Introduction

In 1885, when John Shaw Billings started the database which would, over time, morph into PubMed he recognized the hopelessness of trying to keep abreast of the medical literature.  In addition, he was cognizant of how trivial most of what passes for “the literature” is when he wrote:

There is a vast amount of effete and worthless material in the literature of medicine.  Our preparers of compilations and compendiums, big and little, acknowledged or not, are continually enlarging the collection, and for the most part with material that has been categorized as ‘superlatively middling, the quintessential extract of mediocrity.

          Over the past 132 years, the situation has only gotten worse.  Today, the National Library of Medicine (NLM) receives 165 dermatology journals and indexes 57 of them in MEDLINE (searchable via PubMed).  What dermatologist could read all of these even if all one did was pore over skin journals?

We are starting a Virtual Journal Club for Dermatology.  Each month, members will post the one or two (or none) articles they deem most important from their assigned or chosen journals.  The references will be stored here for referral and open-access whenever possible.  The Label field can be used to locate articles of interest to readers.

Please consider joining our Virtual Dermatology Journal Club

Journals Covered in VJC-Dermatology

Journals and Periodicals Regularly Covered

Dermatology

Australasian J Dermatology

British J of Dermatology

International J of Dermatology

J Investigational Dermatology

JAMA Dermatology

JAAD

Pediatric Dermatology

Non-Dermatological

Australian J of Medicine

Annals of Internal Medicine

BMJ

JAMA

Lancet

NEJM

New York Times

Others when appropriate

Isotretinoin: Dose, Duration and Relapse

Isotretinoin: Dose, Duration and Relapse.  30 Years On

Marius Rademaker. Australasian Journal of Dermatology (2012)

Keywords: acne vulgaris, adverse effects, dose, isotretinoin, relapse, retinoid

Abstract: With 30 years of clinical use, it is appropriate to review the use of isotretinoin.  The indications of isotretinoin have expanded from just acne and rosacea to a wide range of inflammatory and malignant skin disorders.   While the standard dose of 0.5 to 1 mg/kg per day for 4 months to a cumulative dose of 120–140 mg/kg per day has served us well in the management of acne vulgaris, there is emerging evidence that much lower dosages (as low as 5 mg/day) are just as effective but have significantly

fewer adverse effects. Relapse of acne vulgaris continues to be a problem but we are beginning to recognise that this is related less to the cumulative

dose and more to the length of sebaceous gland suppression. Other factors important for relapse includea macrocomedonal pattern of acne, smoking and age, both younger (under 14 years) and older (over 25 years).

         After 30 years of use, we now understand why isotretinoin is such an effective drug. Not only does it clear acne in almost all patients, long-term remission can be achieved in 70–80% of patients with a single course. Important changes in the use of isotretinoin include using a lower daily dose for a longer period of time. New indications continue to emerge, particularly

as a potential treatment for both intrinsic and extrinsic (photo) aging. Teratogenicity however, remains a very significant concern.

Key words: acne vulgaris, adverse effects, dose,

isotretinoin, relapse, retinoid.

The Harvard Way

S. Walker

JAMA 1985 Oct 11;254(14):1903-5.

 There are times, every day, I need to swallow the urge to cry. And I need to keep telling myself that I'll be a good doctor. Maybe it's just a product of the place where I was raised. People there were unassuming, and usually kind at first meeting. Here there is no "Nice to meet you," there isn't even a chance to make a mistake. They assume you already have.

They have a way of making you feel worthless. Where they're coming from, or why they feel so superior, I don't know, but I think it's ironic. We work like slaves, get very little sleep, and have no formal didactic teaching on which to base our knowledge of the vast field of surgery. And if we don't perform well on standardized tests – there's no explaining - there's no help – there can be no suggestions. We just get degrading letters in our mailboxes about how poorly we have performed, encouraging us to get into a study program. Excuse me, but I thought that was supposed to be part of the residency!

This is supposed to be the Mecca of medicine – and probably the country’s most renowned medical city. You’d think they'd be proud to share their knowledge; after all, it's a "teaching institution." Well, they've taught me to feel afraid, worthless, ashamed, and often that I don't "deserve" to be a doctor. Physicians don't have the respect they once had. It's our own fault; we have demonized ourselves.

In two months I'll pack up and go home – by my own choice. I know that I am a good, caring doctor. But my self-worth and sense of competency have had to come from within. They've done everything they can to tear it down. This experience did not build character, strength, or "make a man" out of me. I am not and never will be one of the "good old boys." It has only given me many months of disappointment and sorrow. It is sad that people so bright and so famous have lost the ability to do a simple thing – to treat all people as equals. Someday we may all be in a situation where we can't handle the rejection anymore.

JAMA Editors' Comments:

"This personal view generated a good many letters to JAMA. Some agreed with the author’s assessment of the often arduous training of surgeons at Harvard, and others, particularly faculty at Harvard Medical School, protested the singling out of their institution. The editors of JAMA stated that in publishing this article, "The Journal allows its readers to reach their own conclusions concerning the motives, balance, and accuracy of the piece."

Will You Forgive Me for Saving You?

by Toree McGowan

I remember the day I first met you. It was a quiet Sunday, early in the morning. I heard a commotion out by the check-in desk, and your mom’s scream: “My baby’s not breathing!” The first time I saw you was in your mom’s arms. Heartbreakingly, you weren’t snuggled like a baby should be, or even limp. Your tiny body was twitching, seizing. The cold clinical term “decorticate posturing” that flashed in the physician part of my brain seemed too rigid to be applied to your chubby toddler arms.

This is a moving medical meditation.  Well worth reading.  NEJM has made it available FREE.

Toree McGowan, MD, FACEP

Comment of Brian Maurer, Pedicatric PA-C: Dr Torree McGowan’s moving piece “Will You Forgive Me For Saving You?” broaches the fine line between beneficence and malfeasance that clinicians who labor on the front lines in medical practice frequently face: when does medical intervention ultimately do more harm than good? As clinicians, we are trained to do everything in our power to save the life of a patient entrusted to our care, knowing full well that in some instances the ultimate outcome may be less than desirable, not only for the patient, but also for those whose lives will be burdened with her care for years to come. The pain that the clinician carries—call it survivor guilt—testifies to the heightened degree of moral distress experienced, distress that many times persists indefinitely. Hemingway once wrote that he “had gotten rid of a lot of things by writing about them.” That might be true for Dr McGowan in this case, though I suspect her clinician wound may prove to be a difficult one to heal.

Comment of Shay Bintliff, retired pediatrician and E.R. doc:
Having spent the first fifteen years of my medical career as a Pediatric Birth Defects specialist, then the next forty years as an Emergency Room specialist, I so identify with Dr. McGowen’s experience with this patient. Telling this very, and yes, sad special story from her heart  she shares her emotions without hesitation. She is able to share with readers the lessons that she will carry forth and pass on to others in her medical practice.  YES, our patients are our best teachers if only our hearts and minds are open to them. Dr. McGowan has learned this early in her career and I am one  of many who appreciate her sharing her story!!

Mass medicalisation is an iatrogenic catastrophe

by James Le Fanu. BMJ 2018;361:k2794 (June 28, 2018)

Profligate prescribing has brought a hidden epidemic of side effects and no benefit to most individuals.  [All of us who drift into physicians’ offices are subject to over-medicalization by overworked, ignorant, well-meaning, but  often autocratic, physicians. DJE]

Excerpts:

“Tis impossible to separate the chance of good from the risk of ill,” wrote David Hume presciently, anticipating, by 250 years, medicine’s current existential crisis. There is no drug or procedure with its “chance of good” that may not harm some. The more doctors do, the greater that risk. And doctors are certainly doing much more with, over the past 20 years, a dizzying fourfold rise in prescriptions for diabetes treatments, sevenfold for anti-hypertensives, and 20-fold for the cholesterol lowering statins.

There is a hidden epidemic of anxiety-producing symptoms such as fatigue,

muscular aches and pains, insomnia, and general decrepitude, a 75% rise in emergency admissions to hospital for adverse drug reactions.  Le Fanu feels that this was driven by sophistic public health research that played into the drug industry’s goal of mass medicalisation.

This ‘close alignment of the priorities of public health with the marketing practices of this most profitable of industries’ has been achieved by lowering the threshold for initiating treatment to include those whose physiological variables are only marginally elevated, if at all. The simple expedient of redefining diabetes, hypertension, and hypocholesteraemia in this way increased their prevalence in the US by, respectively, 14%, 35%, and 86% -- an additional 56 million cases, more than a third of the total adult population of 187 million.

The population was not “sick” after all, but has certainly been made sick by the iatrogenic consequences of that profligate prescribing.

How to Fix the Premed Curriculum

Lewis Thomas,  New England Journal of Medicine, May 25, 1978

(This was written 40 years ago, and nothing has changed!)

PDF of How to Fix the Premedical Curriculum

  

Notes on article.
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 the growing majority of undergraduates who draw breath only to become doctors, but for everyone else, all the students and all the faculty as well.

Thomas states that the rhetoric of medical school catalogues is to major in non-science discipline as history, English and philosophy; even so, not many do. Pre-medical students didn't buy that line. [In 1978 they continued to concentrate on science. I don't see much difference today.]

The pre-medical students concentrate on science with a fury, and they live for grades. If there are courses in the humanities that can be taken without risk to class standing they will lineup for them, but they will not get into anything tough excepting science. The atmosphere of the liberal-arts college is being poisoned by pre-medical students. This is not the fault of the students. They behave as they do in the firm belief that if they behaved in any other way they won't get into a medical school.

Thomas suggests that any college maintaining offices for people called pre-medical advisers should be excluded from recognition by the medical schools.

Knowledge of literature and language ought to be the major test and the scariest. History should be tested with a rigor. Students should know that if they take summer work as volunteers in their local community hospitals, as ward aids or laboratory assistance, this activity will not necessarily be held against them, but neither will it help.

The first and most obvious beneficiaries of this new policy would be the college students themselves.  Society would be the ultimate beneficiary. We could then look forward to a generation of doctors who have learned as much as anyone can learn, in our colleges and universities, about how human beings have always lived out their lives.

Levels of racism: a theoretic framework and a gardener's tale.

by Camara Phyllis Jones

Am J Public Health. 2000 August; 90(8): 1212–1215.

Note:This is one of the key articles on racism in health care and in our society.

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.Link to Free Full Text.

Osler's Bedside Library Revisited

Osler's bedside library revisited—books for the 21st century: Personal Views

Sanjay A Pai and Roop D Gursahani. BMJ. 2005 Dec 17; 331(7530): 1482.

Free Full Text. (scroll down to page 4)

Medical education is, in many ways, incomplete. Although we are taught about the science of medicine, most medical school curriculums lack formal teaching on the humanity of medicine. Ethics, history, and philosophy are not taught formally in many schools. William Osler was one of the earliest to realise this, and in 1904 he proposed a bedside library for medical students. 

This is a thoughtful article that is worth reading.  Free Full Text. (scroll down to page 4)

Image from the BMJ article

Heartsink Patients

Heartsink" patients exasperate, defeat, and overwhelm their doctors by their behaviour. A group of such patients was followed up over five years in a general practice, and this paper describes what happened to them. As a group they were often in employment and in stable relationships, though women were over represented. Half the group were subjected to a management plan which seemed to make them less heartsink over the five year period. While heartsink patients often have serious medical problems, they are a disparate group of individuals whose only common thread seems to be the distress they cause their doctor and the practice. Heartsink as a phenomenon has features that are unique to general practice.

T. C. O'Dowd. Five years of heartsink patients in general practice. BMJ. 1988 Aug 20; 297(6647): 528–530.  Free Full Text.

[This is an important article.  We all see these patients.  Some of us groan when we see them on the daily list.  Others may look forward to the challenge.  Heartsink patients may be those who are stuck in a chaos story.  They are not questing and have not achieved restitution (see  Frank, AW.  The Wounded Storyteller).

Death is no longer just in the hands of god or fate, but often a decision

"On 30 October 2017 I had just landed at Heathrow from Melbourne. I had the strangest feeling I should not go directly to bed. I wondered if I should visit my mother, Margaret Black, a 92 year old retired anaesthetist living very independently in a warden assisted housing complex in Kent. At midday I got a call from my sister—mum had developed abdominal pain, pressed the alarm button, and phoned her GP. Could I go?

There is much discussion about the right of an individual to die, but not enough about the role of relatives and friends"  Dr. Black's essay is powerfully resonant with our lives.

Black ME. Death is no longer just in the hands of god or fate, but often a decision.  BMJ. 2018 May 22;361:k2217.

Full BMJ article

p53 and Me

Shekinah N.C. Elmore, MD

NEJM May 24, 2018

This is an extraordinary Perspective piece in the New England Journal by a young oncology resident who has the p53  mutation. This is seen in people with Li-Fraumani syndrome.

" A mutation like mine threatens to consume your whole imagination, especially with regards to the future. You start making crazy calculations..."

" Genetic knowledge is power only if both clinician and patient are equipped to move beyond a result and toward action, even if that merely means living well with what we know."

 She feels that people like her need to be studied not just for the data of their genomics but to help build programs for learning to teach people how to live with the uncertainties that their mutations will engender. 

This short essay is has many valuable teaching moments. She says, "I want as many of my days as possible to be untethered to the scans, biopsies and long waiting room sojourns. This is a cry from one who has been there for minimally disruptive medicine.

Trying to Put a Value on the Doctor-Patient Relationship

This is an important article in the NY Times Sunday Magazine (May 20, 2018).

In its push for profits, the U.S. health care system has made it difficult for patients to get personal attention from doctors. But what if hands-on medicine actually saves money — and lives?

The question of what the role of a primary-care physician should be, and how it should be valued, has perhaps never been more urgent. That figure, typically a general practitioner, family doctor or internist, is a patient’s first and often most personal connection to the rest of the health care system. But well-known corporations are betting that Americans would prefer to have health care 'delivered' by a trusted brand rather than a trusted physician."

Kim Tingley's  thoughtful piece is a "keeper' worthy of study.

Photos from a famous 1948 Life magazine article on the life of a country doctor.

Body Ritual among the Nacirema

The anthropologist Clyde Kluckhohn has pointed out that man is distinguished from other living organisms by three characteristics of human activity: the systematic making of tools; the use of abstract language; and religion. Religion is a broad term, embodying not only belief in a supernatural power but also an elaborate web of myth, theology and ritual. Most people like religion in their hearts and in their houses of worship, and they are delighted that modern science has largely emancipated them from irrational ritual and ceremony in medical habits. It is both disturbing and instructive, therefore, to learn that right in the midst of Western civilization there is a tribe of natives that practices daily elaborate rituals filled with mysterious and magical elements designed to sustain the health and well-being of the body. Another distinguished anthropologist, Horace Miner, was able to gain the confidence of these natives, and he has reported on his scientific investigations in an illuminating essay entitled, "Body Ritual among the Nacirema."

See “Miner, “Body Ritual among the Nacirema” The American Anthropologist 1956

Miner’s essay was cited in Barbara Ehrenreich’s book, Natural Causes (2018)

Dermatological PUVA Ritual

High Energy Proton Beam Ritual

Norwegian High Priestess performs Skin Screening Ritual

Sentinel Lymph Node (SLN) Biopsy Decision Aid

The question of whether to undergo a SLN biopsy for melanoma is a difficult one.  It is clear that some experts recommend it while others don't.  Where does that leave a patient?  In England the National Institute for Clinical Excellence provides decision aids for many conditions. Here is a link to the SLN Decision Aid.  Please give it thought and discuss it with your dermatologist or surgeon.  The decision is really up to you.

The Problem With Miracle Cancer Cures

by Robert M. Wachter

April 22, 2018, NY Times

Robert Wachter is Professor and Chairmen of Department of Medicine at UCSF.  His book, “The Digital Doctor,” (2015) is a great trove of information presented in a palatable, non-geeky manner.

A new generation of cancer treatments have become available in recent years.  The medical literature now fairly gushes with terms like “revolutionary” and “cure.”  Oncologists are seeing patients whose cases they once would have pronounced hopeless experience Lazarus-like responses to these new therapies.

If these new treatments worked most of the time, this would be an unambiguously happy story. But they don’t. A recent analysis estimated that about 15 percent of patients with advanced cancer might benefit from immunotherapy — and it’s all but impossible to determine which patients will be the lucky ones.

What can we do to alleviate the hype?

·      First, it turns out that many patients can benefit from palliative approaches even as they continue aggressive treatment for their cancer.

·      Second, doctors need more training in how to have these hard conversations with patients in light of the new cancer treatments. Doctors will need to become more at ease with the prognostic ambiguity.

·      Finally, through the federal Cancer Moonshot program, the government is spending hundreds of millions of dollars to study immunotherapy and other emerging treatment options for cancer. The sooner we can work out which patients will — and just as important, won’t — benefit from these approaches, the better.

Let’s be sure that we don’t rob dying patients of a smaller, more subtle miracle: a death with dignity and grace, relatively free from pain and discomfort.

Throw Deep

The NFL Hall of Fame quarterback Ken Stabler was once being interviewed by Sports Illustrated when the journalist recited a quote from the author, Jack London that was near to London’s statue in Oakland:

“I would rather be ashes than dust!

I would rather that my spark should burn out in a brilliant blaze than it should be stifled by dry-rot.

I would rather be a superb meteor, every atom of me in magnificent glow, than a sleepy and permanent planet.

The function of man is to live, not to exist.

I shall not waste my days trying to prolong them.

I shall use my time.”

When sked what these words meant to him personally, Stabler replied with the gritty confidence of a veteran, “Throw deep.”

The Hypothetical Rabbit

Michael W. Kattan,

Front Oncol. 2016; 6: 123.

Published online

This common analogy for describing newly diagnosed prostate cancer patients appears to be attributable to Hinman,* who borrowed from Crile when applied to breast cancer.

·      Turtles are patients with very slow growing disease. Their disease grows so slowly that they need not be diagnosed, for the disease will never spread to the point of causing problems within the patient’s lifetime. A turtle will die of another cause, not prostate cancer.

·      The bird has been diagnosed too late to have impact on the disease. It has already spread and cannot be meaningfully slowed down, to the point where the patient is likely to die of his prostate cancer. The bird is similarly not helped much by a diagnosis of prostate cancer since it is already too late to stop the disease.

·      The rabbit sits in the sweet spot. The rabbit is the man with prostate cancer who needs to be diagnosed (his disease spreads faster than that of the turtle and indeed poses a threat to his life), yet the disease is still curable (unlike the disease borne of the bird).

This model holds for many other cancers, perhaps most. It can be helpful when patients or physicians think about screening and treatment.

*The value of screening for prostatic carcinoma: a commentary.

Hinman F Jr.  Urol Int. 1991;46(3):275-8.

Abstract

Can routine digital rectal examinations, transrectal ultrasound studies, and prostate-specific antigen determinations reduce deaths from prostatic carcinoma? The evidence is that the benefits of early diagnosis and treatment are at least neutralized by the limited reliability and high monetary and human costs of the test and by the lack of proof that treatment is effective for those tumors detected. One must conclude that universal screening is not now warranted and will await demonstration of effectiveness by controlled studies.

Out of the Straightjacket

Michael S. Weinstein, M.D., M.B.E.

N Engl J Med 2018; 378:793-795

Free Full Text

This is the narrative of a trauma surgeon who has a history of major depressive illness.  He tells it as it was; including his psychiatric hospitalization, electroconvulsive therapy, and recovery.  In some ways, this is a restitution story.

Dr. Weinstein addresses important areas we’d rather not face.

“We often make decisions in the face of uncertainty that deeply affect our patients’ lives. When things went wrong, I frequently blamed myself. I learned that doubt, ignorance, and lack of confidence were my own failings.”

“Though I had mental illness, I still saw it as a weakness, a personal fault. I remember early in my career hearing of a colleague who took a leave of absence for a “nervous breakdown.” I joked about it, said he was weak. Now it was my turn.”

“I wanted out, out of work and out of life. I wished I would get hit by a car, and sometimes took steps to increase my risk. I felt trapped in my work and worried that I would expose my shortcomings if I sought a leave or disclosed my feelings. I’ve subsequently learned that my colleagues were quite concerned about me but found me unreceptive to attempts to help. I was trying to get help in many ways, but nothing seemed to work.”

Free Full Text

This is an important topic.  We’d rather not acknowledge it.  The best-selling author, Sherwin Nuland, was a surgeon who similarly was hospitalized for major depression.  He chronicled that in his autobiography, “Lost in America.”

Doctors, Revolt!

The 96 year old patient lamented that today's hospital is more like a factory.   He told his intern that “healing is replaced with treating, caring is supplanted by managing, and the art of listening is taken over by technological procedures.” 

This is a moving article by Dr. Rich Joseph, a resident at the Brigham and Women’s Hospital in Boston.  His Op-Ed piece, Doctors Revolt!, published in the Sunday Review of the NY Times is a moving introduction to Lown’s fine book, The Art of healing.  It also chronicles a refresher course in humanistic medicine for Dr. Joseph at a crucial point in his career..

Here are notes from The Lost Art of Healing.