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Latest Posts

Constipation: A Common Problem In End-Of-Life Care

Family physicians who care for terminally ill patients must manage a wide range of bothersome symptoms, including pain, fatigue, dyspnea, delirium, and constipation. According to a Cochrane for Clinicians article in the December 1st issue of American Family Physician, constipation affects up to half of all patients receiving palliative care and nearly 9 in 10 palliative care patients who use opioid medications for pain. Unfortunately, a Cochrane systematic review found limited evidence on the effectiveness of laxatives in these patients, as Dr. William Cayley Jr. comments:

“For patients with constipation, especially those with opioid-induced constipation, there is insufficient evidence to recommend one laxative over another. The choice of laxatives should be based on past patient experience, tolerability, and adverse effects. Methylnaltrexone is a newer agent that may be useful especially for patients with opioid-induced constipation that has not responded to standard laxatives, but there is limited evidence of potential adverse effects. Therefore, judicious use preceded by a discussion with patients about known risks and benefits is warranted.”

The Cochrane Library recently discussed this review in its Journal Club feature, which includes open access to the full text of the review, a podcast by the authors, discussion points, and a Powerpoint slide presentation of the review’s main findings.

Additional resources for physicians and patients on advanced directives, hospice care, and ethical issues are available in the AFP By Topic collection on End-of-Life Care.
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The above post was first published on the AFP Community Blog.

*This blog post was originally published at Common Sense Family Doctor*

The Fixation On A Flawed Cancer Screening Test

In the face of accumulating evidence and a U.S. Preventive Services Task Force finding that PSA screening for prostate cancer does more harm than good, the most frequent response I hear from physicians who continue to defend the test is that PSA is all we have, and that until a better test is developed, it would be “unethical” to not offer men some way to detect prostate cancer at an asymptomatic stage. (However, these physicians for the most part don’t question the ethics of not offering women screening for ovarian cancer, which a recent randomized trial concluded provides no mortality benefit but causes considerable harms from diagnosis and treatment.)

I’m currently reading historian Stephen Ambrose’s dual biography of Oglala Sioux leader Crazy Horse and Civil War cavalry general George Armstrong Custer, whose troops were routed by the Sioux at the famous Battle of Little Bighorn in 1876. One premise of the book is that the same aggressive instincts that served Custer so well during the Civil War Read more »

*This blog post was originally published at Common Sense Family Doctor*

Decreasing Jail Time, Treating Drug Abuse As A Public Health Issue

A couple of years ago, I served for several weeks on a grand jury for the Superior Court of the District of Columbia. Mine was designated a RIP (Rapid Indictment Protocol) jury, assigned to efficiently hand down indictments for small drug-related offenses. These cases usually involved undercover officers posing as customers making purchases from street dealers, or uniformed police stopping suspicious vehicles and searching them for drugs. Although rarely we heard testimony about defendants caught with thousands of dollars of contraband, the vast majority of offenses were possession of small amounts of marijuana, heroin, or cocaine for “personal use.” Many of the latter defendants had multiple such offenses, which had resulted in probation, “stay away” orders (court orders to avoid certain neighborhoods where drugs were highly trafficked), or brief stints in jail. Few, if any, had received medical treatment for their addictions.

After a few weeks of hearing these cases, my fellow jurors and I grew increasingly frustrated with this state of affairs. We felt like a cog in a bureaucratic machine, fulfilling a required service but making little difference in anyone’s lives. A young man or woman caught using drugs would inevitably return to the street, violate the terms of his or her probation or “stay away” order, and be dragged before our grand jury again for a new indictment. We openly challenged the assistant district’s attorneys about the futility of the process. They would just shrug their shoulders and tell us Read more »

*This blog post was originally published at Common Sense Family Doctor*

When Public Health Legislation Is More Effective Than Physician’s Advice

Last month, my family was involved in a scary traffic accident en route to the Family Medicine Education Consortium‘s North East Region meeting. I was in the left-hand eastbound lane of the Massachusetts Turnpike when a westbound tractor trailer collided with a truck, causing the truck to cross over the grass median a few cars ahead of us. I hit the brakes and swerved to avoid the truck, but its momentum carried it forward into the left side of our car. Strapped into child safety seats in the back, both of my children were struck by shards of window glass. My five year-old son, who had been sitting behind me, eventually required twelve stitches to close a scalp laceration. Miraculously, none of the occupants of the other six damaged vehicles, including the truck driver, sustained any injuries.

Family physicians like me, and physicians in general, like to believe that the interventions we provide patients make a big difference in their eventual health outcomes. In a few cases, they do. But for most people, events largely outside of the scope of medical practice determine one’s quality and length of life, and Read more »

*This blog post was originally published at Common Sense Family Doctor*

High Value Care: Getting The Maximum Health Benefit

The past few months have offered encouraging signs that physicians and physician organizations are belatedly recognizing the need to take an active role in controlling health care costs by emphasizing “high-value” care and minimizing the use of low-value interventions with high costs and few clinical benefits. On the heels of a best practice guideline issued by his organization, American College of Physicians Executive VP Steven Weinberger, MD recently called for making cost-consciousness and stewardship of health resources a required general competency for graduate medical education.

In light of a recently published estimate that the top 5 overused clinical activities in primary care specialties led to $6.7 billion in wasted health spending in 2009, Dr. Weinberger’s call comes none to soon. Below is an excerpt from my post on this topic from April 13, 2010. Read more »

*This blog post was originally published at Common Sense Family Doctor*

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

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How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

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Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

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The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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