She arrived by ambulance in the middle of the night, awake, alert, and bleeding like crazy. We’d gotten a call earlier in the evening that she was on her way from a small hospital about forty miles to the north. We were the big city hospital, and an attending physician had agreed to have her transferred for a life-saving procedure, in this case a shunt that might stop her bleeding. People ...

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Most of us reject the rational argument that better medical quality costs more money.   Conversely, I have argued that spending less money could improve medical outcomes.  Developing incentives to reduce unnecessary medical tests and treatments should be our fundamental strategy.  Not a day passes that I don’t confront excessive and unnecessary medical care -- some of it mine -- being foisted on patients. At one point in my career, I would ...

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The holiday season is well underway. This is the time of year for celebrating with family and close friends and reflecting on what is truly important to us. It can also be a  time of significant stress, inevitable over-eating and deviation from our usual routines. Essentially, the holidays can be hazardous to your health and this is particularly true when it comes to your gastrointestinal (GI) system. So what can ...

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Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians. A 50-year-old man is evaluated in follow-up for a recent diagnosis of cirrhosis secondary to nonalcoholic steatohepatitis. He has a history of asthma, type 2 diabetes mellitus, hyperlipidemia, and obesity. His current medications are inhaled fluticasone, montelukast, insulin glargine, insulin lispro, simvastatin, and lisinopril. On physical examination, temperature is 37.5 °C (99.5 °F), ...

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A few days before I wrote this, a patient had a complication in my office. I have discussed previously the distinction between a complication, which is a blameless event, and a negligent act. In my experience, most lawsuits are initiated against complications or adverse medical outcomes, neither of which are the result of medical negligence. This is the basis for my strong belief that the current medical malpractice system ...

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We always want to get it right the first time when treating patients, but the truth is this is difficult. When there is uncertainty of disease course and prognosis, multiple treatment options, and variable responses to therapy this becomes even more challenging.  Our typical strategy to making it “just right” isn’t too different from Goldilocks. We have mild treatments (too cold), and aggressive treatments (too hot), and even in the ...

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One of the most frequent questions gastroenterologists are asked about is diet, health and disease; and some of the questions gastroenterologists are least comfortable answering are about diet, health and disease. This disconnect occurs for several reasons. Although the subject of nutrition is taught in medical school, it usually covers malabsorption of nutrients, vitamins and minerals that have limited relevance to the concerns of most patients. The modern physician does not see ...

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One catch phrase in health care reform is cost-effectiveness.  To paraphrase, this label means that a medical treatment is worth the price.  For example, influenza vaccine, or flu shot, is effective in reducing the risk of influenza infection.  If the price of each vaccine were $1,000, it would still be medically effective, but it would no longer be cost-effective considering that over 100 million Americans need the vaccine. Society could not ...

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Did you know that your digestive tract contains over 400 different types of bacteria? This complex ecosystem is called intestinal microflora. The concentration of bacteria in the gastrointestinal tract increases dramatically moving from the stomach towards the colon. In humans, the intestinal microflora is vital in many important functions including digestion of nutrients and prevention of infection. Disruption of the “normal flora” can lead to many problems including diarrhea, bloating, ...

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Prevent the overdose of OTC pain medications Recently in the emergency room, I saw a 35-year-old patient -- we’ll call her Jane -- who was vomiting blood. The source of the vomiting turned out to be a bleeding ulcer caused by unintentionally overdosing on ibuprofen. Jane was in pain -- she was taking prescription ibuprofen for her chronic knee pain -- but she was also taking over-the-counter (OTC) ...

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