September 17, 2018

When I grow up, I’ll be a worse GP | Pulse Today

Swedish and British humor are fairly similar. That’s why I always enjoyed British sitcoms, back when I lived in Sweden and on PBS when I had a TV (stopped when they went digital, ten or fifteen years ago).

This entertaining piece was on the British GP website Pulse:

“At the age of 37, I contrive to look like a sensible professional to those who don’t know me. But I am not. I cannot adult. I don’t know if I’ll ever be able to. And the more I meet people older than me, the more I realise they are no more wise or together than I am, but are simply bemused adolescents trapped in the body of a grown-up.

I may never master adulting. But do you know what? I am proud. I am proud I frequently make stupid mistakes and laugh at them, and I choose my friends because they do the same. I think I am a more human and relatable GP for it.”

September 16, 2018

Air Pollution, Blood Pressure and Heart Attacks

Fine particle air pollution is associated with increased cardiovascular morbidity. Air purifier use causes measurable, rapid decrease in blood pressure in urban US elderly populations according to an article in JAMA Internal Medicine:

Effect of Portable Air Filtration Systems on Personal Exposure to Fine Particulate Matter and Blood Pressure Among Residents in a Low-Income Senior Facility –

September 15, 2018

Love in Medicine

Many physician bloggers do a lot of kvetching about the bureaucratic aspects of Medicine. I found one on KevinMD who seems to have a nobler purpose:

“Science as we know it today is a tool that we use in medicine, and how we use it and apply it can vary depending on whether we have love as our foundation or not. A medicine that is founded upon love, will use science responsibly for the benefit of all mankind and never could it allow its misuse for purely personal gain, and financial agendas as we often see today in the pharmaceutical business for example.”

September 14, 2018

The Lancet: A Broken Heart is the Epitome of Mind Body Medicine

Takotsubo cardiomyopathy of the 1990s, described in the 1847 Novel Wuthering Heights, is the topic of one of the typically philosophical essays in the current issue of The Lancet:

“Brontë’s assertion that the mind and emotions have control over the physical body, that Heathcliff can remind his “heart to beat”, is a progressive departure from a traditional biomedical focus on mind–body dualism. She is aware of the toll that despair can have on health. Heathcliff visits Catherine’s grave time and time again until her ghost at last appears. Overcome not by misery, but by happiness, Heathcliff’s heart finally breaks from overwhelming joy. The next day he is found dead in his room, a ghastly smile on his face: his weary heart at last broken with delight.”

September 13, 2018

JAMA: Is US Medical Care Inefficient?

September 12, 2018

Quality When Nobody is Watching?

Last week’s issue of The New England Journal of Medicine has an article that demonstrates that, in Britain, when incentives for achieving quality targets are removed, doctors’ behavior changes, and they don’t do those things anymore.

But the authors do admit that it may have something to do with the EMRs. It’s one thing to counsel a patient on a myriad of things, yet another to click all the awkwardly placed boxes to actually get credit for it. In my own EMR, there are a half dozen ways to document that BMI counseling was done, but only one shows up in the quality reports. If nobody’s counting, why make all the extra clicks for the bean counters; the office note still says I did it…

What the authors don’t say is that the “quality” parameters they looked at, from 2010 to 2017, include lipid control. I don’t know about the U.K., but in this country, the 2013 lipid guidelines ABANDONED and DISMISSED lipid TARGETS, since some cholesterol treatments have turned out to have little or no effect on cardiovascular mortality.

Quality is really too hard for nonmedical people and even medical administrators to try to measure.

September 11, 2018

Suicide: A Silent Contributor to Opioid-Overdose Deaths | NEJM

Not all opioid overdoses are accidental. But how common a method of suicide is prescribed opioid pain medication? And what is the likelihood that suicides by opioid go unreported?

“Perhaps of most relevance, 2006–2011 data from the Nationwide Emergency Department Sample that include information on more than 250,000 emergency department visits by adults for opiate overdose show that only 54% of the overdoses were classified as “unintentional”: 26.5% were deemed intentional, and 20.0% were “undetermined.” The data also document a steady annual increase in opiate-overdose visits to emergency departments. Together, these data suggest that the true proportion of suicides among opioid-overdose deaths is somewhere between 20% and 30%, but it could be even higher.”

September 2, 2018

Premortem Examination Can Help Decisions

This was an interesting read in the Sunday paper. Of course, the word “premortem” brought to mind “vivisection” in H.G. Wells’ “The Island of Dr. Moreau”, which I remember reading as a teenager:

Instead of weighing real or imagined pros and cons of two alternative courses of action, imagine the choice has already been made.

“The psychologist Gary Klein has developed a variation on this technique. He calls it a “premortem.” As the name suggests, the approach is a twist on the medical procedure of post-mortem analysis. In a post-mortem, the subject is dead, and the coroner’s job is to figure out the cause of death. In a premortem, the sequence is reversed: “Our exercise,” Dr. Klein explains, “is to ask planners to imagine that it is months into the future and that their plan has been carried out. And it has failed. That is all they know; they have to explain why they think it failed.”

Imagine having to make a difficult treatment decision. Then consider being fast forwarded into the future. Your patient’s surviving spouse says, in a faint voice:

“Doc, you made the wrong decision…”

August 23, 2018

Minority of GP trainees to stay in full-time clinical work

“Less than a quarter of GP trainees plan to practise full-time one year after qualifying, a think tank survey has revealed.

The survey of 729 GP trainees, conducted by the King’s Fund, found that just 22% of respondents ‘planned to work in full-time clinical general practice one year after qualifying.”

August 19, 2018

NYTimes: Vitamin D, the Sunshine Supplement, Has Shadowy Money Behind It

I never thought the vitamin D hysteria was making doctors rich; after all, you can buy it over the counter. But some docs are profiting…

“The doctor most responsible for creating a billion-dollar juggernaut has received hundreds of thousands of dollars from the vitamin D industry.”