Clinical Conversations

Intermittent fasting has salutary effects. Listen how Dr. Mark P. Mattson, co-author of a recent NEJM review on the topic, assesses the practice — and how he’s managed to skip breakfast for the past 30 years or so.

Dr. Ali Raja joins Joe as co-host again this time.

Links:

de Cabo and Mattson’s review in the New England Journal of Medicine

Michael Mosley and Mimi Spencer’s book “The FastDiet”

Running time: 18 minutes

It turns out that the disrespect starts even earlier — when women are questioned about their choice of a surgical specialty. Nor is the bad behavior the exclusive province of the “old guard.”

We talk with Dr. Pringl Miller, a Chicago surgeon who’s compiled a collection of instructive stories from women surgeons who’ve had to dodge demeaning questions (and sometimes, flying chairs in the OR). The stories appear in the latest issue of Narrative Inquiry in Bioethics.

“#MeToo in Surgery: Narratives by Women Surgeons” article in Narrative Inquiry in Bioethics

Recent NEJM article on harassment in surgical residency training

Time’s Up Healthcare website

Patricia Dawson’s book: “Forged by the Knife: The experience of surgical residency from the perspective of a woman of color”

Preeti John’s book: “Being a Woman Surgeon: Sixty women share their stories”

Joan Cassell’s book: “The Woman in the Surgeon’s Body”

Running time: 18 minutes

Why aren’t you able to navigate your electronic health record (EHR) as easily as you can find a recipe on, say, Google?

And, what about those requirements for documenting everything?

Listen to a chat with Julia Adler-Milstein, the author of an editorial that comments on a recent Annals of Internal Medicine study detailing the amount of time clinicians typically spend hunched over their EHRs during a patient visit.

Links:

Annals of Internal Medicine editorial

Annals paper on the time clinicians spend

Running time: 17 minutes

The process of identifying super-users of healthcare and reducing the frequency of their hospitalizations — so-called “hotspotting” — was subjected to a randomized, controlled trial in Camden, NJ, the birthplace of the idea. It failed there.

Those in the intervention group had a readmission rate within 6 months that was statistically identical to those getting usual care.

True, the Camden patients had particularly complex social and medical problems, so that doesn’t mean that the program can’t work elsewhere.

Listen to our chat with the report’s senior author, Prof. Joseph Doyle, and as well, listen to our interview with Dr. Jeffrey Brenner from 6 years ago — he’s the one who put “hotspotting” on the map. Despite the apparent failure of the trial, the Coalition still has a lot to offer.

Results of the randomized trial in NEJM

Interview with Dr. Jeffrey Brenner from 2013

Camden Coalition’s website

Running time: 15 minutes

A “network meta-analysis” (we’ll explain that) finds that “test and treat” is the best way forward in managing this common condition.

Patients, paradoxically, prefer immediate endoscopy to test-and-treat, but unless the patient has “alarm symptoms” (such as dysphagia, weight loss, and anemia), endoscopy is likely to add complications and costs without adding further benefit.

Our guest is Prof. Alexander Ford of Leeds, senior author on the guideline-affirming study in The BMJ.

Links:

Article in The BMJ

Physician’s First Watch summary

NEJM Journal Watch Gastroenterology summary of 2017 joint U.S. – Canadian guideline

For the first time in almost a century, Americans are dying at home more often than dying in hospitals.

This seems to mark a cultural change that will affect both how and where clinical medicine is practiced.

Dr. Haider Warraich’s letter to the editor of the NEJM presents the numbers, and he’s agreed to talk about their implications.

Links:

Cross and Warraich’s New England Journal of Medicine letter (Dec. 12 issue)

Warraich’s 2017 book “Modern Death”

“Near Death,” a Frederick Wiseman 6-hour documentary worth finding

Running time: 16 minutes

In November 2018 we interviewed two authors of an Annals of Internal Medicine study comparing the quality of diabetes care afforded by three provider types: nurse-practitioners, PAs, and MDs. They reported that there were no clinically significant differences in the intermediate outcomes — glycated hemoglobin, systolic pressure, or low-density lipoprotein cholesterol — among the groups.

We’re posting that interview again for two reasons: first, this week’s planned interviewee remained unreachable, no matter my pleadings; second, listeners reacted strongly (and positively)  the first time around, and I hope newer listeners will find it as interesting.

Links:

URL of the original podcast

Annals of Internal Medicine paper

Running time: 20 minutes

The anti-inflammatory colchicine is powerful and cheap. It’s thought that, because cardiovascular problems often stem from inflammation, colchicine could help prevent secondary events after MI. That’s what Jean-Claude Tardif and an international group of colleagues set out to investigate.

The group reports in the NEJM that daily low-dose colchicine was associated with a lower rate of a composite endpoint than a placebo: death from cadiovascular causes, resuscitated cardiac arrest, MI, stroke, or urgent hospitalization leading to coronary revascularization.

New England Journal of Medicine report

Editorial commentary in NEJM

Harlan Krumholz’s tweet on the report

Running time: 20 minutes

Controlling hypertension lowers the relative risk for dementia and Alzheimer’s disease by roughly 15%.

Given that many people have poorly-controlled hypertension, the finding that all antihypertensives are effective in bringing about this result might get your patients to be more adherent.

We talk with Dr. Lenore Launer of the NIH’s Institute on Aging about her recent meta-analysis in The Lancet Neurology.

LINKS:

Launer’s paper in The Lancet Neurology

Lancet comment on the article

Running time: 16 minutes

Tranexamic acid, which frustrates clot dissolution, has been shown to reduce death from intracranial bleeding in a large international placebo-controlled trial — “CRASH-3.”

Ali Raja and Joe Elia host a lively chat with Ian Roberts, the co-chair of the trial’s writing committee, who, in addition to chastising the hosts’ seeming fascination with P-values, recounts a story from early in his training that first stirred his devotion to preventing bleeding-related death after trauma.

NEJM Journal Watch Emergency Medicine summary of CRASH-3

CRASH-3 report in The Lancet

Ian Roberts explains CRASH-3 on YouTube to collaborators in Malaysia

Roberts presents CRASH-3 results at World Congress on Intensive Care on YouTube

Running time: 23 minutes