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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