This conversation was recorded on June 7th, 2021. In this interview, we talk with Deborah Korenstein, MD, about medical overuse and overdiagnosis. We discuss her April 2021 publication in JAMA Internal Medicine, the Accuracy of Practitioner Estimates of Probability of Diagnosis Before and After Testing as well as the diagnostic process, the teachability of diagnostic reasoning, cognitive biases, and other topics.Who is Deborah Korenstein?Dr. Deborah Korenstein is Chief of the General Internal Medicine Service at Memorial Sloan Kettering Cancer Center in New York. Her clinical work focuses on care to adult survivors of childhood and other high-risk cancers. As a researcher and an educator of physicians in training, she is interested in improving the value of care while minimizing unnecessary and potentially harmful tests and treatments. To learn more about mitigating medical overuse, check out the ABIM Foundation's Choosing Wisely campaign and Dr. Korenstein's project Testing Wisely.Factoids:In this week's episode, we list some factoids on the overprescription of antibiotics for viral URIs, the incidence of incidentalomas, and the detection of PE with high resolution CTA. If you'd like to read the articles from which these factoids were taken, check them out below:1. 2019 Update on Medical Overuse: A Review in JAMA Internal MedicineHighlights: Procalcitonin does not affect antibiotic duration in patients with lower respiratory tract infection (4.2 vs 4.3 days)Incidentalomas are present in 22% to 38% of common magnetic resonance imaging or computed tomography studies9% of women dying of stage IV cancer are still screened with mammographyClinics commonly overprescribe antibiotics (in 39% of all visits, patients received antibiotics)State medical liability reform was associated with reduced invasive testing for coronary artery disease, including 24% fewer angiograms2. Overdiagnosis in primary care: framing the problem and finding solutions in BMJ (2018)Highlights:Overdiagnosis is defined as the diagnosis of a condition that, if unrecognized, would not cause symptoms or harm a patient during his or her lifetimeOverdiagnosis can harm patients by leading to overtreatment (with associated potential toxicities), diagnosis related anxiety or depression, and labeling, or through financial burden.Many entrenched factors facilitate overdiagnosis, including the growing use of advanced diagnostic technology, financial incentives, a medical culture that encourages greater use of tests and treatments, limitations in the evidence that obscure the understanding of diagnostic utility, use of non-beneficial screening tests, and the broadening of disease definitions.______________________________What is the External Medicine Podcast?The External Medicine Podcast explores some of the most exciting ideas in medicine. Co-hosted by Daniel Belkin, MD, and Mitch Belkin, MD. Support the showFollow us at @ExMedPod Subscribe to our Youtube channelConsider supporting us on Patreon

In this interview, Mitch Belkin and Daniel Belkin speak with Professor Alex Tabarrok about what economists can bring to discussions of the pandemic, the US government’s response to COVID-19, the performance of the FDA and the CDC, regulatory nationalism, the first doses first campaign, and why America should vaccinate the world. This conversation was recorded on May 2nd, 2021. Who is Alex Tabarrok?Professor Alex Tabarrok is the Bartley J. Madden Chair in Economics at the Mercatus Center and a professor of economics at George Mason University. He is the co-author of the popular economics blog Marginal Revolution and co-founder of Marginal Revolution University. He is the author of numerous academic papers in the fields of law and economics, criminology, regulatory policy, voting theory and other areas in political economy. His articles have appeared in the New York Times, the Washington Post, the Wall Street Journal, and many other publications.What is the External Medicine Podcast?The External Medicine Podcast explores some of the most exciting ideas in medicine. Co-hosted by Daniel Belkin, MD, and Mitch Belkin, MD.Support the showFollow us at @ExMedPod Subscribe to our Youtube channelConsider supporting us on Patreon

This conversation was recorded on April 5, 2021. In this interview, Mitch Belkin and Daniel Belkin speak with Dr. Paul Offit about mRNA vaccine technology as well as a number of topics from his book, Overkill: When Modern Medicine Goes Too Far. They discuss the use of antipyretics to treat a fever, the overuse of antibiotics, vitamin D and C, as well as cancer screening. Who is Paul Offit?Dr. Paul Offit is a pediatrician at the University of Pennsylvania specializing in infectious diseases, vaccines, immunology, and virology. He is the co-inventor of the RotaTeq vaccine for rotavirus, has published more than 130 papers in medical and scientific journals, and he is the author or co-author of books on vaccines, vaccination, and antibiotics. To learn more about Dr. Offit, visit his website.  What is the External Medicine Podcast?The External Medicine Podcast explores some of the most exciting ideas in medicine. Co-hosted by Daniel Belkin, MD, and Mitch Belkin, MD.Support the showFollow us at @ExMedPod Subscribe to our Youtube channelConsider supporting us on Patreon

In this episode, Daniel Belkin and Mitch Belkin interview Nir Barzilai, MD, the founding director of the Institute for Aging Research and an expert in the genetics of longevity. Dr. Barzilai is a professor in the departments of Medicine and Genetics at the Albert Einstein College of Medicine. He is the recipient of numerous awards and grants. He has published over 230 peer-reviewed papers, reviews, and textbook chapters, as well as the book Age Later. In this interview, we discuss the field of gero-therapeutics, the hallmarks of aging, and gender differences in aging. We review his work on centenarians and what they can teach us about the genetics of longevity. Finally, we delve into metformin, its use as an anti-aging therapy, its mechanism of action and the TAME trial, on which he is the primary investigator. To learn more about the latest in aging-related research, check out the American Federation of Aging.   This interview was recorded on March 26, 2021. Centenarian studies:The Longevity Genes Project is geared at understanding which genetic factors contribute to exceptionally long life. The project focuses on Ashkenazi “super agers”–people between the ages of 95 and 112–to determine how their genetics differ from controls without exceptional longevity. In addition, the study follows the children of “super agers” with matched controls.What is Metformin?Metformin (Glucophage) is a biguanide that is a first-line treatment for type 2 diabetes. While it has many mechanisms of action, its primary mechanisms of action are believed to be (1)  decreasing hepatic glucose production by inhibiting gluconeogenesis, (2) inhibiting complex I of the electron transport chain, and (3) inhibiting the mammalian target of rapamycin (mTOR) signaling pathway. It is the 4th most prescribed medication in the United States. Metformin use is associated with a reduction in the incidence of cancer. It is also associated with reductions in cognitive decline and Alzheimer’s among diabetics. If you are interested in learning more about how metformin attenuates the hallmarks of aging, Nir Barzilai wrote a paper in cell metabolism: Benefits of Metformin in Attenuating the Hallmarks of Aging (2020).What is the TAME Trial?The Targeting Aging with Metformin (TAME) Trial is a placebo-controlled clinical trial designed to determine whether taking metformin delays the development or progression of age-related chronic diseases, including heart disease, cancer, and dementia. The study population will include 3,000 individuals at 14 sites across the U.S. who are between the ages of 65-79. Patients will receive either 1500mg Metformin daily or a placebo for up to 6 years.What is the External Medicine Podcast?The External Medicine Podcast explores some of the most exciting ideas in medicine. Co-hosted by Daniel Belkin, MD,Support the showFollow us at @ExMedPod Subscribe to our Youtube channelConsider supporting us on Patreon

*Since recording this podcast in January 2021, Steve Kirsch has publicly made misleading allegations regarding vaccine effectiveness and safety (e.g., Kirsch has claimed that mRNA vaccines are ineffective and are responsible for large numbers of deaths). While ExMedPod believes diverse viewpoints ought to be publicly discussed, we do not endorse Kirsch's beliefs regarding vaccine safety and efficacy.*[Update: August 2022 - A RCT published in the NEJM tested the efficacy of fluvoxamine and did not find a reduction in emergency department visits, hospitalizations, or deaths associated with Covid-19.]In this episode recorded in January 2021, we interview Steve Kirsch, the executive director of the COVID-19 Early Treatment Fund. We discuss why the antidepressant Fluvoxamine is being investigated as a potential treatment for COVID-19. We explore the observational and clinical data supporting its efficacy and examine the limitations of these studies. We briefly touch on why physicians and regulatory agencies have not embraced this medication despite some convincing real-world evidence on its clinical efficacy. What is Fluvoxamine?Fluvoxamine (Luvox) is a Selective Serotonin Receptor Inhibitor (SSRI) that is clinically indicated for OCD in children, and can be used off label for depression. It was approved by the FDA in 1994 and has been used in millions of patients worldwide. Side effects include nausea, upset stomach (up to 25%), and other sexual side effects typical of SSRIs.Clinical Data:Eric Lenze’s Phase 2 RCT on Fluvoxamine vs Placebo (Nov 2020) Results: “Of 152 patients who were randomized (mean [SD] age, 46 [13] years; 109 [72%] women), 115 (76%) completed the trial. Clinical deterioration occurred in 0 of 80 patients in the fluvoxamine group and in 6 of 72 patients in the placebo group (absolute difference, 8.7% [95% CI, 1.8%-16.4%] from survival analysis; log-rank P = .009). The fluvoxamine group had 1 serious adverse event and 11 other adverse events, whereas the placebo group had 6 serious adverse events and 12 other adverse events.”David Seftel's Open Label Clinical Trial of Fluvoxamine (Jan 2021)Abstract: “We report a real-world experience using fluvoxamine for coronavirus disease 19 (COVID-19) in a prospective cohort in the setting of a mass outbreak. Overall, 65 persons opted to receive fluvoxamine 50mg twice daily and 48 declined. Incidence of hospitalization was 0% (0/65) with fluvoxamine and 12.5% (6/48) with observation alone. At 14 days, residual symptoms persisted in 0% (0/65) with fluvoxamine and 60% (29/48) with observation.”Support the showFollow us at @ExMedPod Subscribe to our Youtube channelConsider supporting us on Patreon