ACP Internist Blog

Thursday, November 14, 2019

3 reasons to be a doctor and have a career in medicine

There's so much negativity out there when it comes to health care, it must be a concern to any young person thinking about entering the field. I certainly spend a lot of time writing about all the challenges we face, and have to hold my hands up to (occasionally) spreading some of that negativity as well! Guilty as charged. That's why it's important for anyone outside of health care (or any field) to be wary of a certain type of “negativity bias,” which can occur when you are only exposed to people with things to complain about—who tend to be the only ones speaking up.

Another honest truth not to be overlooked, is that we as humans will always tend to overly focus on what's wrong, and not what's right, about our current circumstances. Looking at this in a positive way, it's also a useful survival mechanism to make sure everything keeps getting better.

I've written previously about all the good things about health care in America (see this article) and why I have no regrets becoming a doctor, despite any bumps in the road and disillusionment with our current health care system. Here again are three of them:

1. Job demand
If you're a doctor, rest assured that barring any unforeseen unique circumstance, you will never be out of a relatively highly-paid job. Demand for physicians in most specialties far outstrips supply. For sure, we keep hearing all the usual stuff that everybody does, about their jobs “being replaced by robots.” If this ever happens—which it won't—doctors will be the last it will happen to (in a highly improbably world where apparently where only 1 percent of the population will have jobs). Every year I've been in practice, the physician shortage only gets worse as the population ages and chronic comorbidities continue to rise. The job security in health care is really second to none.

2. Options
As a trained physician, you have a multitude of options about how you work, and on what terms you practice. America is a big country, and there are endless environments to work in. Even if you want to break away from working clinically, there are administrative, startup and also other industrial routes you can go down. Some doctors out there have only worked in one place for decades since finishing their residency, and eventually bemoan feeling stuck. Don't listen to them. Be open, look around and network!

3. Meaning
No matter what specialty you are in, being a physician means that you will never go home at the end of the day feeling like you haven't done anything important and worthwhile with your day. I used to tell my residents when I was a teaching Attending that you have the opportunity to do more good and touch more lives in one hour in your work, than most people get in a month.

No doctor should ever let their job become so routine that they forget that simple truth about what we do. If there's any physician out there who really feels disrespected and trodden on every minute of the day, they really need to take a long hard look at themselves. There are a lot of people out there in their 40s, 50s, and 60s, who find themselves working in office cubicles and have a realization that their job lacks any true meaning or worth. That should never happen to anyone in health care.

None of the above means that we should not talk about the immense challenges to physician practice that we face, nor turn a blind eye and seek to improve our dysfunctional and ridiculously expensive health care system. But it does mean that we should have some perspective too. If you're reading this and considering a career medicine, two other huge sacrifices should also be mentioned: debt and time. If you're not fortunate enough to have had family support or trained at a cheaper medical school, debt is a realistic concern and something to carefully plan for. It's good to see some medical schools slashing their fees and implementing other initiatives like loan forgiveness for those going into primary care. Second, sacrificing your 20s (and for some, their 30s) to be in lengthy relatively low-paid training. And aside from these two things, it's damn hard work becoming a doctor!

Choosing a career in medicine is not for the faint-hearted, but the above three things will always be there for you as a physician. I have no regrets whatsoever doing medicine. It has allowed me to meet unbelievably inspiring people (both physicians and patients), travel the world, and have a sense of appreciating every moment in life— that I don't think I would have gained doing anything else.

Suneel Dhand is an internal medicine physician, author and speaker. He is the founder of DocSpeak Communications and co-founder at DocsDox. He blogs at his self-titled site, where this post first appeared.
Thursday, November 7, 2019

Colonic hydrotherapy: Is it time to bend over?

From time to time, patients asks my advice on colonic hydrotherapy, vigorous sessions of enemas that aim to cleanse the body of toxins that are reputed to cause a variety of ailments. The logic sounds plausible to interested patients. Over time, toxins accumulate and leech into the body wreaking havoc. Indeed, using the label “toxins” already suggests that these are noxious agents. If one accepts this premise, it is entirely logical that cleansing the body of these injurious agents would have a salutary effect.

Not surprisingly, the health benefits of hydrotherapy usually target very stubborn and vague symptoms and conditions that conventional medicine do not treat adequately. It makes sense that if your own physician is not making sense of your chronic fatigue, for example, that you would entertain other options. I get this. Who wouldn't want to enjoy having more energy, better concentration, an enhanced immune system or delayed aging? But, in medicine and in life, just because one pathway seems blocked, doesn't mean that an alternative pathway will be a better avenue.

The reason that I do no actively recommend hydrotherapy is because there is absolutely no persuasive and credible medical evidence that it is effective. While their advertising materials may boast of ‘clinical studies', there is no firm scientific basis for their claims. And, these sessions can be costly as patients are often advised that several visits are necessary to address years of toxin build up.

If gastroenterologists did believe that the treatment works, we would be offering it in our ambulatory surgery centers along with our standard endoscopic amusement activities. (A cynic might suggest here that if medical insurance covered these treatments, then we would!)

It may very well be that practitioners of this treatment believe in the therapy and genuinely want to provide healing. And, I have no doubt that many who undergo hydrotherapy feel better. I'll never talk a patient out of success from my or anyone's treatment. If a hydrotherapy patient were to tell me that his depression has eased, I would express great satisfaction over this.

I admit readily that I, along with every other breathing physician, prescribe treatments and remedies for which no supportive medical evidence exists. We physicians may sanitize this fact by claiming that our action is an example of the art of medicine, but we are more likely hoping for the placebo effect.

Physicians who deviate from evidence-based medicine shouldn't casually criticize other practitioners who practice off the grid, particularly when patients have great faith in complimentary and integrative medicine.

However, all of us who claim to be healers should aspire for supportive scientific evidence for our recommendations, and we should admit to patients when such evidence is lacking.

If you opt for periodic colonic cleanses, and you perceive a personal benefit, then be aware that you are engaging in an art, and not a science.

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Monday, November 4, 2019

New dietary guidelines ignore science

The federal government has issued dietary guidelines every 5 years since 1980. They are the ones that came out with the food pyramid, and most recently gave limits for sugar, saturated fat, and sodium (salt). These guidelines affect many things, including what children get served for lunch at school.

For the first time ever, the Department of Health and Human Services and the Department of Agriculture, under the direction of the Trump administration, is limiting the scope of the committee. They gave them a list of 80 questions, and said they are not to consider anything outside that list. Those questions do not include health risks such as too much salt, red meat, and processed foods.

The nature of science is that with ongoing research things change. Most of you can probably recall getting conflicting diet recommendations over the years. We were told to avoid fats, as we subsequently got collectively heavier, then ketogenic diets said the opposite. Alcohol can decrease heart disease, then studies showed it can increase breast cancer. That's why it's important to periodically review the literature and adjust recommendations if warranted.

Why would the Trump administration want to limit the committee? For one thing, they have generally been anti-science in many areas, such as global warming. For another, as they say, follow the money. Thirteen out of 20 of the committee members have food industry ties. This compares with two of 12 members in 2015. You can read more details in a Washington Post article.

Health care costs have been going up at a rate higher than inflation for many years. Although there are many reasons for this, part of it is because people are getting more obese. This leads to such health issues as diabetes, hypertension, heart disease, and arthritis. The new rules effectively says that corporate interests trump human health. So that corporations can profit more, we will pay the price in our health, and in our future medical bills.

The statute (Public Law 101-445, 7 U.S.C. 5341 et seq.) that required the guidelines specifically says that the Dietary Guidelines be based on the preponderance of current scientific and medical knowledge. As that wouldn't be the case, unless the restrictions are removed, I expect that from 2020 to 2025 I'll be advising my patients to follow the 2015 guidelines.

Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington. This post originally appeared on his blog, World's Best Site.
Thursday, October 31, 2019

Treatment for diverticulitis revisited

Is there stuff that you do just because that's the way you've always done it? I'll answer for you—yes.

In many circumstances, this makes sense. For example, I stop my car at red lights just as I have always done. I recommend that readers do the same as there is an underlying logic for this recommendation. It is not simply a rote routine that has no rationale. However, the particular order that we pour ingredients into a pot when making soup, may be more random than rational. We follow the same order we always have, never pausing to wonder why or if there might be a better way.

And, so it is with many practices and procedures in the medical profession. Let's return to the medical condition of diverticulitis, which I presented on this blog recently. Follow the link, if interested.

For the last several decades, this disease has been treated in the same way, with antibiotics. This means that physicians believe this to be an infectious disease, like strep throat, caused by bacteria. But, the real reason I think that physicians like me prescribe antibiotics for this condition as because that's the way we've always done it.

Changing established medical practices is like having an ocean liner make a U-turn. It's not easy. For example, when I was a medical student, kids with red ear drums, or otitis, were routinely given antibiotics, assuming that this was a bacterial infection. But, after a few decades, experts concluded otherwise.

Similarly, I have a strong sense that the established treatment for diverticulitis may be revised. The classic understanding of this disease was that this was a bacterial infection in the wall of the colon. The theory was that a tiny puncture would develop in one of the diverticula, which are pouches that are weak points in the colon. Germs from inside the colon would travel through the puncture site to the outside wall of the colon, which is usually sterile, and an infection would start. We prescribe antibiotics and the patients generally recover well.

But, should the antibiotics really get the credit? What if these patients would have recovered anyway on their own? I believe many of them would have. In fact, many patients who have had diverticulitis, often have had episodes that recovered spontaneously without having seen a physician.

In fact, a prominent gastroenterology professional society recently issued guidelines that expressed that not every case of diverticulitis requires antibiotic treatment. It may take another 10 years for this recommendation to gain traction.

I'm not abandoning antibiotics for diverticulitis in my practice yet. But, I am following the issue closely in the journals. There needs to be a better reason to do stuff than simple habit and routine, and that includes reading this blog.

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.