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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