A harder death for people with intellectual disabilities

Several weeks after my patient was admitted to the intensive care unit for pneumonia and other problems, a clear plastic tube sprouted up from the mechanical ventilator, onto his pillow and down into his trachea. He showed few signs of improvement. In fact, the weeks on his back in an I.C.U. bed were making my 59-year-old patient more and more debilitated.

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Still worse, a law meant to protect him was probably making him suffer more.

When the prognosis looks this bad, clinicians typically ask the patient what kind of care they want. Should we push for a miracle or focus on comfort? When patients cannot speak for themselves, we ask the same questions of a loved one or a legal guardian. This helps us avoid giving unwanted care that isn’t likely to heal the patient.

This patient was different. Because he was born with a severe intellectual disability, the law made it much harder for him to avoid unwanted care.

To learn more, including what happened, read my new post here at The New York Times.

Will New Hampshire open safe sites for people who inject drugs?

New Hampshire is still in the throes of one of the worst opioid epidemics in the country. Deaths are mounting, and mostly in young people.

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As hospitals around the nation and our fair state scale up to provide medication assisted therapy and other evidence-based ways to help, safe injection sites remain controversial.

Based on data from Vancouver's Insite program showing lower public drug use, less needle sharing, and prevention of infectious diseases like HIV, I think it's time for us to get over our hangups and act to save lives.

It was fun and illuminating to talk with Laura Knoy's and guests on NHPR's Exchange. For a stream of the hour-long show, click here

Did I make a professionalism mountain out of a medical education molehill?

Every March I run the last required course at Dartmouth's Geisel School of Medicine. It’s a three-week-long, 47-hour sprint – a sort of boot camp for professional formation. Midway through the usual mechanics of instruction, I got an email that felt routine at first - but then it felt like an opportunity to talk with a student about professionalism.

Click here to read it, over at Reflective MedEd. What do you think? Did I make a professionalism mountain out of a logistical molehill? How do you try to support your students’ professional formation?

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Posted on March 28, 2018 .

Go ahead, hit "record" in the doctor's office

The elderly woman’s right knee was bright red and twice its normal size. Her doctor explained that her prosthetic knee joint was infected and would have to be removed — antibiotics alone couldn’t cure her.

Her doctor (T.L.) began discussing treatment options, but the patient stopped him. “Do you mind if I record you?” she said, picking up her cellphone.

Surprised, the doctor leaned back in his chair.

This simple request can elicit starkly different reactions from patients and clinicians.

To learn more, check out my new article (with co-author Glyn Elwyn) at STAT.

Posted on July 12, 2017 .

How (and why) academics can (should!) write for the popular press

It has been wonderful to publish in The New York Times, The Atlantic's health section, and other popular outlets. 

Writing for the popular press has felt like learning in a whole new language. The rules of academic writing do not apply. 

Through luck, the smoking hot wisdom of a nationally prominent education writer, and invaluable training as part of Dartmouth's chapter of the Op-Ed Project, I've been able to write about what moves me.

For tips on how (and why) academics can (should!) write for the popular press, check out this interview on episode #61 of the popular podcast #AmWriting hosted by Jessica Lahey and her former New York Times editor KJ Dell'Antonia.

Posted on July 4, 2017 .

When you are too sick to fly

Air travel is a great way to get free peanuts, a deep vein thrombosis and the worst cold of your life. Plus: baggage fees!

Ever since Andrew Speaker took to the friendly skies with drug resistant tuberculosis, and brave Ebola outbreak workers returned sick to the United States, avid international attention has focused on the infectious risks of air travel, too.

Could the next pandemic spread on planes? 

We should care more about the people who live in areas where millions of people get sick from infectious scourges without having to invoke international travel. Yet it is reasonable for people who travel in rich countries to want to stay healthy as well. 

Proudly quoted in this brief article by Allison Fox of HuffPo.

Posted on June 8, 2017 .

What's the best way to incentivize immunizations?

Vaccination saves lives.

Yet, resistance to immunization has become entrenched in some sociodemographic strata. Wealthy, educated liberals who care about organic food and "natural" products among them. 

Under-immunization of school-aged children in turn has led to outbreaks of measles and other transmissible infections, and contributes to  thousands of preventable influenza deaths in children each year. 

It's not enough to tout the benefits of vaccines, and then stand back with syringe in hand. Potential vaccines want to know vaccines are safe, and hear misconceptions about the low risks of vaccines. A seminal article by my Dartmouth colleague Brendan Nyhan showed that trying to disabuse vaccine skeptics of their misconception too may fail. 

Many states and countries are piloting various incentive programs designed to enhance immunization rates without engaging in potentially polarizing debate. From making immunizations mandatory to attend school to linking welfare benefits to vaccine receipt and even straight up cash incentives, lots of experiments are happening. Some of them even work.

Check out this great article by Susan Scutti of CNN and its accompanying video. I was proud to be quoted in it.

Let Opioid Users Inject in Hospitals

It is a new world in health care as America grapples with an epidemic of opioid drug abuse. The Centers for Disease Control and Prevention reported that opioid overdoses killed over 28,000 people nationwide in 2014, more than ever before.

From heart-valve infections to drug overdoses, the casualties of this epidemic wash up in our hospitals. It has changed my hospital service significantly. Almost every day, we try to save a young person dying from infectious complications of injection drug use.

Addicted patients usually bond with their providers over the shared goal of healing. Yet these interactions, which often bridge divides of class, culture and personal psychology, can break down. When addicted patients inject drugs in the hospital, doctors and nurses can find themselves cast in the role of disciplinarians, even jailers.

Confining patients to their rooms, restricting their activities and posting guards is expensive. It may also compromise a patient’s well-being: Ambivalent providers may visit less often, educate patients less avidly and spend less time devising the best treatments.

The worst effect of confining addicted patients in the hospital may be the damage to the patient-provider bond. 

To read more, including my proposal to let opioid users inject in the hospital, check out my new op-ed at The New York Times

Also, check out my new 8-minute radio spot about the topic at for Word of Mouth by Virginia Prescott at NHPR. It was also a trip to appear on Sirius XM's widely-syndicated Michael Smerconish show, although a recording has not been archived. The controversy the post created was nicely covered in Concord's Union Leader.

Vaccines just aren't as easy to discover as they used to be

Edward Jenner had it easy. Swab some cowpox in 1796, scratch the nastiness into the arm of a little kid (see below), and, PRESTO, instant immortality. 

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Vaccine success after vaccine success followed. Measles, mumps, rubella, polio... one after another global scourge quaked before the mighty pipettes of vaccine researchers.

I admit, the stalwarts who discovered those vaccines did more than transfer cow-pus to an un-consented minor research subject prior to doing a victory lap around the farm. Rather, they earned their laurels by working hard, and by being brilliant.

But ease wrought hubris, and as deadly viral menaces fell in succession, you could forgive one noted twentieth century sage, US Surgeon General William Stewart (pictured below), for saying, "It’s time to close the books on infectious diseases, declare the war against pestilence won, and shift national resources to such chronic problems as cancer and heart disease."

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Whoops!

These early triumphs gave way to a long, hard slog. Vaccines against HIV, tuberculosis, herpes, staphylococci, and hepatitis C, among others, have proven far more elusive. Amid small successes, and spectacular failures, we have discovered an uncomfortable fact: we don't really know what makes a good vaccine tick. 

This week I was glad to contribute both heat and noise to the mix. In an op-ed in the Health Affairs blog, I write about the dangers of dogmatism and the lessons learned on the road to a new HIV vaccine. And, we also published preclinical data this week on a new scalable version of our tuberculosis vaccine. Data from our Phase 1 trial of the same vaccine should come out soon!

Who knows if all this will lead to glory. Probably not! Either way, it's been a pleasure to try. 

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Posted on December 21, 2016 .

Lessons learned from a beatbox heart

Jimmy’s mother cries in the corner. She holds her hands up and open, the way you might receive a baby.  Or, the way you indicate helplessness when your baby is now addicted to heroin and shivering in a hospital bed.

Jimmy’s heart is failing.  Antibiotics alone will fail him.  Soon a surgeon will open Jimmy’s chest, cut out his heart valve, and sew in a new one.  I say this as gently as I can.

Standing with a medical student beside me, I try to teach about the physical exam. About compassion. About how to respond when a young man who hasn't opened his eyes for minutes suddenly does, and says something frightening. 

Check out my new essay at ReflectMedEd for more.

Posted on December 6, 2016 .