I only applied to one medical school. Maybe that was hubris, but I didn’t think so at the time. Then, in a moment of sudden insecurity, I asked myself, “What if I don’t get accepted?” During the six months between my military service and the beginning of classes at Uppsala University, I worked as a substitute teacher in my hometown, teaching second to eleventh grade depending on where there was a ...

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I did a peer review once of an office note about an elderly man with a low-grade fever. The past medical history was all there, several prior laboratory and imaging tests were imported, and there was a long narrative section that blended active medical problems and ongoing specialist relationships. There was also a lengthy review of systems under its own heading. In an over ten-page long printout, the final diagnosis was ...

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Using a treatment without having any understanding of how it works is often thought of as unscientific, and suggesting that a placebo can help a sick patient has until now been viewed as unethical. The New England Journal of Medicine just published an article about placebo (making you feel better) and nocebo (making you feel worse) effects, two of the most intriguing aspects of the supposedly scientific practice of ...

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He canceled his follow-up appointment because he was feeling fine. He didn’t see the point in wasting a Saturday to come to my clinic when he had lawns to mow and chores to do. Less than two weeks before that, he was sitting on the exam table in my office, again and again nodding off, waking up surprised every time his wife prodded him. The stack of printouts from the emergency ...

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Some people have high cholesterol but not much atherosclerosis. We think of their arteries as having nonstick surfaces. We know inflammation can predispose to plaque formation and plaque rupture, which is the trigger of most heart attacks. We know statin drugs can prevent and reverse plaque buildup, and make existing plaque sturdier and less likely to rupture. These drugs lower blood levels of inflammatory substances. Most doctors focus on their cholesterol-lowering ...

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I have noticed several articles describing how antibiotic development has bankrupted some pharmaceutical companies because there isn’t enough potential profit in a ten-day course to treat multi-resistant superbug infections. Chronic disease treatments, on the other hand, appear to be extremely profitable. A single month’s treatment with the newer diabetes drugs, COPD inhalers, or blood thinners costs over $500, which means well over $50,000 over an effective ten year patent for each ...

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I looked at a free book chapter from Harvard Businesses Review today and saw a striking graph illustrating what we’re up against in primary care today, and I remembered a post I wrote eight years ago about burnout skills. Some things we do, some challenges we overcome, energize us, or even feed our souls because of how they resonate with our true selves. Think of mastering something like ...

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He did a double-take as we passed on our small town sidewalk the other day. “Hey Doc, I didn’t recognize you dressed like that, without your …”, he gestured to where my tie or stethoscope would have been. I was wearing a cafe-au-lait colored T-shirt and faded Levis. “Did you hear about the appointment with the cardiologist yet,” I asked. “It’s in two weeks,” he answered. “Tell me, Doc, how serious is this ...

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An excerpt from A Country Doctor Writes: CONDITIONS: Diseases and Other Life Circumstances. “Welcome back. How was your trip? Or exile ... you were away for a long time.” “Almost a year,” my nine o’clock patient answered. A woman just over forty, she looked tan and physically strong. ...

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Opiates relieve pain and can transport people to their apparent happy place. So does marijuana.  Lyrica, the seizure-turned-pain medication, caused enough of a buzz in early study participants that it became a controlled substance. The anesthetic ketamine is now used for treatment-resistant depression. Years ago, we had to be very specific about the location and classification of our patients' pain. When pain then became a self-reported vital sign and chronic opioid ...

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We have all heard that 90 percent of the time, a patient’s history provides the diagnosis before we even perform a physical exam or order any tests. At the same time, much of our reimbursement used to hinge on how many body systems we examined. Like so many other things in the new reality we find ourselves in, what constitutes a proper medical visit has suddenly changed and will probably continue ...

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It took a 125-nanometer virus only a few weeks to move American health care from the twentieth to the twenty-first century. This had nothing to do with science or technology, and only to a small degree was it due to public interest or demand, which had both been present for decades. It happened this month for one simple reason: Medicare and Medicaid started paying for managing patient care without a face ...

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It is well known by now that a physician’s demeanor influences the clinical response patients have to any prescribed treatment. We also know that even when nothing is prescribed, a physician’s careful listening, examination, and reassurance about the normalcy of common symptoms and experiences can decrease patients’ suffering in the broadest sense of the word. This has been the bread and butter of counselors for years. People will faithfully attend and ...

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We knew that the most powerful way to provide substance abuse treatment is in a group setting. Group members can offer support to each other and call out each other’s self-deceptions and public excuses, oftentimes more effectively than the clinicians. They share stories and insights, car rides, and job leads, and they form a community that stays connected between sessions. Participants with more experience and life skills may say things in ...

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Talking to patients on the phone can be very efficient and quite rewarding, like when I called a worried patient today and told her that her chest CT showed an improving pneumonia and almost certainly no cancer, but a repeat scan some months down the road would still be a good idea. She told me she was feeling better, but still quite weak and that her sputum was still dark ...

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If my hypertensive patient develops orthostatism and falls and breaks her hip, I fully expect the orthopedic surgeon on call to treat her. I may kick myself that this happened, but I’m not qualified to treat a broken hip. If my anticoagulated patient hits his head and suffers a subdural hematoma, I expect the local neurosurgeon to graciously treat him even though it was my decision and not his to start ...

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I ran late the other morning. My first patient, an internal transfer, was already waiting. Booting up my laptop seemed to take forever. Usually, I try to poke around at least a little in the EMR before I enter the exam room, even when I know the patient well in order to remind myself of what we are supposed to do in today’s visit. I decided to walk in cold because I ...

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Imagine if your bank handled all your online transactions for free but charged you only when you visited your local branch -- and then kept pestering you to come in, pay money and chat with them every three months or at least once a year if you wanted to keep your accounts active. Of course, that’s not how banks operate. There are small ongoing charges (or margins off the interest they ...

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Earlier this month Ross Douthat wrote a piece in The New York Times titled “The Age of American Despair” where he posed the question “Are deaths from drugs and alcohol and suicide a political, economic or spiritual crisis?” Douthat writes:

The working shorthand for this crisis is “deaths of despair,” a resonant phrase conjured by the economists Anne Case and Angus Deaton to describe the sudden rise in ...

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The Swedish word for physician is läkare, which literally means healer. That seems a lot more glamorous than the American word physician, which is derived from physic, the old fashioned laxatives that were thought to rid the body of poisons and impurities. But we are actually the healers a lot less often than we think. The more we learn about how the body works, the more we have to admit that ...

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