Relative risk reduction is a troublesome way to convey the benefits of treatments

Meds
January 1, 2018

How excited would you be about a medication that lowered your risk of cardiovascular death, heart attack or stroke by 1.5%? Excited enough to spend a few thousand dollars a year on the drug? I expect not.

What if, instead, the drug reduced those same terrible outcomes by 20%? That’s probably enough benefit to interest some in the drug.

Well, those statistics come from the same clinical trial, evaluating the same drug. …

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Learn pulmonary hypertension with a Medcomic

Conditions
December 30, 2017

Pulmonary hypertension (PH) refers to increased pressure in the pulmonary circulation. It develops when pulmonary vessels become constricted and/or obstructed, which can occur in a wide variety of conditions. The increase in pressure is measured by right catheterization, and is defined as a mean pulmonary arterial pressure ≥ 25 mm Hg at rest.

PH leads to right ventricular hypertrophy and enlargement as the …

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MKSAP: 64-year-old man with diabetes

Conditions
December 30, 2017

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 64-year-old man is evaluated for his quarterly diabetes care follow-up visit. Point-of-care HbA1c level is not at goal for this patient, who has high function, long life expectancy, few comorbidities, good support, health literacy, and access to care. Medical history is significant for hypertension, hyperlipidemia, and obesity. His family history is notable for type …

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Safe pediatric dental anesthesia is the right of every child

Physician
December 29, 2017

When you tell anyone in health care that “sedation” to the point of coma is given in dentists’ and oral surgeons’ offices every day, without a separate anesthesia professional present to give the medications and monitor the patient, the response often is disbelief.

“But they can’t do that,” I’ve been told more than once.

Yes, they can. Physicians are not allowed to do a procedure and provide sedation or general anesthesia at the …

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The physician’s relationship with the beeper

Physician
December 29, 2017

If you’re thinking about a career in medicine, there’s a piece of technology you’ll come to know intimately. It’s small and sleek, with excellent battery life and remarkable durability. It’s not an iPhone; it’s not a Pixel. It’s a beeper. You will come to know, and to respect, this tiny black rectangular prism. It will govern your life. You will be at its mercy, yes, but it also offers you a chance at salvation. …

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What to do if you have high expense ratio mutual funds

Finance
December 25, 2017

A common question from readers is what to do about an account that contains a bunch of high expense ratio mutual funds or individual stocks.

The reason for having such an account varies from person to person. Maybe it was the only funds available to them in their 401(k) portfolios. Perhaps they collected a bunch of individual stocks and actively-managed mutual funds over the years based on tips from magazines or …

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How to create a household budget: a physician’s simple approach

Finance
December 24, 2017

Learning to budget is scary.  After all, it means you have to say NO to unnecessary purchases and keep your eye on long-term goals at the expense of short-term pleasure.  There are a variety of ways to budget, ranging from the restrictive and somewhat impractical “envelope system” to the more vague and potentially ineffective “wing it” system.  I’d like to present a balanced approach to budgeting that …

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MKSAP: 63-year-old man with mid-upper back pain

Conditions
December 23, 2017

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 63-year-old man is evaluated for severe mid-upper back pain following a minor fall 1 day ago. He also notes progressive fatigue of 6 months’ duration and a 6.8-kg (15-lb) weight loss. Medical history is notable for an 80-pack-year smoking history, although he is currently a nonsmoker.

On physical examination, temperature is 37.3 …

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What it’s really like in a post-baccalaureate program

Education
December 21, 2017

More than 15 percent of last year’s new crop of first-year medical students completed a post-baccalaureate program. These programs exist in two flavors: one type helps students who want to improve their undergraduate academic record, and the other helps those who want to redirect their careers toward medicine, like me. Both are growing rapidly in number.

With so many future doctors launching …

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End the resident physician abuse now

Physician
December 21, 2017

Let’s talk about the cycle of abuse. No, I am not referring to the very serious issue of domestic violence. Instead, I am talking about the graduate medical education system. No one is a resident forever: the duration of each residency is predetermined with a wide range of three to nine years. The self-limited nature of this experience decreases the incentive for participants to advocate for changes. And the attitude …

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Are post-apocalyptic disaster films inspiration for doctors?

Physician
December 20, 2017

What would medical education that is relevant for the here and now — for America in the early 21st century — address? It is impossible to teach the content relevant for an entire career. It is important to educate practitioners able to adapt to the changing landscape of medicine. We must consider what the future might hold.

Watching science fiction may serve to prompt future physicians to practice preventive medicine for …

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Why nurse practitioners train on the backs of physicians

Policy
December 19, 2017

“Nurse practitioner (NP) education is seriously underfunded. The profession is attempting to saddle private physicians with this cost.”

That is how “Dr. X” replied to my email asking whether he would be willing to precept a nurse practitioner student for her clinical rotation. I read through his clearly disgruntled letter and wanted to explain to him why NPs have to train “on the backs” of physicians and why funding for nursing …

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A doctor saved a patient’s life. Twice.

Physician
December 18, 2017

I have good days and bad.  Some days I am content, connected, focused, and motivated.  On those days I enjoy my job, I enjoy the people I’m with, I am willing to be inconvenienced by interruptions.

On other days, not so much.  I wake up as grumpy Rob and (despite multiple cups of coffee) the old codger doesn’t leave me alone.  I keep score of all the ways in which life …

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The Good Doctor shows us the value of time

Physician
December 17, 2017

In a recent episode of the television series, The Good Doctor, a patient played as Robbie Ato does not tell his doctors he has a history of cancer.  You can see his surgeons stare in disbelief as one consulting surgeon recognizes the patient’s name and then alerts the team leader that she treated him three years ago for cancer.

This is one of the very most troubling and dangerous acts of …

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The myth of multitasking in primary care

Physician
December 15, 2017

Primary care doctors don’t usually have scheduled blocks of time to read incoming reports, refill prescriptions, answer messages or, what we are told the future will entail, manage their chronic disease populations. Instead, we are generally expected to do all those things “between patients.”

This involves doing a little bit of all those things in the invisible space between each fifteen-minute visit, provided we can complete those visits, their documentation and …

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The first rule of medical school interviews: Don’t talk about cost

Finance
December 14, 2017

The fall is over, and winter has come, which means I have just wrapped up a busy season of medical school interviews. Most interviews are conducted in a similar fashion with an hour of introduction, speeches by the dean, presentations of facts I already knew from the website, and finally the interviews.

Within the first hour, I understand the reason: “We are the best medical school at (fill in the blank).” …

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