we've done what we generally do: Introduce a new treatment, technology or care model, and assume doctors will figure out how to use it.

But as telemedicine moves from a technology used to manage minor ailments — coughs, rashes, sore throats — to one that affects nearly every field of medicine, it's important to consider whether its increasingly complex application is being matched with increasingly sophisticated training.

Misdiagnosis, for example, remains a fundamental problem in medicine, and it's not clear whether telemedicine will ameliorate or exacerbate it. Much of medical diagnosis remains clinical gestalt: an integrated assessment based on labs, history and exam. But how should this evaluation vary by the medium in which a patient is cared for? Should doctors feel comfortable making some diagnoses remotely, but not others? Should they adjust their threshold for ordering more tests, or dismissing minor complaints, when caring for patients on a screen instead of in an office?

Building rapport with patients remotely is also more difficult than in person. The subtle cues that bond doctor and patient are largely absent during a virtual visit, and some argue we should teach not just bedside manner but also "webside manner."

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Doctor Shortage May Reach 120,000 by 2030

The U.S. could see a shortage of up to 120,000 physicians by 2030, according to a report published Wednesday by the Association of American Medical Colleges. The association urged medical schools to train more physicians and use different strategies in doing so. It also encouraged the federal government to intervene with funding and legislation.
According to the report, "The Complexities of Physician Supply and Demand: Projections from 2016-2030," the shortage of physicians in primary care and medical, surgical and other specialties is projected to range from 42,600 to 121,300.
The report attributed the shortage to a growing and aging population. The U.S. population is estimated to rise by almost 11 percent by 2030, and the over-65 age group is expected to increase by 50 percent.
The association offered several ways to reverse the shortage, including training more physicians; educating future physicians in team-based, interprofessional care; developing innovative care-delivery and payment models; and integrating cutting-edge technology and research into the patient care environment. In addition, the association encouraged the government to support federal incentives and programs, increase funding for residency training, and introduce legislation to add 3,000 residency positions over the next five years.
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Sunday, April 15, 2018

Diagnosis: A New Series From The New York Times and Netflix - The New York Times

This week The New York Times Magazine is reintroducing a version of "Think Like a Doctor," the online column in which I told the story of a patient with mysterious symptoms — including posting some medical records and test results — and challenged readers to unravel the puzzle of that patient's illness and come up with a diagnosis. But this time, the stakes are higher. In that original column, which I wrote from 2011 to 2016, I already knew the final diagnosis, and I watched as readers commented and discussed the case on the site, finding their way to an answer, a suggested diagnosis. This time around, I will be presenting an unsolved case and asking our readers to do their best to actually help the patient.

Again, I will provide test results and other relevant medical data and will challenge you to think like a doctor and come up with a solution to the patient's illness. In posting these unsolved cases, we hope to leverage the knowledge and wisdom of this particular crowd — the readers of The New York Times — to make a difference in the life and well-being of someone in search of an answer, in search of a diagnosis.

Below you will find the case of a 23-year-old woman who has recurrent episodes of terrible pain in her muscles, along with urine the color of cola, often after exercising. Reader responses will be reviewed, and the most promising will be forwarded to the provider who is managing the patient's care. Updates on the patient's condition and diagnosis will be posted here as progress in the case is made, and each patient's story, along with input from readers, will be shared in the Diagnosis show on Netflix. O.K., let's get started.

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How Profiteers Lure Women Into Often-Unneeded Surgery - The New York Times

Jerri Plummer was at home in Arkansas, watching television with her three children, when a stranger called to warn that her life was in danger.

The caller identified herself only as Yolanda. She told Ms. Plummer that the vaginal mesh implant supporting her bladder was defective and needed to be removed. If Ms. Plummer didn't act quickly, the caller urged, she might die.

Ms. Plummer, 49, didn't ask many questions. Her implant was causing her discomfort, and she was impressed by how much Yolanda knew about her medical history. She was scared. "It was like I had a ticking time bomb inside of me," she said. Yolanda assured Ms. Plummer that all her expenses would be covered and that she would be set up with a lawyer to help her sue the mesh manufacturer, Boston Scientific.

Days later, court records show, Ms. Plummer was lying on an operating table in a medical office in a shopping mall in Orlando, Fla.

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Thursday, April 12, 2018

First Clinical Practice Guidelines for Sjögren's Syndrome Developed - Rheumatology Advisor

The Sjögren's Syndrome Foundation has released the first clinical practice guidelines for the disease, which includes recommendations on the management of fatigue, inflammatory musculoskeletal pain, and use of biologic agents.

Steven E. Carsons, MD, from the Division of Rheumatology and Allergy and Immunology at Winthrop University Hospital in Mineola, New York, and colleagues said they developed the Sjögren's Syndrome Foundation clinical practice guidelines after "patient requests for improved care and physician requests for guidance."

The Sjögren's Syndrome Foundation clinical expert panel consisted of clinicians, nurses, and patients who, using a modified Delphi process (75% agreement level), achieved consensus on 19 different recommendations. Three topic review groups were created on the issues of musculoskeletal pain, fatigue, and biologic use, in which panelists performed systematic reviews of the MEDLINE/PubMed and Cochrane databases and compiled data on the topics published between January 1988 and April 2015. A summary of the recommendations was recently published in Arthritis Care & Research.

"Among all chronic autoimmune rheumatic disorders, Sjögren's syndrome remains one of the most difficult to manage," Dr Carsons and colleagues wrote in their recommendations. "Development of [clinical practice guidelines] for the ocular, oral, and systemic/rheumatologic manifestations should substantially improve the quality and consistency of care, guide reimbursement policies, and decrease the overall burden of illness."

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What the Hospitals of the Future Look Like - WSJ

The days of the hospital as we know it may be numbered.

In a shift away from their traditional inpatient facilities, health-care providers are investing in outpatient clinics, same-day surgery centers, free-standing emergency rooms and microhospitals, which offer as few as eight beds for overnight stays. They are setting up programs that monitor people 24/7 in their own homes. And they are turning to digital technology to treat and keep tabs on patients remotely from a high-tech hub.

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Wednesday, April 11, 2018

Your Body Is a Teeming Battleground - The Atlantic

I went to medical school, at least in part, to get to know death and perhaps to make my peace with it. So did many of my doctor friends, as I would find out. One day—usually when you're young, though sometimes later—the thought hits you: You really are going to die. That moment is shocking, frightening, terrible. You try to pretend it hasn't happened (it's only a thought, after all), and you go about your business, worrying about this or that, until the day you put your hand to your neck—in the shower, say—and … What is that? Those hard lumps that you know, at first touch, should not be there? But there they are, and they mean death. Your death, and you can't pretend anymore.

I never wanted to be surprised that way, and I thought that if I became a doctor and saw a lot of death, I might get used to it; it wouldn't surprise me, and I could learn to live with it. My strategy worked pretty well. Over the decades, from all my patients, I learned that I would be well until I got sick and that although I could do some things to delay the inevitable a bit, whatever control I had was limited. I learned that I had to live as if I would die tomorrow and at the same time as if I would live forever. Meanwhile, I watched as what had been called "medical care"—that is, treating the sick—turned into "health care," keeping people healthy, at an ever-rising cost.

In her new book, Barbara Ehrenreich ventures into the fast-growing literature on aging, disease, and death, tracing her own disaffection with a medical and social culture unable to face mortality. She argues that what "makes death such an intolerable prospect" is our belief in a reductionist science that promises something it cannot deliver—ultimate control over our bodies. The time has come to rethink our need for such mastery, she urges, and reconcile ourselves to the idea that it may not be possible.

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Tuesday, April 10, 2018

Lack Of Research On Medical Marijuana Leaves Patients In The Dark : Shots - Health News : NPR

By the time Ann Marie Owen, 61, turned to marijuana to treat her pain, she was struggling to walk and talk. She was also hallucinating.

For four years, her doctor prescribed a wide range of opioids for transverse myelitis, a debilitating disease that caused pain, muscle weakness and paralysis.

The drugs not only failed to ease her symptoms, they hooked her.

When her home state of New York legalized marijuana for the treatment of select medical ailments, Owens decided it was time to swap pills for pot. But her doctors refused to help.

"Even though medical marijuana is legal, none of my doctors were willing to talk to me about it," she says. "They just kept telling me to take opioids."

Although 29 states have legalized marijuana to treat pain and other ailments, the growing number of Americans like Owen who use marijuana and the doctors who treat them are caught in the middle of a conflict in federal and state laws — a predicament that is only worsened by thin scientific data.

Because the federal government considers marijuana a Schedule 1 drug, research on marijuana or its active ingredients is highly restricted and even discouraged in some cases.

Underscoring the federal government's position, Health and Human Services Secretary Alex Azar recently pronounced that there was "no such thing as medical marijuana."

Scientists say that stance prevents them from conducting the high-quality research required for FDA approval, even as some early research indicates marijuana might be a promising alternative to opioids or other medicines.

Patients and physicians, meanwhile, lack guidance when making decisions about medical treatment for an array of serious conditions.

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