ACP Internist Blog

Friday, April 3, 2020

Can Sherlock Holmes teach today's doctors?

“To Sherlock Holmes, she is always THE woman.” Thus begins Sir Arthur Conan Doyle's “A Scandal in Bohemia,” published in 1891. In this gripping tale, Holmes is bested by a woman who proves to be the detective's equal in intelligence and deception.

For reasons I cannot explain, I restrict my exposure to Holmes and Dr. Watson to podcast listening when I am airborne. Years ago, I did love watching the classic movies starring Basil Rathbone and Nigel Bruce who defined the roles for me.

Conan Doyle, a physician, was a superb story teller, who wove his tales with texture, plot and humanity. I think he wields words with surgical precision. I admire his skill.

I wonder to what extent Conan Doyle's medical training influenced his writing. Certainly, the stories often discuss arcane medical conditions that provide the detective with important clues. In “The Adventure of the Blanched Soldier,” Holmes suspects that the protagonist is suffering from leprosy, a diagnosis that is revised after Holmes arranges for a consulting dermatologist to examine the soldier.

Beyond these medical intricacies that the author includes, I suggest that Conan Doyle has a more direct connection to the world's most famous sleuth. Physicians operate as detectives. We gather facts and evidence in real time. We have suspicions which may be strengthened or refuted as additional data emerges. There may be competing theories that torture us. At times, we are forced to make judgments and recommendations when our knowledge base in incomplete. And some of our patients' dilemmas remain unsolved, similar to crime solvers' cold cases.

In “The Sign of the Four,” Holmes remarks to Watson, ”How often have I said to you that when you have eliminated the impossible, whatever remains, however improbable, must be the truth.” Holmes would have been a superb physician.

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.
Thursday, April 2, 2020

Working during a pandemic reinforces that health care workers are heroes

I spent the last week working in a large community hospital in a state with a soaring number of coronavirus cases. I previously had a few days off while this whole situation was escalating, and heard from colleagues that our hospital was taking huge measures to prepare for the onslaught. New protocols were being put in place, there was a scramble for personal protective equipment (PPE), and the hospital had dedicated an entire medical floor exclusively for coronavirus patients. Two new walls were rapidly constructed to make the whole unit negative pressure (in other words, seal it off and theoretically lower the potential contagion). That floor is rather tucked away in a corner of the hospital, away from other floors. It is used to having general medical patients, but not necessarily specialized in high acuity cases.

I wasn't sure what to expect when I started work. Would everyone be on edge? Would there be a sense of doom? Would all my colleagues be projecting a sense of alarm? Very soon after walking in to inherit my list of patients, which included some with suspected coronavirus, those questions were decisively answered. Everyone around me, from doctors and nurses, to housekeeping and unit clerks, had risen to the occasion magnificently. Unlike the sense of panic and hysteria one can get from watching cable news and scrolling through social media, the health care workers in our hospital were the total model of professionalism, calmness, and selflessness. We were absorbing information and guidelines that were changing on an almost hourly basis, while giving 110% to care for the patients in front of us. I would hazard a guess that this was the case in most hospitals up and down the country. It's what we all signed up for, and despite limited supplies and rationing of equipment, we would not neglect our duty at this time of crisis. I couldn't have been prouder to work among such an amazing group of people.

But back to the special “coronavirus unit” our hospital had created at light speed. I have been seeing patients on that floor for years. They have an excellent bunch of nurses and aides. We are all used to sharing a laugh and trying to keep things as lighthearted as possible in the environment that is health care. I didn't know what would hit me when I first walked onto this new walled off unit. Would it feel completely different?

I have written previously about how nurses are the superstars of health care, but nothing could have made me more certain of this after seeing the professionalism of the staff on that unit. They really got thrown into this situation, and despite the dire circumstances, were going above and beyond to care for their patients. And they did it all while trying to maintain a semblance of normalcy about the situation. I was blown away with how well everyone on that floor had adapted to their grim new reality, treating a highly contagious disease that none of us had even heard of a few months ago. Lives needed to be saved, and they'd all been called to action.

Heroes come in all shapes and sizes. It's been quite eye-opening these last couple of weeks to watch normal society as we know it unravel, and adjust to an unprecedented situation. One thing in particular that struck me was seeing the reaction of a number of celebrities and sports stars stuck in their homes. Some of the pictures and videos posted online have been quite obnoxious, as they appear to be desperately bidding for some attention at this unique time (perhaps realizing for the first time that their jobs are really not that essential). Their days of fame in the limelight will surely come again soon. But I hope etched in the memory of many people for years to come, will be that at this time of national crisis, when the health of millions was at stake, we have seen who the real everyday quiet heroes are.

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.
Monday, March 30, 2020

Facts about hydroxychloroquine and COVID-19

Thanks to a shout out by President Trump that hydroxychloroquine would be a “game changer” this drug is all over TV and web as the possible treatment for COVID-19. Because this virus has no known treatment, the FDA is fast-tracking pharmaceuticals and vaccines. There are at least 22 known studies ongoing to test the effectiveness in humans and COVID-19. Here's what we know (today, March 28, 2020) about hydroxychloroquine:
• As a drug used to treat rheumatoid arthritis and lupus, hydroxychloroquine works in a complex manner on cells and proteins to down regulate the immune response.
• It is also used to treat uncomplicated plasmodium malaria but is not effective against all malaria strains.
• The brand name for rheumatology use is Plaquenil and it can be found in the urine three months after taking. It has a very long half-life.
The Journal of Antimicrobial Agents reported a study of 26 patients receiving hydroxychloroquine. Six patients were lost to follow up, but of the 20 who remained there was significant effectiveness in clearing the virus, even in patients who were asymptomatic. Azithromycin was added to six of the patients and they showed a greater response than hydroxychloroquine alone.
• Some studies are showing that the drug can work in cell cultures against COVID-19.
• Two clinical trials in the U.S. are looking at whether hydroxychloroquine can prevent COVID-19 in health professionals exposed to the disease.
• In past studies, hydroxychloroquine was found to be not effective for treating dengue, chikungunya and influenza viruses.
• Serious adverse effects include cardiac arrhythmias due to prolongation of Q-wave, blurred vision due to changes in the retina, nausea, vomiting, and headache. As with any medication, the list of side effects is long but the most worrisome is the change in the heart rhythm, which can be fatal.
• Millions of Americans currently take drugs that can interfere with hydroxychloroquine and cause side effects, liver dysfunction and prolonged Q-T syndrome.
• Patients who are dependent upon this drug are finding shortages because of stockpiling and hoarding. Nevada governor, Steve Sisolak, has blocked the use against coronavirus to protect the patients who need it. Pharmacies are directed to fill only one month at a time for patients with “legitimate medical purposes”.
• The run on hydroxychloroquine is driven by fear as patients are experiencing a pandemic and want hope.
• Doctors are being overrun with messages to prescribe this medication to patients and to tell the CDC to “cut the red tape and make it available to everyone.” According to the LA Times, these messages are sponsored by a conservative organization founded and funded by wealthy supporters of Donald Trump.
• Health professionals and experts are saying “hydroxychloroquine is not a harmless panacea for COVID-19.”

When doctors do not have a treatment for patients that are in critical condition, we often use therapies that are not yet “evidence-based” with controlled studies, but may have some benefit based on smaller studies, anecdotal reports, or laboratory evidence. This is happening with COVID-19 patients that are in ICUs as we attempt to save lives. We try everything!

This is very different from prescribing untested drugs to healthy or mildly ill patients.

It is my strong hope that hydroxychloroquine, azithromycin, and other therapies will be effective. We will find out very soon.

This post originally appeared at Everything Health. Toni Brayer, MD, FACP, is an ACP Internist editorial board member who blogs at EverythingHealth, designed to address the rapid changes in science, medicine, health and healing in the 21st Century.

Lessons from 'Range' by David Epstein

I received an email from Ryan Holiday – author of The Obstacle is the Way, a wonderful book that introduced me to Stoic philosophy as a guiding principle. In that email, he recommended ”Range: Why Generalists Triumph in a Specialized World” by David Epstein. As a generalist, the title intrigued me. So as I am prone to do, I bought the Audible version, and over a 10 day period, listened to the book.

Like many books in this genre, one can criticize the trees of his argument, but I think he gets the forest right. This website has a collection of reviews, many of which are somewhat critical. Nonetheless, I found that his stories helped me understand much of my personal success and happiness with my career.

The book has several major points. He makes a reasoned argument that for complex careers (be it sports, arts, business or medicine) one benefits from starting with breadth. Unless one is working towards expertise in a “kind problem” (examples, chess and golf), then a variety of experiences allows one to discover where they want to specialize. Often early specialization fails because as we grow, we too often find that the early specialization ignores the most important success attribute – finding ones passion.

As I think of my career, I “flirted” with many majors in college prior to settling on psychology. Then for the first 2.5 years of medical school I again dated several specialties. After a week on the internal medicine rotation, I knew that I had found my home, my passion and my career.

Yet once I chose internal medicine, I once again considered a variety of subspecialties. I even did a year of basic science nephrology fellowship, and had the courage to quit, as I missed patient care and teaching too much. The research did not give me the same satisfaction.

Epstein devotes significant time in the book to the value of leaving certain situations. I left a fellowship and joined a new division of general internal medicine. Originally, I had considered finishing a clinical fellowship, but general internal medicine grabbed me as a great choice. I actually like most subspecialties in internal medicine. The complexity of managing multiple problems satisfies my love of puzzle solving and mystery novels.

Epstein worries that overspecialization makes it more difficult to solve many complex problems. He argues that breadth of background allows us to make intellectual connections that overspecialization makes less likely.

Now I must admit that the idea of this book and the many examples likely appeals to me because of confirmation bias. One look at my CV shows that I do have some recurring themes, but also a great variety of articles. Many articles started with thinking about a problem in a different way thanks to varied experiences.

He is a storyteller. I suspect he has found stories that fit his general hypothesis, but since I like his hypothesis, it does not bother me.

Regardless, this book will stimulate your thoughts about expertise, the advantages of generalization and the advantages of specialization. As a clinician-educator, reading books like this eventually help me and give me insights into the education process. Perhaps that is the most important message of the book. We should not restrict our learning to our specialty. We should learn from other fields. This book makes my top list of non-medical books for junior academicians.

For those interested:
1. Made to Stick – Chip and Dan Heath
2. First, Break All the Rules – Marcus Buckingham
3. 7 Habits of Highly Effective People – Stephen Covey
4. The Elements of Style – Stunk & White
5. Drive – Daniel Pink
6. The Obstacle is the Way – Ryan Holiday
7. The Tipping Point – Malcolm Gladwell
8. Sources of Power – Gary Klein
9. Originals – Adam Grant
10. Thinking, Fast and Slow – Daniel Kahneman
11. Range – David Epstein

db is the nickname for Robert M. Centor, MD, MACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and the former Regional Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds regularly at the Birmingham VA and Huntsville Hospital. His current titles are Professor-Emeritus and Chair-Emeritus of the ACP Board of Regents. This post originally appeared at his blog, db's Medical Rants.