The recently instituted 30-hour-shift work restrictions placed on medical residents have created a need for "dayfloat" services to safeguard potentially unsafe handoffs in patient care and help residents adhere to duty hour limits. The past two weeks I’ve been the dayfloat resident for the cardiology inpatient service. My job is to round with the post-call team, help them get out of the hospital on time, and then take care of their ...
Shantanu Nundy, MD
The entire approach to food based on nutrients is wrong
The science of nutrition is changing and not in the way you might expect. After years of "reductionist" thinking — where food has been viewed as the sum of its parts – a call to treat food as food has been sounded. No more poring over nutrition labels to calculate grams of fat or chasing down the latest go-to chemical – be it vitamin E, fish oil or omega-3. ...
In medicine, the greatest save is not having to make a save at all
In the real world of medicine, "great saves" are rare. Most patients that you expect to die will die, and those who experience a cardiac arrest or code rarely survive. Mr. GR is the closest I’ve seen to an exception to both of these rules, and his story illustrates the best but also the worst of what our health care system achieves.I first met Mr. GR in the emergency room. As ...
Cancer patients get better care than patients in primary care
Why do my patients with cancer get better care than my patients in primary care? As the senior resident on my hospital’s inpatient leukemia service recently, this question troubled and intrigued me daily.Despite the sheer complexity of treating leukemia (administration of chemotherapy, bone marrow biopsies, stem cell transplantation), the resources required (transplantation routinely costs $1 million), and the severity of the illness ...
Obesity and the crossroads between relative health and medical illness
At the end of a busy afternoon, Mrs. MJ was exactly the kind of case I needed.Two of my patients had come in late but needed to be seen and another was acutely short of breath and refusing to be admitted to the hospital. The chaos had put me almost an hour behind schedule, and I still had to return to the wards to round on my cancer patients. Fortunately ...
How the health care industry competes for patients
On my drive in to work this past week I came across this:
A bus-side advertisement for a local hospital (sadly, not mine) claiming that it was “home to the city’s best transplant outcomes.” Normally I drive right by these moving billboards without paying much attention. But this time I immediately got excited, whipped out my cell phone and snapped ...
People live and die by their chronic illnesses by what they do at home
"You know, what Mr. HD really needs is for his mom or somebody to chain herself to him …" [the ICU team laughs] … "But seriously, he needs to be watched over, he needs to be talked to. He needs someone to give him his medications, someone to take him to his appointments, someone to take care of him. With that somebody he can live for years to come. Without ...
Tamoxifen for breast cancer prevention is not routinely used
Cancer prevention is built around screening. In screening, the hope is to catch cancer at an earlier stage than it would be found otherwise and increase options for treatment and chances of cure. In some cases, screening prevents cancer — for example, when a precancerous polyp is removed from the colon during colonoscopy — but generally it is aimed at early detection.What if instead we could prevent cancer from developing ...
Chronic illness needs to be managed at home, not at the hospital
“You know, what Mr. HD really needs is for his mom or somebody to chain herself to him…” [the ICU team laughs] …"But seriously, he needs to be watched over, he needs to be talked to. He needs someone to give him his medications, someone to take him to his appointments, someone to take care of him. With that somebody he can live for years to come. Without that somebody ...
Reducing salt is a good idea but won’t save your life
In case you missed it, salt is the new fat.It seems that everybody from the FDA to Steven Colbert of the Colbert Report has set their sights on limiting our consumption of salt. In the past week, I’ve seen dozens of articles from the blogosphere to the front page of USA Today and a recent edition of Time on reducing our alarming levels of salt consumption.Many of us are aware ...
Shingles vaccine and the price of preventive care
They say an ounce of prevention is worth a pound of cure, but is that still true in today’s money? Recently I had an illuminating conversation with a patient that got me thinking about how I may try to answer this question. This is the first in a short series on the price of preventive health care.Mr. GR, as I will call him, had recently turned 60 years young. Though he ...
Failing to prevent disease in patients costs lives
An excerpt from Stay Healthy At Every Age: What Your Doctor Wants You to Know.When you were growing up, somebody probably told you that “an ounce of prevention is worth a pound of cure.”Many of us have learned from experience how much better it is to prevent a bad thing from happening than to try to fix the consequences once it has happened. Most people can agree that prevention ...
Added sugars worsen cholesterol levels
Added sugars hit a new low this week. A study published in JAMA found that people who consume higher quantities of added sugars have worse cholesterol profiles than those who consume less.First of, what are added sugars? Added sugars simply put are sugars that are added into foods (in contrast to naturally-occurring sugars that you find in fruits). The JAMA article writes that added sugars are “defined as caloric sweeteners ...
Patient adherence to drugs is low and what doctors can do
Frequently in preventive health we ask patients to take medications that will reduce the risk of a certain bad medical outcome years down the road: cholesterol-lowering agents that lower the risk of a heart attack, blood pressure-lowering agents that reduce the risk of kidney disease, glucose-lowering medications that reduce the risk of diabetes-related complications.Sometimes these medications make patients feel better — for example, insulin in patients with symptomatic diabetes or ...
Patient advance directives are critical in the ICU
When someone dies at home we call it ‘going to a better place.’ When someone dies in the hospital we call it a ‘code.’Recently, working in the cardiac ICU, I have been thinking a lot about code status. Code status is the medical term that describes what a patient’s wishes are should his or her heart stop or lungs fail. While code status is not a topic that typically ...
Allopathic medicine has alternative medicine roots
Whether we like it or not, the lines between allopathic and alternative medicine continue to blur. Just last week I recommended glucosamine-chondroitin to a patient who suffers from osteoarthritis and wrote a prescription for Lovaza, a prescription-strength preparation of fish oil. And today I was asked about red yeast rice from a patient interested in controlling her cholesterol through “natural means.”Like nutrition, complementary and alternative medicine, or CAM, is somewhat ...
Quit smoking by using Facebook
At 3am on Jan 1st 2010 my cousin-brother stubbed his last cigarette. New Year’s resolutions to quit smoking, lose weight, or change another bad habit are certainly not uncommon. Having tried — and failed — to quit a number of times before, my cousin took a bold, new approach to quitting. Whether a cleverly devised plan, or just a whim, he decided to post his quitting on Facebook.On January 4th, ...
Why cancer screening is not a black or white decision
Last month I saw a 65 year-old woman with a mass in her kidney in clinic for follow up. She had recently transferred her medical care to our clinic after her insurance changed.She came with a few medical problems including high blood pressure, tobacco use and arthritis — diseases which are the bread and butter of primary care medicine — but she also came with a history of a mass ...
How to better notify patients of their abnormal test results
I just returned from vacation to find email messages from three patients inquiring about their recent test results.The first email was from a young man who had fainted and underwent Holter monitoring, a test that checks for abnormal heart rhythms. The second was from a woman I recently started on cholesterol-modifying therapy who wanted to know whether her recent blood work showed a satisfactory improvement in her cholesterol. The third ...
Not enough patients receive vaccines and what doctors can do about it
Imagine a world where consumers all knew about the latest developments in preventive health.Earlier this month the Advisory Committee on Immunization Practices (ACIP) released the 2010 immunization schedules. Revised annually, the immunization schedules are what doctors in the U.S. use to decide who should be immunized against what diseases. Far from esoteric, the schedules pertain to every single person living in the United States. If the H1N1 pandemic and subsequent ...
