What do I want to accomplish?

“Is it good to try to live as moral a life as possible –a saintly life? Or does a life like that lack some crucial human quality? …Is it presumptuous, even blasphemous, for a person to imagine that he can transfigure the world –or to belive that it really matters what he does in his life when he’s only a tiny flickering speck in a vast universe?”

Strangers Drowning, Larissa Macfarquhar

Frequently I think about the question of what I want to accomplish in my role as a physician.  Sometimes the answer is to get home at a reasonable hour that day.  However, when looking past the day-to-day, I definitely strive for more, even if I am only a tiny fleck in the universe.

I like to think that I’ve tried to help families that see me as best as I can.  I try to make sure that I am not overbooked so that I have enough time to think about problems carefully and perhaps have an opportunity to make a connection/have a conversation with families who come to see me.

So much of what I do everyday becomes fairly routine, particularly when in the office.  For a family who has a child with severe stomach pain and is missing school, this is a critical problem. Yet, I may see several similar children each day of the week.  I know that the child will improve, but I don’t know exactly how long it will take and how difficult it will be.

Most of the problems that I see are alarming for parents, including the following:

  • severe stomach pain
  • rectal bleeding
  • poor growth
  • difficulty feeding
  • soiling
  • vomiting

Yet, very few patients who come to our office need to be admitted to the hospital.  Most of the time, some fairly routine advice and/or treatment will resolve (or at least improve) these problems.

In clinical care, what really stands out for me is when a rare medical problem is quickly identified and treated.  I was delighted recently when I helped establish a diagnosis of chronic granulomatous disease in one child when he was seen at his first encounter with me.  In the previous week, I identified a child with familial Mediterranean fever.  Both of these problems are extremely rare and can be difficult to diagnose.

But truly, how often does it matter if a child sees me compared with another pediatric gastroenterologist?  My suspicion is that most of the time it does not matter; though this opinion may be due to the fact that I’ve had the chance to work with some truly terrific colleagues.  So while it is gratifying to help families, I am often thinking about what I can do to accomplish more.  I am sure others struggle with the same issue of trying to do meaningful work.  Some may leave a legacy through their focus on research, teaching or charity.

In some ways, I have considered my participation in the AAP, my blog, my role at the hospital, and (at times) research/teaching as important opportunities for different types of work to keep everyday a little more exciting and to make a useful contribution.

What are you trying to accomplish?

Related blog posts:

Sunrise at Spruce Point, Maine

Sunrise at Spruce Point, Maine

NEJM Presidential Candidate Health Proposals

Full text: My Vision for Universal, Quality, Affordable Health Care –NEJM

From NEJM: The editors invited the Democratic and Republican presidential nominees, Hillary Clinton and Donald Trump, to answer the following question for Journal readers: What specific changes in policy do you support to improve access to care, improve quality of care, and control health care costs for our nation? Secretary Clinton responded. Mr. Trump did not respond.

The main topics in Hillary Clinton’s commentary include expanding insurance coverage through the affordable care act (i.e. Obamacare), improve affordability in health care with proposals that affect both insurance companies and pharmaceutical companies, improve access to primary care/community care, and to continue to promote innovation/research.

screen-shot-2016-10-03-at-8-46-34-pm

 

 

One of 340,000 Followers of NEJM

A recent editorial (EW Campion et al. NEJM 2016; 375: 993-4) made a few worthwhile points and shows how NEJM has been successful and innovative over 20 years of using the web and social media.

  • This has allowed more widespread access to its content, even by resource-poor countries.
  • The use of the web has facilitated quick distribution of multiple resources for outbreaks like  Ebola and Zika.
  • Currently, every article back to 1812 is available online (over 173,000 with more than 570,000 pages)
  • NEJM has 340,000 twitter followers and 1.3 million followers on facebook
  • Despite the importance of NEJM, as well as other healthcare media, important caution is needed.

“We do need to be wary of challenges and dangers that the new media have created.  On the Internet, speed and simplicity often displace depth and quality, especially on complex subjects.  Our privacy is increasingly vulnerable. Misinformation, misrepresentation, and piracy are common.  There are health scams and even sham medical conferences and fake medical journals.”

My take: Careful use of internet resources has been incredibly helpful.  But, beware of the inherent hazards that have accompanied these advances.

Related blog posts:

Balancing Rock, Bar Harbor

Balancing Rock, Bar Harbor

 

The Indispensable Physician

A recent pair of commentaries (RM Wachter, L Goldman. NEJM 2016; 375: 1009-1011, R Gunderman. NEJM 2016; 375; 1011-13) provides some insight into what has been gained and what has been lost with the proliferation of hospitalist care in the past 20 years.

The growth of hospitalist care has developed due to numerous factors:

  • evidence of cost savings/better outcomes
  • need for rapid evaluation of acutely ill patients/repeated evaluations which would be disruptive to efficient outpatient physician practices

Decline of comprehensive care:

  • at times of extreme vulnerability when admitted to the hospital, patients have a physician assigned to them who they have probably never met.  This has led to a diminishment of the patient-physician relationship.
  • increasing number of physicians creates opportunities for miscommunication, particularly on admission and discharge, but also at every step of hospital care during “handoffs”

The second commentary, in particular, challenges the way medicine is evolving.  This article stresses the central role of the physician as opposed to the hospital filling that role.

“The reality is that medicine can be practiced without hospitals, but hospitals cannot function without physicians.”

The goal of developing personal relationships with our patients is often at odds with work-life balance.  Thus, having hospitalists and other ways of having cross-coverage, when we are unavailable, often conflict with being able to provide the best care.

My take (from 2nd commentary): “The true core of good medicine is not an institution but a relationship — a relationship between two human beings.”

Related blog posts:

Glacier Nat'l Park

Glacier Nat’l Park

 

Is a Gluten-Free Diet a Healthy Diet for Those without Celiac Disease?

A helpful commentary (NR Reilly. J Pediatr 2016; 175: 206-10) on the gluten-free diet (GFD) tries to separate fact from fiction.  A few key points:

  1. There are some health problems that can occur with a GFD, particularly when the diet is started without the support of an experienced dietician. GFD foods frequently contain a greater density of fat and sugar and can contribute to obesity and metabolic syndrome.  A GFD may lead to nutrient deficiencies in B vitamins, folate, and iron.  GFD without sufficient dietary diversity may contain increase in toxin exposures (eg. arsenic, and mercury).
  2. Gluten is not toxic. “There are no data to support the theory of an intrinsically toxic property of gluten for otherwise-healthy and asymptomatic adults and children, and certain studies have specifically demonstrated a lack of toxic effects.
  3. Most individuals with NonCeliac Gluten Sensitivity (NCGS) do not have NCGS!  First of all, many receive a GFD without proper testing to exclude celiac disease.  Secondly, most will tolerate gluten reintroduction.  In an Italian study, “only 6.6% of consecutive patients with presumed gluten sensitivity…actually had NCGS. 86% did not experience symptoms when gluten was reintroduced.”
  4. Timing of gluten introduction: “The most current understanding…in at-risk infants is that neither delaying gluten introduction from the recommended 6 months of age to 1 year, nor introducing at 4 months of age alters long-term CD risk estimates.”

My take: This is an excellent commentary.  While many people (without celiac disease) perceive benefit from a GFD, only a minority are likely  to derive better health or improved quality of life.  Those who stick with a GFD should seek the help of a well-qualified dietician.

Related blog posts:

Glacier Nat'l Park

Glacier Nat’l Park