Land of the C-section

Brazil has one of the highest rates of cesarean sections in the world. In 2015, they accounted for 55 percent of all births. (By comparison, that same year, the United States had a C-section rate of 32 percent, while in Sweden, they accounted for just 17.4 percent of births.) Sure, C-sections are necessary and lifesaving in certain situations, like cord prolapses or placental abruptions. But according to the World Health Organization, once C-section rates climb higher than 10 percent, there is no evidence that they help reduce maternal and newborn mortality; on the contrary, the surgery can lead to significant complications, which is why the W.H.O. recommends it only be undertaken when medically necessary.

This informative and important essay deserves to be read by every pregnant woman. They have to keep their obstetricians honest.

Full article: Land of the C-Section.

How To Fix The Pre-medical Curriculum

Forty years ago, in 1978, Lewis Thomas, M.D., then president of the Memorial Sloan-Kettering Institute, wrote an important essay for the New England Journal of Medicine.  As one of the top medical educators in the country, he words should have carried some weight.  Strangely, nothing appears to have changed in the past two score years, maybe it is even worse today.  

This Op-Ed piece deserves to be reread today.  It begins:

"The influence of the modern medical school on liberal-arts education in this country over the last decade has been baleful and malign, nothing less. The admission policies of the medical schools are at the root of the trouble. If something is not done quickly to change these policies, all the joy of going to college will have been destroyed, not just for that growing majority of undergraduate students who draw breath only to become doctors, but for everyone else, all the students, and all the faculty as well."

For the article in full:  Download L. Thomas Pre-medical Curriculum

From the Annals of Overdiagnosis

Perspective article

Income and Cancer Overdiagnosis — When Too Much Care Is Harmful

H. Gilbert Welch, M.D., M.P.H., and Elliott S. Fisher, M.D., M.P.H.

N Engl J Med 2017; 376:2208-2209

There are scores of articles on over-medicalization, over-diagnosis and over treatment.  This short Perspective piece in the New England Journal of Medicine by H.G. Welch and Elliott Fisher is a great introduction to this topic.

Link to PDF.

“Although higher-income people live longer than poorer individuals, there is little evidence that people with higher incomes live longer because they receive more medical care.  In fact, there are reasons to wonder whether wealthier people receive too much care.

We used data from the SEER program to examine incidence and mortality trends for four types of cancer whose reported incidence is known to be sensitive to observational intensity: breast cancer, prostate cancer, thyroid cancer, and melanoma. The combined incidence of these cancers has been rising in all U.S. counties, but there hasn’t been a parallel increase in cancer-specific mortality — which suggests that considerable over-diagnosis may be occurring.

We found that high-income counties have experienced markedly greater increases in incidence than low-income counties since 1975; but mortality rates are similar in high and low income counties.  The graph also shows that combined mortality from the four cancers is similar in high- and low-income counties, suggesting that the underlying disease burden is similar. What’s more, mortality hasn’t been increasing — as one might expect given the increasing incidence in some areas — but rather decreasing, reflecting decreasing mortality from breast and prostate cancer in particular.

Excessive screening is responsible for the increasing rates and this has had no impact on overall morality.  Excessive testing of low-risk people produces real harm, leading to treatments that have no benefit (because there is nothing to fix) but can nonetheless result in medication side effects, surgical complications, and occasionally even death.

Physicians have overstated medicine’s role in promoting health. In so doing, we may have unintentionally devalued the role of more important determinants of health for people at every income level — healthy food, regular movement, and finding purpose in life.”

A Remembrance of Life before Roe v. Wade

"We chatted as the dialysis shift began. Jane was a young nursing student whose name and face I still remember five decades later. She was from the Virgin Islands and had come to New York for nursing school. She was nearly done — justifiably proud, since she had funded it herself. I was a fourth-year medical student doing an elective rotation on the renal service. The dialysis machine was working well, so we continued to talk when we could as the hours went by. It was 1968...

Jane did what thousands of young women were forced to do in the 1960s — she underwent a back-alley abortion, with disastrous consequences. Should Roe v. Wade be overturned, there will be countless more young women like her."

Please read the FULL TEXT of this short and powerful essay by Julie R. Ingelfinger, M.D. in the August 23^rd New England Journal of Medicine.

This image is from the article

Ingelfinger is a pediatric nephrologist in Boston

Asphodel

Asphodel, The Greeny Flower

Excerpt

                Look at                              

what passes for the new.

You will not find it there but in

               despised poems.

                  It is difficult

to get the news from poems

               yet men die miserably every day

                        for lack

of what is found there.

               Hear me out

                 for I too am concerned

and every man

        who wants to die at peace in his bed

                       besides.

Asphodel comes in many colors

Anya Krugovoy Silver

Poetic Voice on Mortality

NY Times Obituary

By Richard Sandomir

August 11, 2018

Anya Krugovoy Silver, the poet who, after receiving a diagnosis of advanced breast cancer in 2004, wrote lyrical verse that gave readers an exquisite, intimate and sometimes angry account of her illness, died on Monday, August 6^th,  in Macon, Ga. She was 49.

Full Article.

Hear Anta Silver read her poem, The Dybbuk.

As health care professionals, we learn about disease in the classroom, mostly from clinicians and scientists.  Poets, like Anya Silver, introduce us to cancer’s humanistic reality.

Also read Williams Carlos Williams insightful lines from Asphodel, The Greeny Flower:

                Look at                              

what passes for the new.

You will not find it there but in

               despised poems.

                  It is difficult

to get the news from poems

               yet men die miserably every day

                        for lack

of what is found there.

               Hear me out

                 for I too am concerned

and every man

        who wants to die at peace in his bed

                       besides.

Jarrod Lyle, Golfer Who Played On Despite Cancer, Dies at 36

New York Times Obituary
August 9, 2018
Hypertext Link

Lyle, as he was dying, asked his wife to pass along this message, " “My time was short, but if I’ve helped people think and act on behalf of those families who suffer through cancer, hopefully it wasn’t wasted.”


There is much in this obituary to educate and inspire.

To Fight Burnout, Organize

by Leo Eisenstein

N Engl J Med. 2018 Jun 20  Free Full Text

Leo Eisenstein is a fourth year medical student at Harvard.  His essay is an impassioned cry for solidarity with his colleagues as they approach the hardships of those in need; with particular attention to the social determinants of health (SDH).

From my vantage point of decades of private practice, I applaud Leo’s passion and idealism.  In my community and across the country, private practitioners rarely accept poor people (Medicaid) as patients.  These patients, when they are lucky, serve as teaching material for medical students and residents.  It’s been the same for centuries.

Private physicians who turn their backs on the poor, may suffer more burnout that those of us who welcome the underprivileged into our offices.  That topic has not been investigated, to my knowledge.

Emily Dickinson has articulated our calling more succinctly:

If I can stop one Heart from breaking
I shall not live in vain
If I can ease one Life the Aching
Or cool one Pain

Or help one fainting Robin
Unto his Nest again
I shall not live in Vain

Thank you, Leo, for giving us hope in yours, the next generation of healers.

The Language of Kindness

A Nurse’s Story

by Christie Watson

TM Duggan Books (2018)

Almost 3 decades ago, I heard a nurse, Hob Osterlund, speak at a conference devoted to the art of medicine. 
The audience, mostly physicians, was enraptured by her talk. During the question period, an elderly, self – 
important physician asked her, "Your our talk was so impressive that I wonder why you never became a doctor?"
Ms. Osterlund replied, "Because being a nurse is equally as important as, and sometimes more important than, 
being the physician."

At that moment, a light went on in my chauvinistic brain. Reading Christie Watson's, The Language of Kindness, 
has many such epiphanies. It's a wonderful introduction to a greatly undervalued profession.

Over the years, I've read many books but doctors about the practice of medicine, but only a few about 
the call of nursing. This book will be a great help to any healthcare professional who makes the time 
to read it.

Introduction: Nursing was left to "those who were too old, too weak, two drunken, to dirty, too stupid 
or to bad to do anything else." Florence Nightingale

Sympathy, compassion, empathy: this is what history tells us makes a good nurse.

And 17, she decided to become a nurse. Plus, she knew there would be parties. Student nurses were 
almost all young and wild. A significant number were Irish women, who had two choices: nurse or 
nun.

20 years in nursing has taken so much from me, but has given me back even more. I want to share 
with you the tragedies and joys of a remarkable career.

Read my full notes at: The Language of Kindness.