Category: Medical decisions

COVID-19 in a nutshell

As a former hospital-based infectious diseases physician, I have been reading everything I can about the coronavirus pandemic. Because this is a new coronavirus not previously seen in humans, the World Health Organization gave the disease the name COVID-19, which stands for Coronavirus Disease 2019. While there is a flurry of high quality up-to-the-minute, information available, especially on Twitter, it is challenging to get the most important information in one place. Based on questions I am getting, here is my attempt to provide a quick overview and answer the key questions.

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Is the microbiome the key to health?

Interest in the microbiome – those trillions of bugs (bacteria and other microorganisms) in your gut – is increasing and according to an article in the NY Times, drug companies are trying to get in on the action.

As I’ve written before, these bugs may be important in the development of chronic disease leading to the possibility that you can “transplant” healthier bugs into someone with a disease. In fact, transferring the feces (poop) from one person to another has been shown to cure cases of Clostridioides difficile (C. diff) colitis (a life threatening infection of the gut caused by overuse of antibiotics). This is called fecal microbiota transplantation (FMT). Studies are ongoing to see if FMT can be used to treat inflammatory bowel disease (IBD), irritable bowel syndrome (IBS) and other chronic conditions. But there are a limited number of places doing FMT so people are doing their own transplants by harvesting the feces of a friend or family member and using a home blender (I’ll spare you any additional details but the DIY instructions are readily available online).

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Physician burnout

Physician burnout has been in the news for the past few years. Defined as a sense of physical and emotional collapse related to work stresses, symptoms include exhaustion, cynicism, feelings of incompetence and poor work performance. In a survey of 6,880 physicians in 2014, 54.4% reported at least 1 symptom of burnout (up from 45.5% in 2011) and the numbers are continuing to rise. A systematic review summarizing articles written about physician burnout suggests that burnout can also lead to an increase in medical errors. Among the suspected causes of burnout are the pressures of seeing more patients in less time, the challenges of documenting clinical visits in an electronic health record, increasing paperwork required by insurance companies, etc. In short, the demands of a fragmented, dysfunctional healthcare system are thought to be an important contributor to the suffering experienced by physicians.

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Patient-collected data

In April 2018, I participated in the 2018 Quantified Self (QS) Symposium on Cardiovascular Diseases held in San Diego. I was reminded of that session several weeks ago while attending the 2nd Annual Meeting of the Society for Participatory Medicine. In both conferences I was struck by the power of patients’ observations and measurements to manage their own diseases.

I first learned about the Quantified Self movement a few years ago while reading about Larry Smarr, an astrophysicist and computer scientist who started tracking his own exercise and weight but ultimately began expanding his self-tracking to include blood tests when he was told he had “pre-diabetes”. He ultimately diagnosed his own Crohn’s disease long before he had any symptoms based on analyzing his own blood and stool tests (including twice weekly stool microbiome analysis). He has since published a how-to guide in a biotechnology journal and participated in planning his own bowel resection for Crohn’s disease in 2016.

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Hospital centered care

Healthcare decisions are increasingly driven by efficiency and economic factors, even at the end of life. This was brought home to me several months ago with my mother’s death after a short hospitalization for a lung infection.

Because I was planning to be on vacation during the time of her hospitalization, I was able to be at her side pretty much full time, allowing me a front row seat to a series of decisions that were based on efficiency and hospital reputation rather than patient care.

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Clinical trial problems in the news (again)

PillRandomized controlled trials (RCTs) may have lots of problems, but they remain the “gold standard” to determine whether a drug or treatment works. A recent study published in the BMJ, again raises concerns about trusting clinical trial results. The situation is outlined in an article in the New York Times about the antidepressant drug Paxil (paroxetine) and its safety in teens. The original study was published in 2001 in the Journal of the American Academy of Child and Adolescent Psychiatry (JAACAP) and the authors concluded that Paxil is “generally well tolerated and effective” for adolescents with major depression. However, since that time, experts have questioned whether the data really supports this conclusion and whether Paxil is really safe in young adults with depression.

In the recent BMJ analysis, the authors looked at the data from the original 2001 study and also some additional data they were able to get from the drug company that makes Paxil, GlaxoSmithKline. They concluded that Paxil is neither safe nor effective in adolescents with depression.

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How to pick a surgeon

Scalpel combinedSeveral years ago a close friend asked me to recommend a surgeon for an elective procedure. I told her I had a colleague with a great bedside manner who also had great technical skills. He was absolutely the person I would go to if I needed general surgery. My friend went to see him but ended up using a different surgeon. When I asked her what she liked about the other guy, she said that he told her that he was “the best” surgeon to perform the procedure. She didn’t like his personality but he instilled her with confidence.

The truth is that there is no single “best” surgeon for everyone. And there are many factors that go into picking a surgeon: insurance issues, convenience, etc. And there are advantages to going to a surgeon who works well with our primary care physician (communication) and in having surgery in a place that has an electronic medical record that our primary care physician can access (coordination of care). But the most important thing is how skilled the surgeon is at performing the surgery we need. How do we figure that out? The short answer is that we don’t.

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Personal experiments

N-of-1During my medical training, we were taught that if a patient responds to a treatment, it doesn’t necessarily mean that every patient will respond in the same way. The results in a single patient might be due to chance so it was important to look at the results of well-designed research studies before we could conclude that the treatment really worked.  In statistics, “N” refers to the sample size in an experiment so we referred to these individual observations as “N-of-1” experiments (and we did not look at them very favorably).

Unfortunately, there are lots of problems with research studies – they take a long time to complete, the patients in the studies are very carefully selected and may be very different from you, there is often bias in the way the results are interpreted, etc.

What if doctors and patients had tools that allowed them to design high-quality experiments specifically for the individual patient?

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Vaccines and trust

VaccinesMany years ago I worked in a travel clinic advising people about the immunizations they needed before visiting other countries. Sometimes shots were required for entry into a country, such as the yellow fever vaccine. But we also made sure that MMR (measles-mumps-rubella) and other vaccines were up-to-date. The reason was that while immunizations have been very successful in getting rid of measles (and other childhood illnesses) in the US, many countries still have outbreaks. The booster shots were not necessary in the US because we no longer had cases of measles. Until now.

We are seeing cases of measles (and other childhood illnesses) again because parents are increasingly refusing to get their kids vaccinated. The current outbreak of measles in California is causing a lot of public debate about how to force people to get their kids vaccinated. While we may need to find new ways to enforce vaccination, we also need to restore trust – people increasingly don’t trust doctors, pharmaceutical companies, government agencies or payers.

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The power of placebos

placeboLots of people talk about the placebo effect but what exactly is it?

The most reliable clinical studies compare a treatment that is being tested with a fake treatment (called a placebo). Generally, half the people in the study get the treatment and half get the placebo and the then the two groups are compared. In the case of pills the placebo is often a sugar pill. Researchers can even test the effectiveness of a surgical procedure by comparing it with a sham or fake procedure. In these studies (called randomized controlled trials or RCTs), patients (and their healthcare teams) don’t know who is getting the pill or procedure being studied and who is getting the placebo. The reason for this is that patients sometimes get better when they are given a placebo because they believe they will get better (called the “placebo effect”) or because their disease got better on its own.

So can patients get better just by believing they will get better? And can doctors actually prescribe placebos to help people get better?

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