Monday, December 23, 2019

Science can’t fix dementia’s most heartbreaking problem — Quartz

On a balmy weekday afternoon around the time spring was melting into summer, my partner and I made plans to meet up after work. We picked a spot in my neighborhood, which happens to be near the Nationals baseball stadium. As we sipped our beers and chatted about the week, my partner, Ben, saw two of our friends, Tom and Hannah, on their way to a baseball game. He waved them down and invited them to join us before the opening pitch.

It would have been a perfectly forgettable evening—pleasant and ordinary. DC is small enough that it's not too uncommon to run into friends. We hadn't seen Tom and Hannah for a bit, and I knew Tom had been visiting his hometown in Connecticut. "How's your family doing?" I asked.

Tom and Hannah exchanged glances.

"Actually, not great," he said.

A few months ago, he shared, his dad had abruptly lost his short-term memory. He'd be doing something like cooking a meal and forget what he was doing; he'd put the stove on and leave the room, or he'd be driving and forget where he was going. He was only 61.

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Monday, December 16, 2019

The Hidden Drug Epidemic Among Older People - The New York Times

While news reports focus on an epidemic of opioid abuse among young adults, another totally legal and usually hidden drug epidemic is occurring at the other end of the age spectrum: the fistfuls of remedies — both prescription and over-the-counter — taken by older adults.

According to the American Association of Consultant Pharmacists, people aged 65 to 69 take an average of 15 prescriptions a year, and those aged 80 to 84 take 18 prescriptions a year. And that's in addition to the myriad over-the-counter drugs, herbal remedies, vitamins and minerals they may take, any of which — alone or in combination — could cause more problems than they cure.

Among people over 65, 44 percent of men and 57 percent of women take five or more nonprescription and/or prescription drugs a week, and 12 percent take 10 or more.

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A Doctor’s Diary: The Overnight Shift in the E.R. - The New York Times

My choices as a doctor in the emergency room are up or out. Up, for the very sick. I stabilize things that are broken, infected or infarcted, until those patients can be whisked upstairs for their definitive surgeries or stents in the hospital. Out, for everyone else. I stitch up the simple cuts, reassure those with benign viruses, prescribe Tylenol and send home.

Up or out is what the E.R. was designed for. Up or out is what it's good at. Emergency rooms are meant to have open capacity in case of a major emergency, be it a train crash, a natural disaster or a school shooting, and we are constantly clearing any beds we can in pursuit of this goal.

The problem is, traffic through the emergency room has been growing at twice the rate projected by United States population growth and has been for almost 20 straight years, despite the passage of the Affordable Care Act, and through both economic booms and recessions. Americans visit the E.R. more than 140 million times a year — 43 visits for every 100 Americans — which is more than they visit every other type of doctor's office in the hospital combined.

The demand is such that new E.R.s are already too small by the time they are built. Emergency rooms respond like overbooked restaurants during a chaotic dinner rush, with doctors pressed to turn stretchers the way waiters hurriedly turn tables. The frantic pace leaves little time for deliberating over the diagnosis or for counseling patients. Up, out.

Private exams on stretchers in hallways, patients languishing without attention for hours, nurses stretched to the breaking point; all of it has become business as usual. I think about this on nights like tonight, when I start my shift inheriting 16 patients in the waiting room. I think about what I will learn that these people need, and about what I will fail to provide.

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Saturday, December 14, 2019

Frail Older Patients Struggle After Even Minor Operations - The New York Times

The patient, a man in his 70s, had abdominal pain serious enough to send him to a VA Pittsburgh Healthcare hospital. Doctors there found the culprit: a gallstone had inflamed his pancreas.

Dr. Daniel Hall, a surgeon who met with the patient, explained that pancreatitis can be fairly mild, as in this case, or severe enough to cause death. Recovery usually requires five to seven days, some of them in a hospital, during which the stone passes or a doctor uses a flexible scope to remove the blockage.

But "because it can be life-threatening, after patients recover, we usually take out the gall bladder to prevent its happening again," Dr. Hall said.

A cholecystectomy, as that operation is known, isn't high-risk surgery. When done with a laparoscope to avoid large incisions, it's usually an outpatient procedure.

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A Runner Suddenly Developed Asthma. It Was Stranger Than It Seemed. - The New York Times

It was chest pain that brought the 34-year-old woman to the emergency room at Montefiore Medical Center in the Bronx. She'd been coughing for days, but that morning the pain was so bad she was worried that it had turned into pneumonia. She tried to tough it out, but when it was no better by the end of the day, she decided to go to the E.R.

It took a few hours, but finally the physician assistant caring for her in the E.R. brought some good news. She didn't have pneumonia; she didn't have a clot in her lungs. This was just muscle strain from coughing. The year before, she was told she had asthma.
She was given inhalers to stop the coughing and wheezing, but they didn't seem to do much. So she didn't use them.

The P.A. encouraged the woman to use her inhalers; they really would prevent the episodes of coughing and wheezing that had sent her to the E.R. so often that year. The woman nodded; she'd heard this speech before. The P.A. asked whether she'd like ibuprofen for the pain. Absolutely not, the patient said. After years of taking it for muscle pain after working out or racing, she had developed some kind of allergy to it. What about ketorolac? the P.A. offered. It's the same type of painkiller but a completely different compound.

Pain relief sounded appealing. But within seconds of getting the intravenous medication, the woman felt an intense pressure in her chest. Her windpipe narrowed as if she had something stuck in her throat. She tried to shout, "I can't breathe!" The only sound that came out was an unintelligible whisper.

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Friday, December 13, 2019

Snapshots of My Patients - The New York Times

A little over a year ago, our electronic medical record started to include photographs of patients along with their medical information.

These thumbnail images, which appear at the top left-hand corner of the computer screen next to a name, age and birthdate, are intended as a safety measure, to help ensure that clinicians are placing orders and entering documentation for the correct patient when multiple patient records might be open simultaneously.

As I was scanning through my day's clinic schedule recently, I was struck by the different ways my patients approached taking the picture. All of them had been given a diagnosis of cancer, and many were dealing with a range of health issues. I found myself wondering whether these snapshots might give me further insight into how they viewed their medical conditions.

The standard photo is taken from a camera located at the registration desk, by the cancer center's main entrance. The photos are always taken at an upward angle, usually capturing my patients slightly off-center, with the lobby's drop ceiling and a couple of LED canister lights as an unflattering backdrop. Most don't smile — no fun fighting traffic into downtown Cleveland, searching for a parking spot, walking to our building and then having a doctor's appointment, often many times per week.

No fun having cancer.

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Friday, November 29, 2019

Apple’s Reach Reshapes Medical Research - The New York Times

In 1976, the Harvard School of Public Health and two other major medicalinstitutions started a study on nurses that has become one of the largest and longest research efforts ever conducted on women's health. They have so far enrolled more than 275,000 participants.

On Thursday, the Harvard school announced an even more ambitious women's health study, one that aims to enroll a million women over a decade.

The new ingredients allowing the huge scale: Apple's iPhones, apps and money.

Harvard's new study is just one of three new large research efforts that Apple is working on with leading academic research centers and health organizations. Together, the studies, which Apple is paying for, show how the Silicon Valley giant and its popular products are reshaping medical research.

To enroll in clinical trials, patients have often had to travel to medical centers to be briefed by researchers and fill out the study paperwork in person. Many studies also follow patients only intermittently, in periodic surveys and visits to hospitals.

But Apple tools are enabling large-scale virtual studies that can follow people as they go about their daily lives. The company has developed a research app for iPhones — which participants can download from its app store — that is helping researchers quickly and easily recruit hundreds of thousands of study volunteers.

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Monday, November 11, 2019

Our Hospital’s New Software Frets About My ‘Deficiencies’ - The New York Times

We had been waiting for this day for years — the day our hospital in San Francisco would shed its antiquated electronic health records system in favor of a more modern alternative called Epic, which has been, or will soon be, adopted by many of the nation's top medical centers.

Our hospital was full of strangers in turquoise T-shirts, called Epic Superusers, who provided "at the elbow support" for the staff, there to usher in the "death of the legacy system" (as the administrators' emails put it) and the birth of a new, well, epoch.

But on a recent Monday morning when I logged into so-called Epic Hyperspace for the first time, I was greeted with a pop-up box and an urgent message: "You currently have deficiencies that are either delinquent or will become delinquent within one week. Please complete at your earliest convenience."

I blinked. The words on my monitor were thick and black on a background of rich mustard yellow. On the left side of the message was an exclamation point inside a circle. Today was my first day using Epic. Had I already done something wrong?

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Chronic Pain Eased With Meditation And Lower Doses Of Opioids : Shots - Health News : NPR

There's new evidence that mind-body interventions can help reduce pain in people who have been taking prescription opioids — and lead to reductions in the drug's dose.

In a study published this month in JAMA Internal Medicine, researchers reviewed evidence from 60 studies that included about 6,400 participants. They evaluated a range of strategies, including meditation, guided imagery, hypnosis and cognitive behavioral therapy.

"Mindfulness, cognitive behavioral therapy and clinical hypnosis appear to be the most useful for reducing pain," says study author Eric Garland, a professor at the University of Utah. The reductions in dose were modest overall, he says, but the study is a signal that this approach is beneficial.

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Wednesday, October 23, 2019

Insurance companies aren’t doctors. So why do we keep letting them practice medicine? - The Washington Post

William E. Bennett Jr. is an associate professor of pediatrics at the Indiana University School of Medicine.

We know how important it is to have insurance so that we can get health care. As a physician, parent and patient, I cannot overemphasize that having insurance is not enough.

As a gastroenterologist, I often prescribe expensive medications or tests for my patients. But for insurance companies to cover those treatments, I must submit a "prior authorization" to the companies, and it can take days or weeks to hear back. If the insurance company denies coverage, which occurs frequently, I have the option of setting up a special type of physician-to-physician appeal called a "peer-to-peer."

Here's the thing: After a few minutes of pleasant chat with a doctor or pharmacist working for the insurance company, they almost always approve coverage and give me an approval number. There's almost never a back-and-forth discussion; it's just me saying a few key words to make sure the denial is reversed.

Because it ends up with the desired outcome, you might think this is reasonable. It's not. On most occasions the "peer" reviewer is unqualified to make an assessment about the specific services. They usually have minimal or incorrect information about the patient. Not one has examined or spoken with the patient, as I have. None of them have a long-term relationship with the patient and family, as I have.

The insurance company will say this system makes sure patients get the right medications. It doesn't. It exists so that many patients will fail to get the medications they need.

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Sunday, October 13, 2019

Overzealous in preventing falls, hospitals are producing an ‘epidemic of immobility’ in elderly patients - The Washington Post

Dorothy Twigg was living on her own, cooking and walking without help until a dizzy spell landed her in the emergency room. She spent three days confined to a hospital bed, allowed to get up only to use a bedside commode. Twigg, who was in her 80s, was livid about being stuck in a bed with side rails and a motion sensor alarm, said Melissa Rowley, her cousin and caretaker.

"They're not letting me get up out of bed," Twigg protested in phone calls, Rowley recalled.

In just a few days at the Ohio hospital, where she had no occupational or physical therapy, Twigg grew so weak that it took three months of rehab to regain the ability to walk and take care of herself, Rowley said. Twigg repeated the same pattern — three days in bed in a hospital, three months of rehab — at least five times in two years.

Falls remain the leading cause of fatal and nonfatal injuries for older Americans. Hospitals face financial penalties when they occur. Nurses and aides get blamed or reprimanded if a patient under their supervision hits the ground.

But hospitals have become so overzealous in fall prevention that they are producing an "epidemic of immobility," experts say. To ensure that patients will never fall, hospitalized patients who could benefit from activity are told not to get up on their own — their bedbound state reinforced by bed alarms and a lack of staff to help them move.

That's especially dangerous for older patients, often weak to begin with. After just a few days of bed rest, their muscles can deteriorate enough to bring severe long-term consequences.

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Thursday, October 10, 2019

Doctors Limit What to Tell Patients About Their DNA Test. Should They? - WSJ

The Mayo Clinic is scanning 20,000 genes for thousands of patients to study genes' role in disease. It will hand over results for just 59.

Mayo will look for certain disease-causing gene variants for heart disease or breast cancer, and offer results to patients who have them. But it doesn't look at variants for early-onset Alzheimer's or Lou Gehrig's disease, meaning patients will remain in the dark.

"There is a risk of causing undue anxiety," said Dr. Keith Stewart, director of the Mayo Clinic's Center for Individualized Medicine.

DNA sequencing is creating vast amounts of data that promise to unlock the secrets of disease. But the information is being collected faster than the medical world can interpret what it all means. That is raising a question for doctors and scientists who perform the scans: How much should they tell patients?

The answer, often, is not much. Many clinics and studies will return only a few dozen results that researchers have deemed "medically actionable"—meaning they reveal genetic causes for conditions that can be treated.

Doctors often don't analyze and return other results because the risk of a trait isn't well-understood or because there is no treatment. Not everyone with disease-causing variants will end up with a related condition, because of other genetic and environmental factors. The risk may be low for some.

If told, some patients could seek unnecessary or harmful care, or unduly worry about a disease they may not get.

Some doctors, however, say it is paternalistic to withhold information if patients want it. Several studies have suggested that most patients want to learn their own genetic results.

"It's their body and their DNA. We have a responsibility to scientific truth and clear communication," including helping patients integrate results into their care, said Dr. Robert Green, a geneticist who is a professor at Harvard Medical School. He said doctors shouldn't "take the Jack Nicholson line, 'You can't handle the truth!' "

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Sunday, September 29, 2019

‘Out here, it’s just me’: In the medical desert of rural America, one doctor for 11,000 square miles - The Washington Post

He woke up to the sound of an ambulance's siren, knowing that the ambulance would soon be delivering another patient to him. Ed Garner, 68, changed into medical scrubs and walked out to his truck. He dialed the hospital as he started driving toward the emergency room.

"Any idea what might be coming?" he asked, but all anyone knew for certain was that the ambulance was still on its way out to a patient. Sometimes the paramedics were back within minutes, and other trips took nearly two hours. Sometimes they delivered Garner a patient in minor distress, and other times they brought him unresponsive victims of car crashes, heart attacks, drug overdoses or ranching accidents.

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What a 'good death' actually looks like - The Washington Post

At age 86, my father had survived both colon cancer and a stroke that left him with aphasia. His mind was sharp, though, and he wasn't depressed. A crack bridge player with a passion for Italian restaurants, he was popular at his assisted living facility even though he couldn't speak much. He told me he'd lived a good life and wasn't afraid of dying, and he didn't want to go through any more medical trauma. No chemo, no radiation, no surgeries, no treatment.

His advance directive read DNR and DNI — do not resuscitate, do not intubate. No one would break his ribs doing CPR or make bruises bloom along his arms trying to find a vein. As his health-care proxy, I was completely on board. I'd read Sherwin Nuland's "How We Die," Atul Gawande's "Being Mortal," Elisabeth Kubler-Ross's "On Death and Dying." Comfort would be the priority and any pain would be "managed," which I assumed meant erased.

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Saturday, September 21, 2019

Football Players? Or Lab Rats Who Can Run and Pass? - The New York Times

The new training room in the $28 million football operations building at Louisiana State features jetted tubs, antigravity treadmills and sodium-infused water coolers. A room nearby holds another piece of equipment tucked out of sight: a centrifuge.

It is another example of how modern efforts to improve performance in big-time college athletics have moved beyond smoothies and sleep monitors. The centrifuge is used for blood work for injury treatments such as platelet-poor plasma therapy and stem-cell injections.

L.S.U. players also regularly have their sweat analyzed for nutritional deficiencies. They swallow digestible electronic pills that monitor body temperature. This summer, a dozen athletes wore neuroimaging headgear for the first time to get a peek at how their brains function in simulated athletic conditions.

Colleges have long boasted about world-class research laboratories and world-class athletic programs. Lately, the chances are greater that the two will intersect.

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Wednesday, September 18, 2019

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

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

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

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

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

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

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Monday, September 9, 2019

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

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

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

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

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

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

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

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Walking on Eggshells in Medical Schools - The New York Times

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

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

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

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Wednesday, August 28, 2019

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

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

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

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

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

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Monday, August 26, 2019

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

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

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

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

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

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

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Sunday, July 28, 2019

What Happens When Lyme Disease Becomes an Identity?

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

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

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

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Saturday, July 27, 2019

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Thursday, July 25, 2019

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

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

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

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

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

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Monday, July 8, 2019

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

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

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

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

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

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Doctors are ageist — and it's harming older patients - NBC News

When I accompanied my 85-year-old father to a doctor's appointment not long ago, his primary care physician brushed off his complaints about chronic back pain, as well as my observations about his failing memory and balance problems. It's normal at his age, he told me. When asked about the 14 different medications and supplements he's on, the PCP quickly scanned several pages in the electronic record but decided not to make any changes since other specialists prescribed them for good reason. He mentioned that he wasn't comfortable overruling another physician, though he also wouldn't take any action on his own, like supplying him with a walker.

My dad, sadly, is not the only elderly patient to take so many medications — and to have his doctor dismiss his concerns about them with a shrug. The problems start early in the drug treatment process: Frequently excluded from clinical trials are the very older adults the medications are meant to help — and whose changing physiology causes them to metabolize drugs differently. Similarly, some doctors fail to recognize when standard medication doses are only appropriate for much younger patients.

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Thursday, July 4, 2019

Scientists Are Giving Dead Brains New Life. What Could Go Wrong? - The New York Times

A few years ago, a scientist named Nenad Sestan began throwing around an idea for an experiment so obviously insane, so "wild" and "totally out there," as he put it to me recently, that at first he told almost no one about it: not his wife or kids, not his bosses in Yale's neuroscience department, not the dean of the university's medical school.

Like everything Sestan studies, the idea centered on the mammalian brain. More specific, it centered on the tree-shaped neurons that govern speech, motor function and thought — the cells, in short, that make us who we are. In the course of his research, Sestan, an expert in developmental neurobiology, regularly ordered slices of animal and human brain tissue from various brain banks, which shipped the specimens to Yale in coolers full of ice. Sometimes the tissue arrived within three or four hours of the donor's death. Sometimes it took more than a day. Still, Sestan and his team were able to culture, or grow, active cells from that tissue — tissue that was, for all practical purposes, entirely dead. In the right circumstances, they could actually keep the cells alive for several weeks at a stretch.

When I met with Sestan this spring, at his lab in New Haven, he took great care to stress that he was far from the only scientist to have noticed the phenomenon. "Lots of people knew this," he said. "Lots and lots." And yet he seems to have been one of the few to take these findings and push them forward: If you could restore activity to individual post-mortem brain cells, he reasoned to himself, what was to stop you from restoring activity to entire slices of post-mortem brain?

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Wednesday, June 26, 2019

Opinion: Patients’ families are more than just ‘visitors’ | Montreal Gazette

As a medical student, I participated in a group session to demonstrate the impact of illness on families. One patient was asked to stand, given a piece of coloured thread and asked to choose a "spouse" from the group. The chosen spouse stood too, and took the string, creating a bond. This couple pretended to have children: new string colours were chosen. The children grew up and formed their own relationships until everyone was standing with connecting strings. The room became a blend of colours, the tangled network no longer decipherable.

"Imagine someone gets sick," said the facilitator, "what will happen to all the string?"

One person sat. We couldn't maintain our hold, and the web plunged downward, pulling us all toward the floor.

My sister's untimely death in 2017 reinforced this powerful lesson. But doctors shouldn't require a family crisis to understand the family's experience of health care. Health care that focuses only on the patient, and does not engage family, is woefully inadequate.

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Monday, June 24, 2019

The Pediatrician’s Most Awkward Task - The Atlantic

When Carrie Quinn was training to be a pediatrician, she dutifully memorized the list of symptoms for meningitis. She learned the right antibiotics for pneumonia. But when she got into the clinic, she found herself unprepared for what actually concerned parents.

"What I was actually faced with wasn't seriously sick children," Quinn, who's now the executive director of the Mount Sinai Parenting Center, said on a panel at Aspen Ideas: Health, which is co-hosted by the Aspen Institute and The Atlantic. More often, it was parents anxious over what to do about their kids' behavior issues or language delays.

Ben Danielson, another panelist and the medical director of the Odessa Brown Children's Clinic in Seattle, jumped in: "You made the joke the other day that, so often, a [doctor] who finishes pediatric residency would way rather intubate a baby than talk about breastfeeding." Talking about how to parent might be one of hardest parts of being a pediatrician.

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Friday, June 21, 2019

The Need for Clinical Trial Navigators - The New York Times

Since a Phase I trial has prolonged my life for almost seven years, I find it perplexing that fewer than 5 percent of adult American cancer patients enroll in clinical studies. Why do so few people — with various stages and types of cancer — participate in research that can improve care?

One obstacle may be the baffling scaffolding scientists erect around their studies. For example, cancer is a disease of aging, but many clinical trials on cancer drugs exclude older people from participating.

One study, in The Journal of Clinical Oncology, found that older patients "are underrepresented in cancer clinical trials relative to their disease burden."

In another study on the exclusion of large segments of cancer populations, published last year in The Oncologist, researchers argued that "the criteria for participation in some clinical trials may be overly restrictive and limit enrollment."

But the problem of low enrollment is often attributed to patient resistance. The reluctance of some patients makes perfect sense to me. Fear about unforeseen side effects escalates when consent forms, like the ones I signed, state that a new regimen cannot cure but might kill patients.

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Wednesday, June 19, 2019

Rude Surgeons May Have Worse Patient Outcomes : Shots - Health News : NPR

As a group, surgeons are not well known for their bedside manner. "The stereotype of the abrasive, technically gifted ... surgeon is ubiquitous among members of the public and the medical profession," write the authors of a 2018 article in the AMA Journal of Ethics. While poor manners aren't commonly accepted in most professional circles, representations of surgeons in popular culture often link technical prowess with rude behavior, and some surgeons have even argued that insensitivity can be helpful in such an emotionally strenuous profession.

A study published Wednesday in JAMA Surgery challenges these ideas. The study, which looked at interactions between surgeons and their teams, found that patients of surgeons who behaved unprofessionally around their colleagues tended to have more complications after surgery. Surgeons who model unprofessional behavior can undermine the performance of their teams, the authors write, potentially threatening patients' safety.

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Thursday, June 13, 2019

In ‘Let Me Not Be Mad,’ a Doctor Is One of His Own Case Studies - The New York Times

There are always two experts in a consulting room, A.K. Benjamin writes in his magnificently unsettling new book, "Let Me Not Be Mad." There is the patient, and there is the doctor — "one skilled in the particular experience of symptoms, the other in investigating them, first- and third-person accounts vying for the same conceptual ground."

What happens when these accounts vie in one person — when doctor and patient are the same? Benjamin, a British clinical neuropsychologist, weaves together the stories of his patients' "unraveling minds" with his own history of mental illness. Portraits of patients suffering from traumatic brain injury or dementia open up to reveal larger aspects of clinical practice, the brain and the kind of porousness Benjamin believes his profession requires. His interest isn't merely in describing this empathy but evoking it, slightly coercively, from the reader (there's an annoying yet undeniably powerful twist in this tale that I'm trying to sidestep).

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Friday, June 7, 2019

Warning of ‘Pig Zero’: One Drugmaker’s Push to Sell More Antibiotics - The New York Times

Facing a surge in drug-resistant infections, the World Health Organization issued a plea to farmers two years ago: "Stop using antibiotics in healthy animals."

But at last year's big swine industry trade show, the World Pork Expo in Des Moines, one of the largest manufacturers of drugs for livestock was pushing the opposite message.

"Don't wait for Pig Zero," warned a poster featuring a giant picture of a pig peeking through an enormous blue zero, at a booth run by the drugmaker Elanco.

The company's Pig Zero brochures encouraged farmers to give antibiotics to every pig in their herds rather than waiting to treat a disease outbreak caused by an unknown Patient Zero. It was an appealing pitch for industrial farms, where crowded, germ-prone conditions have led to increasing reliance on drug interventions. The pamphlets also detailed how feeding pigs a daily regimen of two antibiotics would make them fatter and, as any farmer understands, a heavier pig is a more profitable pig.

The rise of drug-resistant germs, caused by overuse of antibiotics, is one of the world's most nettlesome health predicaments. Excessive use of the medicines has allowed germs to develop defenses against them, rendering a growing number of drugs ineffective for people and animals. The practices of livestock farmers, who for decades have used huge quantities of the drugs deemed important to humans, have long been viewed as one of the roots of the problem, but the role of the companies that make the drugs has received less scrutiny.

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Sunday, June 2, 2019

Tweet by Julia Loewenthal, MD on Twitter

Julia Loewenthal, MD (@LoewenthalMd)
1/21 "Is there a nurse or doctor on board?"

Clinicians—have you ever responded to one of these?

Last week I left the hospital and boarded a flight for my vacation. I then responded to the mother of all in-flight emergencies…

Thursday, May 30, 2019

Doctors Were Alarmed: ‘Would I Have My Children Have Surgery Here?’ - The New York Times

Tasha and Thomas Jones sat beside their 2-year-old daughter as she lay in intensive care at North Carolina Children's Hospital. Skylar had just come out of heart surgery and should recover well, her parents were told. But that night, she flatlined. Doctors and nurses swarmed around her, performing chest compressions for nearly an hour before putting the little girl on life support.

Five days later, in June 2016, the hospital's pediatric cardiologists gathered one floor below for what became a wrenching discussion. Patients with complex conditions had been dying at higher-than-expected rates in past years, some of the doctors suspected. Now, even children like Skylar, undergoing less risky surgeries, seemed to fare poorly.

The cardiologists pressed their division chief about what was happening at the hospital, part of the respected University of North Carolina medical center in Chapel Hill, while struggling to decide if they should continue to send patients to UNC for heart surgery.

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Wednesday, May 22, 2019

Can efforts to bottle MDMA’s magic transform psychiatry? - The Verge

On a chilly spring morning in 2017, Boris Heifets took the podium to talk about MDMA in an Oakland, California, hotel ballroom packed with scientists, therapists, patients, and activists. If he noticed the occasional whiffs of incense and patchouli oil coming from the halls of the Psychedelic Science meeting, he didn't let on. After all, anyone studying the therapeutic benefits of the drug that sparked an underground dance revolution 30 years ago knows that ravers, Burners, and old hippies flock to this meeting. It's the world's largest gathering on psychoactive substances.

Ecstasy enthusiasts and university professors alike heard several research teams report that MDMA helped patients recover from post-traumatic stress disorder (PTSD) and other disabling psychiatric conditions after conventional treatments had failed. Meeting rooms buzzed with excited chatter about the prospect of MDMA getting approved as a prescription therapy for PTSD. That could come as early as 2021 if it proves safe and effective in large clinical studies that are just getting underway. For many advocates of this work, regulatory approval can't arrive too soon.

But Heifets, a Stanford neuroanesthesiologist, had come to lay out an even grander role for the drug federal officials banned in 1985 in a futile effort to quash the burgeoning rave scene. Psychiatric treatments lag decades behind the rest of medicine, even though serious mental disorders carry just as much risk of disability and death as cardiovascular disease, Heifets explained. Psychiatrists desperately need more targeted therapies to give their patients the same kind of rapid, enduring relief that stents and bypass surgery provide for heart patients. He thought they'd benefit from thinking like surgeons. "I don't want to suggest that we can cure psychiatric disease in 30 minutes in the operating room," Heifets said. But we can harness powerful drugs like MDMA that act like a surgeon's knife to alter consciousness and exorcise psychological demons.

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Tuesday, May 21, 2019

A.I. Took a Test to Detect Lung Cancer. It Got an A. - The New York Times

Computers were as good or better than doctors at detecting tiny lung cancers on CT scans, in a study by researchers from Google and several medical centers.

The technology is a work in progress, not ready for widespread use, but the new report, published Monday in the journal Nature Medicine, offers a glimpse of the future of artificial intelligence in medicine.

One of the most promising areas is recognizing patterns and interpreting images — the same skills that humans use to read microscope slides, X-rays, M.R.I.s and other medical scans.

By feeding huge amounts of data from medical imaging into systems called artificial neural networks, researchers can train computers to recognize patterns linked to a specific condition, like pneumonia, cancer or a wrist fracture that would be hard for a person to see. The system follows an algorithm, or set of instructions, and learns as it goes. The more data it receives, the better it becomes at interpretation.
The process, known as deep learning, is already being used in many applications, like enabling computers to understand speech and identify objects so that a self-driving car will recognize a stop sign and distinguish a pedestrian from a telephone pole. In medicine, Google has already created systems to help pathologists read microscope slides to diagnose cancer, and to help ophthalmologists detect eye disease in people with diabetes.

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Opinion | What Superbug Hunters Know That We Don’t - The New York Times

Antibiotic-resistant superbugs are everywhere. If your hospital claims it doesn't have them, it isn't looking hard enough.

Hospitals are losing an important public relations battle over the expanding threat of superbugs, including the deadly fungus Candida auris. Though states are tasked with conducting outbreak investigations, they aren't required to disclose their findings to the Centers for Disease Control and Prevention (and in many cases they haven't). Grieving families are pushing for more transparency, while patient advocates smell a cover-up, likening the scenario to a restaurant failing to report an outbreak of food poisoning. In the midst of all this mistrust, hospital spokesmen are declining to comment. This is a mistake.

I hate to be the bearer of bad news, but these microbes are in our homes, cars and grocery stores. One study found that even after the use of disinfectant, more than half of hospital rooms still contain a superbug. Nurses and doctors carry these things around, too. Roughly 5 percent of health care workers are colonized with MRSA, a bacterium that kills thousands of people in the United States every year, and another study found that 10 percent of patients entering a hospital had a multidrug-resistant species on their hands. You don't want to know what's hiding on a handkerchief.

Here's the thing: You almost certainly don't need to worry about any of this. Potentially deadly bacteria and fungi live harmlessly on our hands, feet, and faces, and may never cause a problem. There are trillions of bacteria living inside all of us. Why are we pretending they aren't on our gurneys, blood pressure cuffs and X-ray machines?

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Saturday, May 18, 2019

For patients, a caregiver’s compassion is essential - The Washington Post

The 34-year-old man lay in his ICU bed for over a month — dependent on a breathing tube and artificial respirator to stay alive. The patient knew his life hung in the balance, as he was a physician himself. Some days the suffering was so intense that he contemplated ways he could unplug the machine on his own.

Now, nearly 50 years later, that patient, Edward Viner, an oncologist who served as chief of the Department of Medicine at Cooper University Health Care in New Jersey for more than two decades, reflects on how he was able to survive such a harrowing experience.

It was the nurses he calls his "angels." But it was not all of his nurses. When it was time for shift change in the ICU, Viner says he felt that he could detect almost immediately if the nurse coming on duty truly cared. He could tell some nurses cared deeply, but some did not.

"When my nurses cared," he distinctly remembers, "I knew that shift would be a positive experience and that their compassion would help me fight on and help save me."

With all of Viner's knowledge from a lifetime of treating patients, does he really believe that his nurses' compassion changed his outcome? Is there data to back up the claim that caring can make a difference and that health-care outcomes are not just dependent on how much health-care providers know, but rather how much they care? We do not raise this consideration on ethical or emotional grounds, but rather on the basis of medical science.

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The Night The Lights Went Out - Deadspin

I am the least reliable narrator when it comes to the story of my brain exploding. This is because, from the time right before I suffered a freakish brain hemorrhage last year to the time I regained full consciousness roughly two weeks later, I remember nothing. My mind is an absolute blank. It's like the fabled pause in the Nixon Tapes. I was not here. That time of my life may as well not exist. Oh, but it did.

I remember hosting the Deadspin Awards in New York the night of Dec. 5 and then heading over to a karaoke bar for a staff after-party, where I ate some pizza, drank a beer, sang one song (Tom Petty's "You Got Lucky," which would soon prove either fitting or ironic, depending upon your perspective), and that's it. After that comes a great void. I don't remember inexplicably collapsing in a hallway, fracturing my skull because I had no way to brace myself for the impact. I don't remember sitting up after that, my co-workers alarmed at the sight of blood trickling out of the back of my head. I don't remember puking all over Barry Petchesky's pants, vomit being one of many fun side effects of your brain exploding, as he held my head upright to keep me from choking on my own barf. I don't remember Kiran Chitanvis quickly calling 911 to get me help. I don't remember getting into an ambulance with Victor Jeffreys and riding to an uptown hospital, with Victor begging me for the passcode to my phone so that he could call my wife. He says I made an honest effort to help, but my circuits had already shorted out and I ended up giving him sequences of four digits that had NOTHING to do with the code. Flustered, he asked me for my wife's phone number outright. Instead, I unwittingly gave him a series of 10 digits unrelated to the number he sought.

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Thursday, May 16, 2019

How Tiger Woods Won the Back Surgery Lottery - The New York Times

Few would have predicted that Tiger Woods would be playing in the P.G.A. Championship this week. He had three failed back surgeries, starting in 2014. He had taken opioids. His astonishing career seemed over.

Then he had one more operation, a spinal fusion, the most complex of all, in 2017. And last month he won the Masters, playing the way he used to.

An outcome like his from fusion surgery is so rare it is "like winning the lottery," Dr. Sohail K. Mirza, a spine surgeon at Dartmouth, said.

The idea behind spinal fusion is to remove a disk — a ring of fibers filled with a nerve-cushioning jelly that joins adjacent spine bones — and fuse the spine together, a procedure that almost inevitably means trading flexibility for stability and, the patient hopes, an existence with less pain.

That was all Woods was looking for when he decided to go ahead with fusion as a last resort — a "normal life" is how he put it. He got that and much more, including a new green blazer, though the lesson that most surgeons say Woods's experience teaches isn't that fusion surgery is a panacea but how much active rehabilitation and physical therapy the procedure requires for it to work.

"If you look at it simplistically, what does fusion do? It provides mechanical support," said Dr. Charles A. Reitman, co-director of the Spine Center at the Medical University of South Carolina. "If they are missing mechanical support and that is the pure cause of the problem, then they will get better."

People with a broken spine, for example, or scoliosis, which is severe spinal curvature, or spondylolisthesis, in which vertebrae slip out of place, tend to have terrific results, he said.

But those are a tiny minority of fusion patients. The vast majority of fusion procedures are performed on patients with one or more degenerated disks, disks that are worn out, dehydrated, stiff and friable. And when those disks move, patients' backs can ache.

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Wednesday, May 15, 2019

#Herpes, #Crohns, and #Depression: Meet the People Making Their Chronic Illnesses Instagram-Friendly - Daily Beast

Late last month, Theresa Eternity took a selfie. It wasn't out of the ordinary for the 22 year-old from Victoria, Canada, who frequently catalogues her many hair colors (pink, blue, green) on Instagram. But this photo was different: sporting a houndstooth blazer, crimson red lipstick, and fully bald head, Eternity announced to the world that she has alopecia.

"It's pretty vulnerable when you can't hide behind your hair, you're there for the world to see," Eternity wrote in an accompanying caption. "Sometimes I open my front camera and I look just like a thumb... but that's okay, because I'm learning and changing what femininity means to me."

Eternity punctuated her 150-word disclosure with 13 hashtags, including #alopecia, #alopeciaareata, and #bigbadbaldie. She joined over 750,000 people (and probably more than a few bots) who have used #alopecia to classify a confessional post. These communities of patients inspired Eternity to share her own story.

After visiting multiple doctors who ran tests for everything from thyroid disease to iron deficiency, Eternity was diagnosed with alopecia areata. In medical circles, the chronic condition—which causes hair to fall out in patches—is considered more of a cosmetic nuisance than a health crisis.

"They were lax in sympathy and empathy," Eternity told The Daily Beast. Her physician unceremoniously ended the appointment by suggesting she see a dermatologist. Not satisfied, Eternity turned to Instagram support groups where she found a community that understood her pain.

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The (A.I.) Doctor Will See You Now - Daily Beast

You've done it before: Perhaps you have a weird rash or feel a little strange, something beyond the usual flu or back pain. You Google it, becoming part of the 75 million Americans who use WebMD each month to check symptoms, rule out conditions, or to go down a hypochondriacal rabbit hole (unsurprisingly, "cyberchondria" is a real thing).

According to a BMJ study, online symptom-checking websites provide accurate diagnoses roughly half the time, amounting to millions of people worrying unnecessarily or, worse, breathing a sigh of relief when something's actually wrong.

But what if artificial intelligence could accurately diagnose you—and save you a trip to the doctor's office?

It's not a crazy idea. The UK has integrated an AI-powered healthcare system called Babylon into its National Health Service, separating patients with urgent needs from those with more run-of-the mill illnesses.

And it's simple. If you type, "I have a cough and fever. What's wrong with me?" Babylon's AI will ask for more details and run through a list of other possible symptoms to determine whether you should go see a doctor or whether you can buy over-the-counter meds and send yourself to bed.

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Monday, May 6, 2019

We Need New Ways of Treating Depression - Vox

As the 21st century was beginning, a South African psychiatrist named Derek Summerfield happened to be in Cambodia conducting some research on the psychological effects of unexploded land mines — at a time when chemical antidepressants were first being marketed in the country.

The local doctors didn't know much about these drugs, so they asked Summerfield to explain them. When he finished, they explained that they didn't need these new chemicals — because they already had antidepressants. Puzzled, Summerfield asked them to explain, expecting that they were going to tell him about some local herbal remedy. Instead, they told him about something quite different.

The doctors told Summerfield a story about a farmer they had treated. He worked in the water-logged rice fields, and one day he stepped on a land mine and his leg was blasted off. He was fitted with an artificial limb, and in time he went back to work. But it's very painful to work when your artificial limb is underwater, and returning to the scene of his trauma must have made him highly anxious. The farmer became deeply depressed.

So the doctors and his neighbors sat with this man and talked through his life and his troubles. They realized that even with his new artificial limb, his old job — working in the paddies — was just too difficult, that he was constantly stressed and in physical pain, and that these things combined to make him want to just stop living. His interlocutors had an idea.

They suggested that he work as a dairy farmer, a job that would place less painful stress on his false leg and produce fewer disturbing memories. They believed he was perfectly capable of making the switch. So they bought him a cow. In the months and years that followed, his life changed. His depression, once profound, lifted. The Cambodian doctors told Summerfield: "You see, doctor, the cow was an analgesic, and antidepressant."

In time, I came to believe that this little scene in Southeast Asia, which at first sounds just idiosyncratic, deeply "foreign," in fact represents in a distilled form a shift in perspective that many of us need to make if we are going to make progress in tackling the epidemic of depression, anxiety, and despair spreading like a thick tar across our culture.

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Wednesday, April 24, 2019

Getting to Know Our Patients - The New York Times

His email started out in a straightforward way, as most of the communications I receive from trainees do. He identified himself as being in his final year of medical school and asked about spending time rounding with me on our inpatient leukemia service. But then he went into territory I didn't anticipate.

"I am going into surgery and feel underprepared in managing patients with terminal diagnoses,'" he wrote. "I was hoping to spend this elective learning about this as it would be useful to my career in the future."

Medical students usually don't enter surgical fields for a love of terminal illnesses. Most are attracted by an approach to medical conditions typified by the braggadocio-laced line, "A chance to cut is a chance to cure." Surgery remains the most effective treatment for the majority of cancers. But leukemia, similar to other hematologic malignancies, is not a cancer for which surgery is a useful therapy, since its source, the bone marrow, can't be removed with a scalpel.

I respected him for recognizing that his education was deficient, and also suspected that whatever event had occurred leading to his request must have been traumatizing. He was asking to spend some of his precious remaining time as a medical student taking care of patients who would never be a part of his future practice. I invited him to join me.

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Tuesday, April 23, 2019

Life — after life: Does consciousness continue after our brain dies? | National Post

He could see a nurse and doctor, a bald, "chunky fella" dressed in blue hospital scrubs. He watched as they frantically worked on his body, which was remarkable, considering he was, essentially, dead.

The man had suffered a cardiac arrest. Normally there is no measurable, meaningful brain activity after the heart stops beating. Within two to 20 seconds the brain "flatlines."

But the man would later tell researchers that he could see an unfamiliar woman beckoning from a corner up in the ceiling. "I can't get up there," he remembered thinking to himself, and then the next second, "I was up there, looking down at me."

He said he saw his blood pressure being taken, and a doctor putting something down his throat. He saw a nurse pumping on his chest. He accurately and vividly described the people, sounds and events of his "resurrection."

The case was part of a widely reported study Parnia published in 2014 called AWARE — the awareness during resuscitation trial, the world's largest study of what happens to the human mind and consciousness in the early period of death.

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Sunday, March 24, 2019

I’m a Journalist. Apparently, I’m Also One of America’s “Top Doctors.” — ProPublica

My eyes narrowed when the woman on the voice message told me to call about my "Top Doctor" award.

They needed to "make sure everything's accurate" before they sent me my plaque, she said.

It was a titillating irony. I don't have a medical degree, and I'm not a physician. But I am an investigative journalist who specializes in health care. So I leaned forward in my seat with some anticipation when I returned the call last year. I spoke to a cheerful saleswoman named Anne at a company on New York's Long Island that hands out the Top Doctor Awards. For some reason, she believed I was a physician and, even better, worthy of one of their awards. Puzzled and amused, I took notes.

I asked how I had been selected. My peers had nominated me, she said buoyantly, and my patients had reviewed me. I must be a "leading physician," she said.

At this point, of course, it'd be tempting to dismiss the call, and the award, as ridiculous. But I knew such awards are the perfect dovetail of doctors' egos and patients' desperate need to find a good physician. Many patients assume that the awards are backed by rigorous vetting and standards to ensure only the "best" doctors are recognized. Hospitals and physicians lend credibility to the facade by hanging the awards in their offices and promoting them on their websites.

And now, for reasons still unclear, Top Doctor Awards had chosen me — and I was almost perfectly the wrong person to pick. I've spent the last 13 years reporting on health care, a good chunk of it examining how our health care system measures the quality of doctors. Medicine is complex, and there's no simple way of saying some doctors are better than others. Truly assessing the performance of doctors, from their diagnostic or surgical outcomes to the satisfaction of their patients, is challenging work. And yet, for-profit companies churn out lists of "Super" or "Top" or "Best" physicians all the time, displaying them in magazine ads, online listings or via shiny plaques or promotional videos the companies produce for an added fee.

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Friday, March 22, 2019

When Email Comes to the Doctor’s Office, Wait Times Decrease - The New York Times

The kind of thing we have done instinctively in our workplaces for two decades — sending a quick email instead of setting up a meeting — has until recently eluded many doctors.

Electronic consultations, or eConsults (sometimes called eReferrals), are a growing way for primary care doctors and specialists to communicate with each other securely. They can help patients avoid additional visits to specialists and free up capacity in crowded health systems, reducing waiting times for others.

Studies have found that a large proportion of referrals to specialists — upward of 40 percent in some cases — are not needed.

Getting the right medical advice without another visit to a specialist might be especially helpful for patients on Medicaid or without insurance. One national study found that nearly one-third of specialists are unwilling to make appointments with new Medicaid patients. Delays in getting the right advice from a specialist can cause harm. For patients who would have to travel far to see specialists — those in rural areas, for example — eConsults can save considerable time, expense and headaches.

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Sunday, March 17, 2019

Did Your Doctor Disappear Without a Word? A Noncompete Clause Could Be the Reason - The New York Times

When Don Cue developed a bladder infection last fall, he called his longtime urologist's office for a urine culture and antibiotics. It was a familiar routine for the two-time prostate cancer survivor; infections were not uncommon since he began using a catheter that connects to his bladder through an incision in his abdomen.

When Mr. Cue called this time, a receptionist told him that his physician, Dr. Mark Kellerman, no longer worked at the Iowa Clinic in Des Moines, a large multi-specialty group. She refused to divulge where he had gone.

"As a patient, 'scared' is too strong a word, but my feeling is, 'What do I do now?'" said Mr. Cue, 58.

Flummoxed, he solved his immediate problem by taking leftover antibiotics he had in his medicine cabinet.

It was only later that he learned his doctor had been fired by the Iowa Clinic and planned to start a urology practice with clinic colleagues. And, under the terms of their contract with their former employer, the doctors were banned for a year from practicing within 35 miles of the clinic, and from recruiting former patients to follow them.

Contracts with so-called restrictive covenants are now common in medicine, although some states limit their use. Noncompete clauses — common in many commercial sectors — aim to stop physicians and other health care professionals from taking patients with them if they move to a competing practice nearby or start their own. But what may be good for business can be bad for patient care — and certainly disquieting for those whose doctors seem to simply disappear.

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Saturday, March 16, 2019

Apple Watch app could save your life by detecting irregular heartbeat, study says - CNN

Has a new bar been set for wearable technologies? An Apple Watch may detect heart rate irregularities that subsequent medical tests confirm to be atrial fibrillation, according to preliminary findings from a new study. AFib is often undiagnosed since it might not cause noticeable symptoms, but it contributes to 130,000 deaths and 750,000 hospitalizations in the United States each year.

New results from the Apple-funded study, which have not been published or peer-reviewed, were presented Saturday at the American College of Cardiology Scientific Session in New Orleans.

"The study's findings have the potential to help patients and clinicians understand how devices like the Apple Watch can play a role in detecting conditions such as atrial fibrillation," Dr. Mintu Turakhia, co-principal investigator and associate professor of cardiovascular medicine at Stanford Medical School, said in a statement.

Turakhia and his colleagues conducted a virtual study with more than 400,000 participants to understand whether a mobile app using data from a heart rate pulse sensor can identify atrial fibrillation.

Participants had both an iPhone and an Apple Watch, though not the most recent version, which features built-in electrocardiography (ECG), because it was released after the study's launch.

Intermittently, a special app checked each participant's heart-rate pulse sensor for an irregular pulse, and if it was detected, the participant would receive a notification and was asked to schedule a telemedicine consultation with a study doctor. Next, the participant would be sent ambulatory (walking) ECG patches to record the rhythm of their heart for up to a week.

The findings suggest how wearables might help to detect conditions before they strike, the researchers say.

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Tuesday, March 12, 2019

What I learned from donating a kidney to my 70-year-old father - Vox

Two summers ago, my father asked if I would give him one of my kidneys.

He was 70 at the time, suffering from kidney disease. I was 39 with a wife and two young kids, and I was blindsided by his request. I just said, "I'll think about it. Give me the information."

I did think about it. A year later, my father and I found ourselves at Saint Barnabas Medical Center in Livingston, New Jersey, where doctors would remove one of my kidneys and transplant it into him. It was one of the most difficult decisions I've ever made — and in the end, while it was certainly gratifying, what truly convinced me to do it was that all the facts and data told me that it was simply the sensible, practical, right thing to do.

You may have read Dylan Matthews's account on this very site of his kidney donation to a total stranger. It was a remarkably generous act, and I admire him deeply for it.

But that experience is fairly uncommon. The fact is that 95 percent of live donors give their kidneys to someone they know. Out of the more than 6,000 live donor transplants made last year in the United States, some 300 were donated to strangers. Most donors never thought this is something we would do until faced with the prospects of a loved one going into kidney failure.

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Sunday, February 24, 2019

Pinterest Restricts Vaccine Search Results to Curb Spread of Misinformation - The New York Times

Pinterest, a digital platform popular with parents, took an unusual step to crack down on the proliferation of anti-vaccination propaganda: It purposefully hobbled its search box.

Type "vaccine" into its search bar and nothing pops up. "Vaccination" or "anti-vax"? Also nothing.

Pinterest, which allows people to save pictures on virtual pinboards, is often used to find recipes for picky toddlers, baby shower décor or fashion trends, but it has also become a platform for anti-vaccination activists who spread misinformation on social media.

It is an especially effective way to reach parents: 80 percent of mothers and 38 percent of fathers in the United States are on Pinterest, according to 2017 data from comScore. The company has more than 250 million monthly active users and is expected to go public this year.

Other platforms like Facebook and YouTube have also been infiltrated with misinformation about vaccines, and are taking steps to combat it. One of YouTube's policies is to demonetize anti-vaccine videos.

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Friday, February 22, 2019

One number determines who gets an organ transplant, and it's horribly unfair - Chicago Tribune

We have a liver selection meeting every Wednesday to consider which patients will get transplants. Each patient is listed by name, age, weight, diagnosis and MELD score - a number, based entirely on lab values, that predicts how bad their liver is and correlates with how likely they are to die waiting for a transplant. A score of 15 is where we start to consider transplantation, and 40 means a 90 percent chance of dying within three months.

Scanning the list, I noticed with discomfort that the patients at the top, with a MELD of 35 or more, had mostly the same diagnoses: alcoholic liver disease; nonalcoholic steatohepatitis, or NASH, a consequence of obesity leading to fatty liver; and an occasional hepatitis C, a virus that was once the most common indication for liver transplant but now is being cured. This was not surprising. These diagnoses make up greater than 60 percent of the national waitlist, and that number continues to grow.

What was making me uncomfortable was that Nate, a medical student on our service, was sitting behind me.

Nate was diagnosed in college with primary sclerosing cholangitis, a rare disease that destroys the liver and leads to irrepressible itching, recurrent infections, possible liver cancer and near-certain death unless a liver transplant is done in time. The problem is, Nate's MELD score remained in the mid-20s - too low to get a liver.

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Tuesday, February 19, 2019

Five Things I Wish I’d Known Before My Chronic Illness - The New York Times

Seven Thanksgivings ago, I got sick and I never got better.

What I thought was food poisoning turned out to be Crohn's disease, a form of inflammatory bowel disease (IBD) that doesn't have a cure. It fools my immune system into attacking my digestive system, resulting in what I can only describe as the attempted birth of my intestines through my butthole. It's a cruel and often debilitating disease.

Since that first hospital stay, I've had colonoscopies, biopsies, CT scans, X-rays, blood and stool tests, enemas, suppositories, rectal foams, antiemetics, antidiarrheals, antivirals, antibiotics, anti-inflammatories, opiates, steroids, immunoglobulin, biologics and three fecal transplants (if you want to hear a story about my 9-year-old poop donor and a blender, find me on Twitter).

My disease is managed now thanks to an expensive drug called infliximab, but the future is unpredictable. IBD works in patterns of flares and remissions, and little is known about what causes either.

When I was diagnosed, I didn't know how much my life would change. There's no conversation about that foggy space between the common cold and terminal cancer, where illness won't go away but won't kill you, so none of us know what "chronic illness" means until we're thrown into being sick forever.

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Tuesday, February 12, 2019

Why Do South Asians Have Such High Rates of Heart Disease? - The New York Times

Mahendra Agrawal never imagined he would have a heart attack. He followed a vegetarian diet, exercised regularly and maintained a healthy weight. His blood pressure and cholesterol levels were normal.

But when Mr. Agrawal experienced shortness of breath in June 2013, his wife urged him to go to a hospital. There, tests revealed that Mr. Agrawal, who was 63 at the time, had two obstructed coronary arteries choking off blood flow to his heart, requiring multiple stents to open them.

"I'm a pretty active guy and I eat very healthy, my wife makes sure of that," said Mr. Agrawal, who lives in San Jose and worked in the electronics industry. "It makes me wonder why this happened to me."

Despite his good habits, there was one important risk factor Mr. Agrawal could not control: his South Asian ancestry. Heart disease is the leading killer of adults nationwide, and South Asians, the second fastest-growing ethnic group in America, have a higher death rate from the disease than any other ethnic group. People of South Asian descent, which includes countries like India, Pakistan, Bangladesh, Nepal, Sri Lanka, Bhutan and the Maldives, have four times the risk of heart disease compared to the general population, and they develop the disease up to a decade earlier.

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Monday, February 11, 2019

A.I. Shows Promise as a Physician Assistant - The New York Times

Each year, millions of Americans walk out of a doctor's office with a misdiagnosis. Physicians try to be systematic when identifying illness and disease, but bias creeps in. Alternatives are overlooked.

Now a group of researchers in the United States and China has tested a potential remedy for all-too-human frailties: artificial intelligence.

In a paper published on Monday in Nature Medicine, the scientists reported that they had built a system that automatically diagnoses common childhood conditions — from influenza to meningitis — after processing the patient's symptoms, history, lab results and other clinical data.

The system was highly accurate, the researchers said, and one day may assist doctors in diagnosing complex or rare conditions.

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Wednesday, February 6, 2019

Making New Drugs With a Dose of Artificial Intelligence - The New York Times

You can think of it as a World Cup of biochemical research.

Every two years, hundreds of scientists enter a global competition. Tackling a biological puzzle they call "the protein folding problem," they try to predict the three-dimensional shape of proteins in the human body. No one knows how to solve the problem. Even the winners only chip away at it. But a solution could streamline the way scientists create new medicines and fight disease.

Mohammed AlQuraishi, a biologist who has dedicated his career to this kind of research, flew in early December to Cancun, Mexico, where academics were gathering to discuss the results of the latest contest. As he checked into his hotel, a five-star resort on the Caribbean, he was consumed by melancholy.

The contest, the Critical Assessment of Structure Prediction, was not won by academics. It was won by DeepMind, the artificial intelligence lab owned by Google's parent company.

"I was surprised and deflated," said Dr. AlQuraishi, a researcher at Harvard Medical School. "They were way out in front of everyone else."

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Friday, February 1, 2019

Caroline Elton Helps Doctors Heal Themselves - The New York Times

Caroline Elton, 61, the author of "Also Human: The Inner Lives of Doctors," is a London-based psychologist with an unusual practice. Her patients are physicians unhappy in their work.

We spoke for two hours on a recent afternoon in New York City. An edited and condensed version our conversation follows.

You titled your book "Also Human." Why?

My editor wanted to call it "Only Human." I was adamant that it should be "Also Human." I had written a book about the shared humanity of doctors and patients. Both are human!

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Saturday, January 26, 2019

Hospitals Are Asking Their Own Patients to Donate Money - The New York Times

Nonprofit hospitals across the United States are seeking donations from the people who rely on them most: their patients.

Many hospitals conduct nightly wealth screenings — using software that culls public data such as property records, contributions to political campaigns and other charities — to gauge which patients are most likely to be the source of large donations.

Those who seem promising targets for fund-raising may receive a visit from a hospital executive in their rooms, as well as extra amenities like a bathrobe or a nicer waiting area for their families.

Some hospitals train doctors and nurses to identify patients who have expressed gratitude for their care, and then put the patients in touch with staff fund-raisers.

These various tactics, part of a strategy known as "grateful patient programs," make some people uncomfortable. "Wealth screenings strike me as unseemly but not illegal or unethical," said Arthur Caplan, a bioethicist at the New York University School of Medicine.

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Wednesday, January 9, 2019

When the Illness Is a Mystery, Patients Turn to These Detectives - The New York Times

They are patients with diseases that mystify doctors, people whose symptoms are dismissed as psychosomatic, who have been given misdiagnosis upon misdiagnosis.

They have confounded experts and have exhausted every hope save one. And so they wind up in the Undiagnosed Diseases Network, a federally funded project that now includes 12 clinical centers, including one at the National Institutes of Health in Bethesda, Md.

Researchers in the network pursue every possible clue — gleaned from genetics, imaging, biochemistry, clinical exams — to discover what is wrong with these patients.

In a recent study, 1,519 patients were referred to the network, but less than half were accepted for intensive evaluation at no charge. The network completed evaluations of 382 participants and found a diagnosis for 132 of them. (In the time since the study ended, the investigators have diagnosed another 128 patients.)

For some, there was good news: a treatment, often a drug that was already on the market for another condition.

Yet even patients who come away with a diagnosis but without a treatment, say the experience can be rewarding.

"Patients find it really valuable even just to give a name to the enemy," said Dr. Euan Ashley, a geneticist at Stanford University and co-director of the network.

Those who come away without a diagnosis or treatment are told that if the science improves and an answer for them emerges, the network will contact them.

"We never give up," Dr. Ashley said.

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