May 30, 2024

A wise doctor (not me) once said, "Rules work great until they don't." I remember this aphorisim came up when thinking about a lupus patient and if they had infection. The rule goes like this: high ESR plus low CRP means the problem is from lupus, while both high means infection. But, do you trust the rule enough to treat for lupus when the drugs for lupus can make infection worse? If a patient has chest pain, you think drastic disease like pulmonary embolism or myocardial infarction. But, if the pain is sharp and worse with inspiration and oxygen saturation is normal, can we use common sense and say the patient has pleurisy and not order a chest x-ray, a cat scan, an EKG and a troponin? The higher the risk for seriously bad outcome, the more you turn to the shotgun approach. 

I remember working in a clinic in a small town in Oklahoma when I was a resident, i.e. moonlighting. I saw a patient with sinusitis and treated her with a prescription. After she left, I couldn't stop thinking that I was missing a case of meningitis. "What if the sinus infection went to her brain and that is why her head was hurting and why she had fever?" Maybe, I needed to do a lumbar puncture ("spinal tap")? I called to check on her and when I didn't get an answer, I drove to her house where she was sitting on her front porch in a rocker looking comfortable, not like a meningitis case, and I think she thought I was crazy. I remember another wise doctor (not me) saying, "if you think about doing an LP, you need to do it." Really? Maybe the point is these "rules" aren't really rules. Actually, maybe I need to check my definition of a rule.

References

https://en.wiktionary.org/

May 30, 2024

Iron deficiency is common especially among pre-menopausal women. Red blood cells transport oxygen. Iron is needed to make a RBC so when iron is low, anemia occurs. Low iron is treated with iron tablets but often this is hard to tolerate or just doesn't work, so some patients need IV iron. 

References

• Iron sucrose: Drug information. Uptodate

Mar 15, 2023

A 90 year old patient had a visible laceration on his arm. When asked about it, he said he was climbing a tree. “I was pretty high up there. I couldn’t leave that broken limb.” His wife said, "Tell him to quit climbing trees." Not infrequently, a family member complains that a patient needs to change their behavior and sometimes the instinctive reaction is a defensive shoulder shrug or add, “Let your family member enjoy his life. A glass of wine or a cheeseburger every now and then isn’t going to kill anyone.” But, in this case, the spouse deserved support and the patient.needed chiding  A fall from a tree at ninety years old could end up causing a lot of misery and if he ended up in a hospital or nursing home, who would take care of his wife?

Mar 8, 2023

Losing any of our senses - taste, smell, touch, hearing, eyesight -  is frightening. Glaucoma is one of the most common causes of vision loss. Surprisingly, vision loss only occurs in a minority of people diagnosed with increased eye pressure. It is treated with drops and some people choose to have laser surgery so they don’t have to use daily drops for years. It is offered as a choice of equivalents, do this or do that. So,  one might assume that the success rates of drops and surgery are equivalent. With drops, there is no question about which is the best drop. But, with surgeons, one might have the repuation of a genius when it comes to laser glaucoma surgery.(“And, he is not afraid to tell you so,” one patient added.) “You should go to Dr. A,” another patient advised. “He invented a certain kind of glaucoma surgery.” So, if drops are good, and surgery is as good as drops, why are people devising improvements to the procedure? 

A patient who was treated for glaucoma for decades by a trustworthy eye doctor eventually lost a lot of vision in one eye despite drops AND eye surgery. 

Another patient lost some vision in one eye from Shingles. If it occurs on the upper face it is from involvement of the first branch of the trigeminal nerve and this also affects the eye. This brings up another mode of disease treatment to consider, prevention or vaccination. She had the original Shingles vaccine and the two shot improved version of the vaccine. The latter is 90% effective but for her it was 100% ineffective. 

We know most people including healthcare workers don’t get vaccinated against the flu. They say, “I was vaccinated and still got it.” 

People love the modern phrase, “One hundred percent.” They use it to mean, “I agree with you,” or “absolutely!” It is emphatic and confident.  And, we are all familiar with the phrase “give 110 percent.” 

I agonize over lupus tests. Rheumatology seems the furthest field from getting to 100% accuracy when it comes to diagnosis. “How do you stand it?” colleagues in more concrete fields ask. Certainly, t is agonizing at times but the point is that most things in medicine are not decisions between 0% and 100% and I guess striving for an educated guess over an uneducated guess has to be an acceptable goal. 

Feb 2, 2023

Farewell to Dr Seo, the Editor

For the last five years, Dr. Philip Seo, professor at John Hopkins School of Medicine, has been the editor of The Rheumatologist, a publication of the American College of Rheumatology. December was his last editorial and like all his others, was brilliant. 

Some highlights of his articles from the last 5 years:

Happiness

Dr. Seo put the unhappiness or maybe last ditch effort for happiness from The Great Resignation during Covid 2020-22 in context of great thinkers like Sir William Osler and Anthony Fauci. (The Rheumatologist, Dec 2022)

Licensure

Dr. Seo tackles one obstacle to filling a demand for more providers and includes this snappy line that is so typical of his prose, “Diploma mills masquerading as medical schools sprung up across the country, like academic kudzu.” (The Rheumatologist, Oct 2022)

Dr. Seo is often invited to speak at meetings and gives lectures in person as informative and entertaining as his written commentaries. So, I look forward to continuing to gather some of his wisdom in his post-editor roles. 

Feb 1, 2023

Artificial intelligence and medicine

Robots, algorithms, machine learning. The future is now. According to a New England Journal of Medicine article on technology in medicine, "Part of the challenge to our current system is encapsulated in the so-called Collingridge dilemma: early in a new technology’s development, uncertainty and minimal evidence about its impact impede policymaking, but once the technology has diffused and harmful effects have become clear, it may be too late to act." Harpers magazine notes that Chat GPT, a new artificial intelligence (AI) app (is it an app?), was able to pass a graduate level university course. While educators worry about Chat GPT replacing human effort, technology scientists are devising algorithms to detect the algorithms to combat plagiarism. More than just Luddites and even the most futuristic thinking experts express concern about AI worsening inequitable access to health resources in a diverse population. Along with leaders in business and academic fields, medical leadership is trying to steward the use of AI. ( Weekly Review. Harper's Magazine. Jan 31, 2023. D Mathews et al. Governance of Emerging Technologies in Health and Medicine — Creating a New Framework. NEJM. Jun 9, 2022. A Butte et al. The Case for Algorithmic Stewardship for Artificial Intelligence and Machine Learning Technologies. JAMA Sep 14, 2020)

Jan 31, 2023

Books Every Doctor and Patient Should Read

List A

The Death of Ivan Ilych - Leo Tolstoy

How We Die - Sherwin B. Nuland

Poems of William Carlos Williams - WCW

The House of God - Samuel Shem

The Mismeasure of Man - Stephen Jay Gould

Aequanimitas - William Osler

The 7 Habits of Highly Effective People (Chapter 5) - Steven Covey

The Plague - Albert Camus

Brain on Fire - Susannah Callahan

Pedagogy of the Oppressed - Paolo Freire

The Spirit Catches You and You Fall Down - Anne Fadiman

List B

My Own Country - Abraham Verghese

The Radium Girls - Kate Moore

To Siri With Love - Judith Newman

The Poison Squad - Deborah Blum

The Immortal Life of Henrietta Lacks - Rebecca Skloots

Cancer - The Emperor of all Maladies* - Siddhartha Mukherjee

The Mayo Clinic - Faith Hope Science* - David Blistein and Ken Burns

*PBS documentary

Revised Apr 13, 2023

Posted Dec 18, 2022

Medical marijuana - where are we now?

Now that I have seen 2 cases of cannabis hyperemesis syndrome (CHS), it makes me wonder about the downsides of medical marijuana. I was all for legalization. I was even excited about prescribing it. We had a medical marijuana clinic on Friday afternoons but I quickly lost interest. I saw a patient on marijuana with severe vomiting and upper middle abdominal pain that I thought was ulcer disease. He had marked weight loss, too. But, when he told me the symptoms abated with a hot shower, I thought that sounded really weird.  I read about CHS and it made more sense than anything else. The frequency might not be much but it makes you wonder if it can do this to nerve transmitters, i.e. the brain, what other effects does it have?

A review of use of cannabis for chronic pain resulting in some type of guide was published in 2023. Most studies (38/47) reported at least moderate benefits of cannabinoid-based medicine (CBM) for chronic pain, seven were inconclusive or found insufficient evidence and two reported mixed results.

In summary, data on use for chronic musculoskeletal pain was weak but showed some positive effects. Data on neurologic pain, sleep and anxiety associated with chronic pain was better. Adverse events were listed as drowsiness, dizziness, and dry mouth, so were mild. (A Bell, et al. Clinical Practice Guidelines for Cannabis and Cannabinoid-Based Medicines in the Management of Chronic Pain and Co-Occurring Conditions. Cannabis and Cannabinoid Research Volume X, Number X, 2023)

Dec 16, 2022

Good luck to an old friend

I wish the best to a friend who is not young but once again starting a new practice in a medical specialty. He has a long and distinguished career and I respect him greatly. He is at an age where people might ask, “When are you going to retire?,” and, I assume, worked enough to have made enough money to retire. I have many patients who probably make less money than a doctor specialist but have been able to retire comfortably.

That reminds me of a conversation  about former athletes who are commentators on TV. I think they must have so many millions of dollars, why are they working? I mean it is not like manual labor and they are mostly just talking about sports, something most of us enjoy as a pastime let alone get paid for. But, they have to travel, be away from family, do a considerable amount of homework, and are not out golfing like other retirees. I concluded they like the attention. Shaq and Charles Barkley have charismatic personalities and enjoy being in the limelight. But, from a conversation I had with a friend and his wife, I got a different take. They assert that people’s expenses always exceed their incomes and theirs is just at a higher level. So, they need to work to pay the bills, like everyone else. 

I remember hearing about another doctor who was said to have died on a Saturday at desk in his office. I can picture papers or a computer on his desktop and his head resting on his arm or maybe a leather trimmed desk pad. No more work to catch up on or problems to solve. I recently read an interview with the author, John Irving, who is now 82 years old. He said, "I know I'm fortunate to have the only job I ever wanted to have and to imagine myself, as I always do, dying at my desk, head down. It'll be a little uncomfortable on that damn thing." (NPR)