The Mayo Clinic: A Documentary

by Ken Burns – PBS – September 25, 2018

"The Mayo Clinic," is a two hour video that "chronicles the history of this unique medical institution, from its 19th century roots as an unlikely partnership between a country doctor and the Sisters of Saint Francis — forged in response to a devastating tornado in 1883 — to its position today as a worldwide model for collaborative patient care, research and education,"

Discussion about the show: Amanpour and Company.

FAITH, HOPE AND SCIENCE

DJE:  I watched this documentary on September 25th.  It is sensitively done and deserves a repeat viewing.  It would be a powerful viewing experience for premedical students and trainees.

Precision Medicine

Are We Being Misled About Precision Medicine?

By Liz Szabo

NY Times, September 11, 2018  Link

Doctors and hospitals love to talk about the patients they’ve saved with precision medicine, and reporters love to write about them. But the people who die still vastly outnumber the rare successes.

“There are very few instances in which we can look at a genomic test and pick a drug off the shelf and say, ‘That will work,’” said Dr. Nikhil Wagle, a cancer specialist at Dana-Farber Cancer Institute in Boston who helped develop precision-medicine tests. “That’s our goal in the long run, but in 2018 we’re not there yet.”

Failed precision medicine studies received almost no news coverage. Against this backdrop of hope and desperation, how are patients supposed to make informed decisions?

The phrase “precision medicine” suggests a high rate of success. While its successes should be celebrated, its failures must be acknowledged, reminding us how much is left to learn.

[This is a great overview of the rapidly growing field of "precision medicine."  The hype cannot be ignored.]

Coeur d'Alene

by Richard B. Weinberg, M.D.

Wake Forest School of Medicine

Winston-Salem, North Carolina

Ann Intern Med. 2016;165:822-823

The EMR meets a teachable moment…

This essay appeared in the On Being a Doctor section of the Annals of Internal Medicine. It is a teachable moment for students, trainees and practicing physicians.

Weinberg tells his millennial resident:

“Let me tell you the advice that my physical diagnosis teacher gave me over 40 years ago. Right off, ask every patient four questions:

1.     Where were you born?

2.     Are you married, and do you have children?

3.     Where did you go to school?

4.     What kind of work do you do?

If you do this, it will be a rare patient with whom you don't find some point of connection.”

See:  Full Text.

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