Sensible Medicine

TR is a 72-year-old woman, a retired executive, who had been in excellent health until she began experiencing exertional dyspnea and palpitations. After waiting out the symptoms for about a month, she called and made an appointment to see her primary care doctor. The day before her appointment, she awoke unable to move her entire right side. With difficulty, she reached for her phone and called her daughter. Her daughter was unable to understand her and called 911.This Substack is reader-supported. If you appreciate our work, consider becoming a free or paid subscriber.Someday, I will close up my practice and be left with an enormous hole in my life. I will miss the 12-24 people I get to spend time with every day during their appointments. I will miss the sometimes-intense relationships with a fantastic diversity of people. I will miss working to make people’s lives better and longer. I will miss the diagnostic puzzles and the reward of seeing someone “get better” over days, or weeks, or months.I will also miss my colleagues, the clinicians who have chosen to dedicate their careers to helping people. I will miss meeting the next generation of doctors, nurses, psychologists, physical therapists, pharmacists, and the like.I will not miss The Look.I was well into my career when I first recognized The Look. I had just returned to our inpatient service after a leave to care for my mother, who had experienced a serious, life-altering illness.A few days after my return, my team admitted TR. She had been in excellent health until a few months before admission, when she began to lose weight and have some trouble sleeping. More recently, the symptoms had progressed to include exertional dyspnea and palpitations. Our evaluation revealed hyperthyroidism from a toxic multinodular goiter, leading to atrial fibrillation, leading to a large, embolic, left middle cerebral artery stroke.From a medical perspective, the case was classic and straightforward. My resident assigned TR to a medical student as she thought it was a perfect teaching case.On the second day of TR’s admission, I met her daughter and learned more about TR. She had grown up on Chicago’s South Side and had always been a star student. She excelled in the public school system and was eventually awarded a full scholarship to the University of Illinois. When she left for Urbana-Champaign, it marked the first time she had left Chicago.She graduated summa cum laude from U of I and began working in a corporate office back in Chicago. She excelled in this world as well, eventually managing a fifty-person team.She had one daughter, whom she adored, and two grandchildren. She retired just before her 70th birthday. She was thriving in retirement, traveling alone and with friends, and serving on two corporate boards. She loved her work on boards because it enabled her to meet a small group of African American women executives of her generation who shared similar experiences.The Look on her daughter’s face was familiar to me. I recognized it because I knew I had worn it a few weeks before, caring for my mother. The Look reflected the emotions TR’s daughter articulated to (and for) me. There was sadness and anger for what her mother had lost. There was anxiety about what was next for her mother. There was a realization that her mother’s situation would affect her. Their relationship had permanently changed. TR’s daughter spoke of how her mom had always been her foundation. Overnight, the daughter had become the middle of the sandwich. She now had to care for her kids and her mother. There was also a little bit of guilt. How can I worry about the impact this will have on my life when my mother is now disabled?Seeing The Look that I knew we shared, the empathy I felt for TR’s daughter made it difficult for me to play my usual role in counseling and planning. I told my resident and the case manager they would have to “do this one without me.”Since that day ten years ago, I recognize The Look not infrequently. I see it on the children who suddenly lose a parent, while gaining responsibility for that parent. I also see it on the faces of husbands and wives when their partners begin to fail. In these situations, my relationship tends to be different. While the adult child is, more often than not, a stranger to me, both members of the couple are often my patients. While I care for one partner with cognitive and/or physical decline, I care for the other living with the trauma of this decline.Filial love and romantic love (if this is the proper term for a decades-long relationship) are different; spouses experience something different than children. The spouse is not only mourning a relationship but also often dealing with direct caregiving. In addition, most couples evolve into productive codependency. Physical tasks are shared – who cooks, who cleans, who does the taxes, who fixes the sink – as well as cognitive ones. Who is better with names, keeps track of birthdays, maintains relationships with friends. While the sandwiched child must manage a new relationship, the spouse must manage losing a part of themselves.I am being overly writerly here. If you showed me 10 pictures of traumatized people, I would not be able to identify who had The Look. I only recognize it when I see the person and hear about the situation. As a clinical skill, though, recognizing this sign is useful. Like knowing what needs to be done when I smell the scent of alcoholic ketoacidosis, or hear the familiar ramblings of delirium tremens, I have come to understand the role I need to play when I see The Look.When I give up clinical practice, I will be happy to see The Look less. The human tragedies that lead to it are situations I’ll be happy to avoid.Photo Credit: Baptista Ime James This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

A “manel” reviewing trials and studies that explore the benefits and harms of hormone replacement therapy.The Women’s Health Initiative* Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women's Health Initiative randomized controlled trial* The Women's Health Initiative Randomized Trials and Clinical Practice: A Review* The Women’s Health Initiative Hormone Therapy Trials: Update and Overview of Health Outcomes During the Intervention and Post-Stopping PhasesMeta-analysese* A systematic review and meta-regression analysis to examine the ‘timing hypothesis’ of hormone replacement therapy on mortality, coronary heart disease, and stroke* Mortality Associated with Hormone Replacement Therapy inYounger and Older WomenHistory: Observational HRT Data* Postmenopausal estrogen and progestin use and the risk of cardiovascular disease* Hormone therapy to prevent disease and prolong life in postmenopausal women This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

Primary Articles* As-Needed Albuterol–Budesonide in Mild Asthma* Early versus Later Anticoagulation for Stroke with Atrial FibrillationReferenced Articles * Albuterol–Budesonide Fixed-Dose Combination Rescue Inhaler for Asthma* Stopping Randomized Trials Early for Benefit and Estimation of Treatment Effects: Systematic Review and Meta-regression Analysis This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

Primary articles discussed:* First myocardial infarction: risk factors, symptoms, and medical therapy* Oral vs Extended-Release Injectable Naltrexone for Hospitalized Patients With Alcohol Use DisorderA Randomized Clinical TrialArticles referenced:* Pharmacotherapy for Alcohol Use Disorder: A Systematic Review and Meta-Analysis* General health checks in adults for reducing morbidity and mortality from disease: Cochrane systematic review and meta-analysis This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

A visit brings back the memories of patients and the lessons they taught. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

Exploring the necessity of preprocedural fasting, the discussion challenges long-standing norms that could hinder patient care. It critically evaluates the validity of clinical studies and highlights the complexities of managing dietary restrictions for patients. New insights into fasting guidelines for cardiac procedures prompt a reevaluation of patient lifestyle changes. The episode also sheds light on the influence of social media on public perceptions of heart disease, emphasizing the importance of rigorous research interpretation.

The discussion kicks off with a look at the latest advancements in a new COVID vaccine and its impact on public trust. A groundbreaking blood test for colorectal cancer screening is explored, weighing its benefits against traditional methods. Challenges in cancer screening reveal the delicate balance between detection and accuracy. Sepsis diagnosis complexities are highlighted, critiquing the one-size-fits-all approach of current treatment bundles. Lastly, financial incentives in cardiology raise questions about aligning healthcare costs with patient outcomes.

This week dives into groundbreaking research on semaglutide, revealing its potential for treating fatty liver disease and the ethical challenges in clinical trials. The intricate link between obesity and liver health is also explored, emphasizing the need for compassion in obesity treatment. Attention shifts to a study on tiotropium, shedding light on its possible dementia risks for COPD patients, while debating the validity of observational studies in medicine. The conversation highlights the complexities of tailoring treatment choices and the importance of rigorous research.

This is a long one! 83 minutes. This is the second podcast in which we answer questions from a our “ask us anything” post. We recorded this one before our most recent podcast — kind of like Abbey Road and Let it Be — so we were still graced by Vinay’s presence. In fact, we recorded it in his studio. We still have about a half dozen questions to answer; we will cover those on an upcoming podcast. Enjoy. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

The hosts explore the implications of a new FDA appointment on the future of sensible medicine. They discuss the financial burdens impacting medical education and workforce diversity, highlighting the challenges faced by aspiring healthcare professionals. A critical examination of cardiac stress tests reveals the need for personalized treatment approaches. The episode also delves into the complexities of managing asymptomatic atrial fibrillation and the intricacies surrounding patient care and healthcare incentives, advocating for better clinical decision-making.