Arrogance

Franz J. Ingelfinger
N Engl J Med. 1980 Dec 25;303(26):1507-11.
This is a classic article; well worth studying.
FULL TEXT:

Franz Joseph Ingelfinger  (August 20, 1910 – March 27, 1980) was a German-American physician. He served as Chief of Gastroenterology at Evans Memorial Department of Clinical Research, part of Boston University School of Medicine. He also served as Editor of the New England Journal of Medicine (NEJM) from 1967 to 1976.[1] His work was influential in the field of science journalism.

Notes from Arrobance.

FJI Obituary in BMJ

Don’t demonise prescription opioids

It is rare that we hear from those who use prescription opioids.  Their voices are important counterpoints to the loud and self-righteous jeremiads of physicians, politicians and law enforcement professionals.

This essay was published in the BMJ in October 2017.

Our preoccupationwith opioid misuse could become the tail wagging the dog

Bob Roehr biomedical journalist.  BMJ

“I use an opioid drug, hydrocodone, every six hours, and have done so for about a decade.“Demonising prescription opioids can come to no good end."

F.W. Peabody: Classic Articles

Francis Weld Peabody was a Boston physician who died in October 1927 at age 45 from gastric carcinoma. He was a humanistic physician whose article "The Care of the Patient" was published in JAMA in 1927 a few months before his death.

This article is one of the most widely cited publications in the medical literature. Two other of Peabody's articles are classics, however one of these has never been published.
 

Oglesby Paul's 1991 biography "The Caring Physician: The Life of Dr. Francis W Peabody is a classic but may be hard to find. Peabody's classic articles are found in the appendices to Paul's book.

For the readers ease, these articles will be linked here:

1. TheCare of the Patient.  FWP, JAMA 1927
This paper originally appeared in JAMA in 1927. It is as valid and inspiring today as it was 90 years ago.  It is the most cited and revered article in the medical literature. Peabody’s wife remembered him saying, “I am absolutely sure that this little lecture will be remembered long after anything of a scientific nature I have written has been forgotten.”

2. The Patient and the Man: (Presented by Francis W. Peabody, MD before the New York Academy of Medicine, November 22, 1922) 
Chemistry, physiology, psychology—these and other sciences are making the foundations of medicine stronger from year to year, but medicine itself can never become merely an applied science. The proper employment of the fundamental sciences in the study of disease has become an essential for good medical practice, but over and above this, there must be something which correlates the scientific findings with the actual problems of the individual case—the art of medicine, which carries us beyond the patient to the man.   

3. Notes on the Effects of Morphine (unpublished.  Finished 5 days before his death)

This unpublished essay is “[a]n example of how FWP the scientist used his

illness to make clinical observations on himself with his description of his reactions

to injections of morphine. This document was completed on October 8, 1927, five days

before his death, and is a unique and vivid record of one physician-patient’s response to the powerful narcotic.” This is an extraordinary essay. Why it was never published is a

great mystery tome; but may lie in the fact that morphine was and still  is a much-maligned drug. Herein, we see how it allowed FWP remain lucid and function masterfully until the his death.

    

How We Shun The Mortally Ill

Richard Smith's: "How we shun the mortally ill" appeared in the BMJ Opinion October 10, 2017 is a definite Keeper

"When you develop a mortal illness, as you will do if you’re not one of the fifth of the population who dies suddenly, you are likely to find that many friends desert you. The same will happen if somebody in your family develops such an illness. And if you’re a doctor then the people most likely to shun you are your medical colleagues. The isolation of the seriously ill and their relatives is the great unrecognised scandal of our age, said Neil Vickers, reader in English literature and medical humanities at King’s College London, at a recent symposium on Ambiguities and Paradoxes in Clinical Medicine. The able bodied in this way make the suffering of the seriously ill much worse."

Importantly, Smith references the famous 1982 article in the New England Journal of Medicine by the endocrinologist David Rabin from Vanderbilt Medical Center who described how when he developed amyotrophic lateral sclerosis he became isolated from most of his fellow physicians.

The Latest on Lice

by Perri Klass  (anything written by Perri Klass is worth reading)

NY Times, October 10, 2017

Full Text.

We spend a billion dollars a year on treatments for head lice, according to the American Academy of Pediatrics.

Head lice is spread from person to person.  It is an infestation, not an infection — they do not actually carry infections.  The AAP argues first and foremost that children should not miss school because of head lice or nits.  It’s not necessary to treat all the children in a classroom, or all the people who live in the house, though anyone who shares a bed should get treated.

It can be helpful to treat more than once, usually after about nine days, if you are using a product that does not kill the eggs, or if you see live lice after a first treatment.

There should never be a case for a child with head lice spending days out of school. Families should be notified, they should be able to access topical medication and they should be able to re-enter the next day.”

Perri Klass is a respected pediatric writer.  This is a level-headed. helpful review.

An effective nonchemical treatment for head lice: a lot of hot air.

Goates BM, et. al. Pediatrics. 2006 Nov;118(5):1962-70.

“RESULTS:  The most successful method, which used a custom-built machine called the LouseBuster, resulted in nearly 100% mortality of eggs and 80% mortality of hatched lice. The LouseBuster was effective in killing lice and their eggs when operated at a comfortable temperature, slightly cooler than a standard blow-dryer. Virtually all subjects were cured of head lice when examined 1 week after treatment with the LouseBuster. There were no adverse effects of treatment.

[Strangely, I think the authors of this article had a conflict of interest.The LouseBuster was made in Salt Lake City and Groates does his research there, too.While hot air is an attractive remedy, it may no be practical. DJE]

A Study on the Nocebo Effect

Nocebo Effects Explored

Brief You Tube Introduction

Title and Abstract:
Interactions between brain and spinal cord mediate value effects in nocebo hyperalgesia.  Tinnermann A. et. al.

Abstract: Value information about a drug, such as the price tag, can strongly affect its therapeutic effect. We discovered that value information influences adverse treatment outcomes in humans even in the absence of an active substance. Labeling an inert treatment as expensive medication led to stronger nocebo hyperalgesia than labeling it as cheap medication. This effect was mediated by neural interactions between cortex, brainstem, and spinal cord. In particular, activity in the prefrontal cortex mediated the effect of value on nocebo hyperalgesia. Value furthermore modulated coupling between prefrontal areas, brainstem, and spinal cord, which might represent a flexible mechanism through which higher-cognitive representations, such as value, can modulate early pain processing.

NY Times Expostulation: 10/10/2017

When people believe a medicine is expensive, they may show a greater response to it.

Researchers told 49 volunteers that they were testing two anti-itch creams — one that was costly, and one cheap — that contained the same ingredient known to reduce itch, but that the ingredient sometimes increased sensitivity to heat.

Then they showed them the two medicines, one in an expensive-looking brand-name box with fancy lettering, the other in a plain generic-looking container. They did not tell them that neither cream contained any medicine, and that both contained only the same inert ingredient.

They randomly assigned them to try either the expensive or cheap cream. All participants knew which cream they were using. The study is in Science.

When exposed to heat, the volunteers using the expensive cream felt consistently more pain than those using the cheap one, and the effect increased over time. Using fMRI brain scans, researchers were able to show exactly which parts of the brain were involved in modifying how price information affects pain.

“These expectations that patients have matter,” said the lead author, Alexandra Tinnermann, a doctoral candidate at the University Medical Center in Hamburg, Germany. “This is something doctors should be aware of and make use of to create positive expectations and reduce negative ones.”

Ask Patients "What Matters To You?"

Ask patients “What matters to you?” rather than “What’s the matter?”

by Sosena Kebede, MD 21287, USA skebede3@jhmi.edu

BMJ 2016; 354

 

This can help reframe interactions in a more patient-centered way:

Maureen Bisognano, one of the keynote speakers at this year’s International Forum on Quality and Safety in Healthcare in Gothenburg, Sweden, told delegates that we should ask our patients, “What matters to you?” rather than, “What is the matter?”

The question “What matters to you?” tries to get to the essence of patient- centered care, which the Institute of Medicine has listed as one of the priorities for quality improvement.

Full article from the BMJ 

The Cliff Analagy of Social Health

Camara Phyllis Jones

Addressing the Social determinants of  children’s Health: A Cliff Analogy

Journal of Health Care for the Poor and Underserved  20 (2009): 1–12.

Full Text

Abstract:

This  paper  presents  a  “Cliff  Analogy”  illustrating  three  dimensions  of  health intervention to help people who are falling off of the cliff of good health: providing health services, addressing the social determinants of health, and addressing the social determinants of equity. In the terms of the analogy, health services include an ambulance at the bottom of the cliff, a net or trampoline halfway down, and a fence at the top of the cliff. Addressing the social determinants of health involves the deliberate movement of the population away from the edge of the cliff. Addressing the social determinants of equity acknowledges that the cliff is three-dimensional and involves interventions on the structures, policies, practices,

norms, and values that differentially distribute resources and risks along the cliff face. The authors  affirm  that  we  need  to  address  both  the  social  determinants  of  health,  including poverty, and the social determinants ofequity, including racism, if we are to improve health outcomes and eliminate health disparities.

Levels of racism: a theoretic framework and a gardener's tale. Am J Public Health.

Camara Phyllis Jones  

Levels of racism: a theoretic framework and a gardener's tale. Am J Public Health. 2000 Aug;90(8):1212-5.  Full Text.

Abstract: The author presents a theoretic framework for understanding racism on 3 levels: institutionalized, personally mediated, and internalized. This framework is useful for raising new hypotheses about the basis of race-associated differences in health outcomes, as well as for designing effective interventions to eliminate those differences. She then presents an allegory about a gardener with 2 flower boxes, rich and poor soil, and red and pink flowers. This allegory illustrates the relationship between the 3 levels of racism and may guide our thinking about how to intervene to mitigate the impacts of racism on health. It may also serve as a tool for starting a national conversation on racism.

C.P. Jones: Allegories of Race and Racism (TED Talk)

This 20 minute TED talk covers what Dr. Jones usually has an hour for.  It is well worth watching.

The Never-Ending Battle Against Sport’s Hidden Foe

by Bill Pennington,

NY Times October 6, 2017

I have serious questions about the value and validity of articles like this.  They tend to scare people and promote health anxiety and lead to cyberchondria.  However, we should know what our patients are reading and what frightens them.

Article in Full

"Although the most recent study by the Centers for Disease Control and Prevention, in 2015, reported a decrease in MRSA infections in the general public since 2005, it is difficult to tell what is happening in locker rooms because there has been no study specifically on sports. Anecdotally, based on the number of cases they have treated in recent years, athletic trainers and team doctors nationwide have insisted that MRSA cases in sports declined substantially in the last decade. But they, too, have no data.

In the N.F.L., the effort to curb MRSA now borders on a crusade, with an official prevention manual that is 315 pages long. There are meticulous protocols for dozens of procedures… [What about C.T.E. I thought while reading this?]

[There have been many MRSA scares.]  About 10 years ago, a Bowdoin athlete was unaware he had contracted MRSA, and with a contagious, open wound on his leg, he wandered around the campus — to the dining hall, the weight room, the locker room and the coaches’ offices."

from "BiologiyStories" web site

Making All Lives Matter in Medicine

by Michael Mensah, M.D.
JAMA Internal Medicine, October 1, 2017

I was in medical school when I learned that I did not matter in medicine.

One particular day on service started uneventfully. However, after the team’s discussion of a patient, all attention turned toward me when a

senior physician asked me a question about the rap music that had been playingin the background.

“Help me understand something:” I recall the physician saying. The physician asked about word choice in rap lyrics, and then, pretending to quote a rap song, repeated the word “nigger” several times in rapid-fire

succession.

So begins this important “Viwepoint” article in JAMA Internal Medicine.  Most of us will benefit from reading it.  Read full article.

Damon Tweedy's Book, Black Man in a White Coat: A Doctor's Reflections on Race and Medicine, eloquently covers the much of the same ground.

The Other End of the Stethoscope

by Evan F. Joiner

NEJM October 5, 2017

This is a fine perspective piece by a 4th year medical student.  Like many of us, he was searching for meaning in his work.

I believe I have come to medicine looking for some kind of peace and some kind of purpose. I do wonder whether it lives here.

The Other End of the Stethoscope is a “keeper” that you will enjoy reading.

Health Anxiety in Dermatology

by Valencia Long and David Elpern
Int J Dermatol. 2017 Sep;56(9):968-971. doi: 10.1111/ijd.13692

Patients see doctors with varying degrees of concern regardin their health. While some require tests or treatments, a subset has severe health anxiety and cannot be reassured by tests, procedures, or pharmaceuticals but may be helped, at least temporarily, by a sympathetic listening face and reassurance. Hence, we designed a questionnaire to investigate health anxiety in patients recruited from a general dermatology clinic.

The study can be accessed at this pdf: Health Anxiety in Dermatology