Sensible Medicine

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The woman with palpitations. The man with whom you used to joke and trade barbs who now sits silently, absent, while you talk to his wife. The woman whose depression dominates every visit; her depression being the one problem she refuses to address. The man whose joy and charisma makes every visit an absolute pleasure, despite his painful disability about which you can really do nothing. The man who never complains. Well, not never. The two times he did complain he ended up with emergent bypass surgery and a diagnosis of acute myeloid leukemia. The woman whose concerns are always uninterpretable. You wonder if the problem is your lack of cultural competence, that her language skills prevent her from articulating her problem, or maybe that her ineloquence keeps her from even knowing what she is experiencing. The woman who asks how you are doing because she recognizes that caring for her, with her dreadful prognosis, is hard. The man who, forever unsatisfied with his health, never accepts your advice, dismisses consultants, yet never misses a visit, praises you as the greatest doctor, and brags about you to his friends. The man whose world is spinning. The healthy 27 year old who is sure that her tension headaches are from a brain tumor. The man who berates the front desk staff, makes inappropriate remarks to the medical assistant, and has made racist comments to your nurse, but in the exam room – alone with you -- is the perfect gentleman. The man who laughs when you pull down his sock to examine his edema and a wad of cash and a dime bag of cocaine fall on the floor. The 75-year-old daughter who accompanies her 95-year-old mother to visits. You know that the older woman’s death will liberate and devastate the younger woman. The man who always exaggerates his symptoms because he is terrified by his own mortality and worries that he won’t be taken seriously. The woman who seemed impossible when you first met her but now brings you joy when the urgent care doctor calls and asks, “How have you taken care of this lady for 15 years?” The woman who doesn’t seem to like you and never seems to trust your opinion but, after 20 years, refers her daughter to you. The woman with six years of dyspnea and no diagnosis. The man you agree to see after he was “fired” by a colleague. His care, and your relationship with him, become an inspiring, and even rewarding challenge. He fires you after a year. The woman whose relapses, lies, and prescription forgeries angered and exhausted you for a decade now sits in a wheelchair, caregiver by her side, vacant. The woman who comes to see you for a new patient visit because her husband, your former patient, insisted that she start seeing you after he died. The man who hung himself three weeks after he saw you. He had complained of fatigue. The man who apologizes because he sees it has been difficult for you to give him the news about his recent scan. The woman with painless jaundice. The patient who fires you, deservedly, because you made a rookie mistake. The man who brightens your day when you see him on the schedule but honestly, if you didn’t know him, you would probably move to the next train car if he got on. The patient you secretly hoped would change doctors and then, when she does, you feel bad that you failed her. The man who steps off the scale, places a thick wallet, two rings of keys, and a Glock on the exam table before getting back on the scale. The man who wrote a thank you note that he had his wife mail to you after his death. The man who fought you until the end, always wanting more treatment, even after every doctor told him we had nothing left to offer. The woman whose diagnosis you could never make, until you got a pretty good idea of it ten years after she died. The man who just has a cold. This is a public episode. If you’d like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

This is a public episode. If you’d like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

This is a public episode. If you’d like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

I learned a lot from Elizabeth Fama’s multipart series on the back-to-sleep recommendation for infants. She agreed to put the entire series into an audio file. Here you go. JMM Sensible Medicine is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber. This is a public episode. If you’d like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

Ask general internists what they love about their field, and they are likely to talk about long-term relationships with patients and the pleasure of solving clinical puzzles. This is a public episode. If you’d like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

My lecture to the cancer care staff at a county hospital. This is a public episode. If you’d like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

Even when a decision is clear, and things turn out badly, the lack of a counterfactual allows endless second guessing. This is a public episode. If you’d like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

I discuss how medical students are selected, and perhaps how they should be selected. This is a public episode. If you’d like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

Remarks about a model clinician. This is a public episode. If you’d like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

It would be foolish to argue that doctors are unaffected by how they are treated by patients. Their treatment may not affect the care they deliver and only affect how they feel at the end of the day. It is probably impossible to know. This is a public episode. If you’d like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

When I type the words coronary artery disease I bet that you picture angiograms with stenotic lesions—blockages in colloquial language. Indeed a high grade plaque from atherosclerosis in the inside of a coronary artery can limit flow to the heart muscle. But. But. Not as much as you think. You know why? Because there is something called the coronary microcirculation. Before blood gets to the beating heart muscle it has to go through small blood vessels. So small that you can’t see them. A study in the NEJM—on one patient—elegantly shows the ability of the microcirculation to autoregulate blood flow in the face of increasing degrees of obstruction in large coronary vessels. We’ve all seen patients who have severe flow-limiting proximal stenoses, which create little to no angina. A likely reason is the ability of the microcirculation to dilate and improve blood flow—at least at rest or minimal exertion. My friend Venk Murthy explains this elegant study. I learned a bunch and likely you will too. We refer often to this figure from the paper. It would be useful to have it handy while you listen. JMM Remember all, Sensible Medicine is a reader supported site that is free from industry advertisement. Thank you for your support. Sensible Medicine is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber. This is a public episode. If you’d like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

VP fixed the audio This is a public episode. If you’d like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

Regard for power implies disregard for those without power; part 3 This is a public episode. If you’d like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

David Cohen is one of the smartest docs on Twitter. I learned a bunch talking with him. The procedure called transcatheter aortic valve implantation or TAVR is a damn miracle. In days of old, a heart surgeon would have to saw open the chest and cut out the heavily calcified immobile aortic valve and sew in a new one. I watched a case as a young doctor and came away shocked that patients survive this surgery. TAVR is even more stunning. Doctors place a valve up the aorta, across the diseased valve, and then place the new valve into the old valve. The verbs squishing or smooshing come to mind. The other unbelievable thing about TAVR is that strokes are less common than you’d think. When I first heard about TAVR, I thought: how is it not limited by all that debris going into the brain? Well, there is less debris than I would have thought. But not zero debris. In fact, there is one device on the market that forms a barrier between the aorta and the brain. We call it an embolic protection device (EPD) or cerebral embolic protection (CEP). Early studies show that the device catches debris that would have occluded blood vessels in the brain—iow, caused stroke. The pictures almost sell the device—because, obviously, catching debris has to be beneficial. But. But. There are always ‘but’s’ in Medicine. The PROTECTED TAVR trial, which compared TAVR with and without an embolic protection device failed to show a statistically significant reduction in stroke. It was a good trial, but it did not close the door for the device. For two reasons: one was that the trial was underpowered. The lower bound of the 95% confidence interval allowed for a 1.7% lower rate of stroke in the treatment arm. Neurologists feel that a 1% risk reduction in stroke is clinically important. The other reason was that a secondary endpoint of “disabling” stroke was 60% lower with the device. We needed more data. Another trial is not likely going to happen. Trials are expensive and take a long time. This is where Dr Cohen’s group comes in. They performed an observational study looking at more than 400k patients in a TAVR registry. About 13% got the device and 87% did not. This is where Sensible Medicine readers should start feeling a rash. Why? Because you know how scary it is to try and compare outcomes in two groups of patients who were not randomized. Cohen, however, tells me about a super-interesting way to approximate randomization in this comparison. It’s called an instrumental variable analysis. He explains this to me in clear terms during our conversation. I love methods so I was enthralled. But that isn’t all. The other thing is that his study, like the PROTECTED TAVR trial, came up with tantalizing close results. We discuss that as well. I loved our talk. If you like evidence, methods, and great medical stories, I think you will also like this conversation. JMM It’s free to all. We appreciate your support for this experiment in bringing ad-free medical information to the public. Sensible Medicine is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber This is a public episode. If you’d like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

This is a public episode. If you’d like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

A spirited discussion of craziness in medicine This is a public episode. If you’d like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

MM is 94 years old. Her only active medical issues are hypertension and vitamin D deficiency. She takes only 20 mg of lisinopril and 1000 units of vitamin D3 each day. She has no cognitive decline and gardens every day if the Chicago weather allows. Her Friday afternoon appointment is the doctor’s last of the week. Sensible Medicine is a reader-supported publication. If you appreciate our work, consider becoming a free or paid subscriber. I’ve already written a reflection on four things patients have taught me. After MM’s visit, I realized how much more there is to write on the topic. So here is a follow up with the unoriginal claim that the most valuable things I have learned from my patients are not about the practice of medicine. Though not profound, the lessons are universal. The longer I practice, and the older my patients get, the more frequently these truths are spoken. Aging is Painful Anybody who gets to middle age knows that things don’t work like they used to. Around my house we say that any day that nothing hurts is remarkable. My patients are full of pithy phrases to make the point that aging is physically difficult. “Getting old is hard, but it beats the alternative.” “Aging is not for wimps.” “Every time I look in the mirror, I ask myself, how the hell did that happen?” People respond to their progressive disability in all manners. Some fight at every turn. Every visit, irrespective of age, is spent discussing aches, pains, and things that can no longer be accomplished. There are demands for me to make things better. I find it challenging to address the concerns, rather than dismissing them with “it’s just age,” while also letting people know that some suffering is “part of the human condition.” Other people accept frighteningly steep and acute declines. My challenge at these visits is to balance, “She’s not asking me to address the problem, so who am I to pry” with “This actually seems like something I should explore, even if she is willing to accept it.” Where there is little diversity is our ability to adjust to disability. I was taught that people rate the quality of life with a disability higher when they are living with it than when they are watching other people live with it. Thirty years of clinical experience has made this real. We should add to the saying, “There but by the grace of God go I” the addendum “but, when I end up there, I’ll be OK.” Aging is Sad When I was an intern, I admitted an elderly woman with pneumonia. Her biggest problem was not the pneumococcus but her depression. Her mood made her miserable and the associated psychomotor retardation was going to make her post-hospital rehabilitation impossible. She was already taking an SSRI and seeing a therapist. I called her primary care doctor, a geriatrician. Like a true intern, I expected he would have an answer to her misery. His response was, “Yup, it is a sad time of life.” There is a lot to be said for the golden years: retirement, family, friends, greater financial security – but as the years go on, the psychological costs mount. Besides the physical decline, there is the constant loss. I repeatedly hear, “Everyone around me is dying.” Siblings, cousins, friends. It sometimes seems like those who are most connected suffer the most – that big family that has always provided support now provides an unending procession of funerals. People mourn their losses as well as their own mortality. You cannot ignore what is to come when your peers are dying. Those who deal with this best seem to be the people who can be honest that their grief about the loss of a friend is partly the fear and sadness that they are next. Loss is Never Easy I never felt like I had enough time with MM. Not that she needed time for me to attend to her medical problems. She was blessed with enviable genes and an outlook that combined cheer and steel. I just wanted time to hear more about her life and her experiences. I wanted to learn from her. On one...

A few short words about our conversation: Two decades have passed and electrophysiologists have learned little about how to ablate atrial fibrillation. Now, and then, we simply ablate circles around the orifices of the pulmonary veins. This works reasonably well. But we don’t—exactly—know why it works. For instance, some patients have total elimination of AF, but when they are restudied, they have reconnection of PV activity. Observations like these suggest there is something else happening with our ablations—beyond building an electric fence around the veins. One possibility is that we are affecting the neural input to the heart. Structures called ganglionic plexi sit next to the areas we ablate. We often see heart rate increases after AF ablation. Say, from 60 to 80 bpm. That’s because ablation has reduced parasympathetic input to the heart. Sensible Medicine is a reader-supported publication. To receive new posts and support our work, consider becoming a free or paid subscriber. Piotr and his team had to suspend typical AF ablation during the pandemic. Surgeons would not provide backup. This gave them the idea of a simple approach—only in the right atrium, with one catheter, and no anesthesia. It turns out that there is often a ganglionic plexus in the upper right atrium. They found patients who had a history of vagally-mediated AF. They documented that these patients had high vagal tone. And… in these patients, simple ablation in the RA yielded a signal of benefit, a reduction of AF. Wow. It’s a small single-center study. It’s just a signal. A first mile of a marathon. But for the curious regarding AF, it is super-interesting. Many athletes and young people have vagally-mediated AF. Here is the link to the paper: Cardioneuroablation of Right Anterior Ganglionated Plexus for Treatment of Vagally Mediated Paroxysmal Atrial Fibrillation Here is Piotr. He works in Rzeszów, Poland. It’s a beautiful city to visit. I once ran a marathon there. JMM This is a public episode. If you’d like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

We discuss the state of medical education, Harvard music video, causal language at JAMA and more This is a public episode. If you’d like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe