Wait for it

At 94, my patient V. was funny and flirtatious.  Her French accent made even the name of her life-threatening fungal infection sound poetic.

“DEE-seminated HEESTO-plasmo-sees,” she said, “Oaf the skin.”

I smiled.

I also admitted her to the hospital because our treatments were not working.  

What I did next, though, surprised both of us. To read more, check out my new article at the great blog Reflective MedEd.

Posted on September 18, 2016 .

Opioid contracts can backfire on patients

The US Senate recently passed legislation designed to address the nation’s opioid addiction epidemic, and President Obama is expected to sign it into law. Among other things, the bill promotes the use of opioid contracts. These are written agreements between doctors and patients about the conditions for prescribing opioids long term for chronic pain.

This is great news. It could also harm patients. My patient, Cindy was a perfect example.

To hear what happened, read my new article at The Boston Globe's new publication STAT.

Posted on July 26, 2016 .

Giving patients what they want, even if the doctor doesn't have the time

Doctors struggle to find the time to have in-depth conversations with their patients. Patients, in turn, don't share their end-of-life preferences with their doctors, which leaves them vulnerable to getting more aggressive care than they want. It also wastes a huge amount of money. 

In my new article, I confess a time I contributed to this problem, and point to a really exciting new solution. Harvard researchers, conducting a huge study across the state of Hawaii, have now proven a new way patients can get their wishes respected even if their doctor doesn't have as much time as they want. Online videos about end of life decisions. The videos are outstanding, and proven to work. Plus - bonus! - they saved the system money. 

It's win-win. Check it out!

Will legislators defuse the ticking time bomb of dirty needle use?

For years, Indiana had slowly dismantled its public health system, and needle exchange programs lacked both funding and legal safeguards. Then an HIV outbreak exploded into public view, and Republican Governor Mike Pence had to do some fancy footwork to undo the damage done. He allowed needle exchange programs to operate and provided some long overdue prevention funding. In the meantime, dozens of young Indianans were infected with hepatitis C and HIV. It was a sad case of politics overturning science and common sense.

Now, New Hampshire and other states are in the same boat: politically-minded legislators bloviate about punitive anti-drug stances while the opiate epidemic rages. Complications of injection drug use are on the rise, and it's only a matter of time before a new HIV outbreak comes to town. Needle exchange programs, proven over and again to prevent infections and thus to save lives, languish in the legal shadows.

Fortunately, new legislation is being considered to change help catch New Hampshire up to the 21st Century, and maybe save some lives in the process. I was proud to be quoted here about this overdue change.

Swipe right to connect young people to HIV testing

Midway through her sophomore year of high school, my patient told her parents that she had missed two periods and was worried she might be pregnant.

Stunned to learn that she was sexually active, her parents took her to the pediatrician, who had another surprise: She wasn’t pregnant but she did have H.I.V.

To learn more - including how my patient could have been protected from late H.I.V. diagnosis by a cool mobile app - check out my new post up at The New York Times. Many thanks to support from Dartmouth Public Voices Fellowship, a chapter of the Op-ed Project.


Will this new diagnostic test help us prevent antibiotic misuse?

Clinicians seeing a miserable patient with the sniffles or a cough commonly face a challenging choice: give them antibiotics on the off chance they help, or educate a patient who feels gross why those antibiotics won't work. More of than not, clinicians take the easy way out and reach for the prescription pad. 

The problem of course is that this leads to millions of unnecessary antibiotic prescriptions every year. It's one major driver of epidemic antibiotic resistance, and also why the epidemiology of the antibiotic-associated infection C diff is worse than ever. 

This problem doesn't persist because clinicians are stupid or uncaring. Rather, it is their best intentions that lead them astray. Faced with a concrete potential benefit for the patient in front of them versus an abstract risk down the road, often times clinicians choose that concrete potential benefit over a hard-to-imagine intangible risk like antibiotic resistance or future C diff. Even if the risks FAR outweigh any potential benefits.

A point-of-care test that could tell both docs and patients that those symptoms are definitively from a virus could really change that whole dynamic. And, it could save us from a lot of antibiotic misuse.

A new study out today brings us closer to that reality. Researchers out of Duke found gene expression combinations that were nearly unique to viral vs bacterial vs non-infectious illnesses. To learn more, check out this new post by Eric Boodman in STATnews. I was proud to be quoted in it. See also this very thoughtful post by the ever- excellent Judy Stone at Forbes.

This is not the first test to try to tell bacterial and viral respiratory infections apart. Other similar tests have tried the same thing, and seemed promising at the outset but ultimately flamed out. Take procalcitonin testing, for instance. The reason so many tests have failed before is that the promising diagnostic data found in early studies conducted amid artificially distinct clinical populations and implausibly controlled lab circumstances looked much worse once applied to the messy real world of clinical medicine. That's the next hurdle this new technology has to surmount: to show convenient quick utility in real patients in the real world.

I have my fingers crossed that this new technology will be better!

Posted on December 9, 2015 .

New science shows how loneliness makes older people frail

Every Monday during the summer, some of the residents of Lyme, New Hampshire, gather up fruits and vegetables from their gardens to donate to Veggie Cares, a program that distributes local food to people living alone. Volunteers collect, sort, and package the produce, then head out in separate directions to deliver the food to some Lyme's most vulnerable, isolated residents.

While the stated goal of the program is to provide people with healthy food, Veggie Cares volunteers also deliver companionship. Visits are often more than a quick drop-off—they may involve a shared cup of tea, an offer to replace burned-out light bulbs, or a chance to check in on sick or elderly neighbors.

Nine million elderly people currently suffer from food insecurity in the United States, and the produce provided by Veggie Cares is one way to safeguard the health of Lyme residents who may be at risk. But recent research supports the idea that the companionship the volunteers provide may be physically nourishing in its own way.

Read more in my new article (with the lovely and talented Jessica Lahey) over at The Atlantic

Why we shouldn't over-hype the use of PrEP to prevent HIV transmission

Recently we got great news from a real-world study of HIV pre-exposure prophylaxis (PrEP).

Researchers at San Francisco's Kaiser Permanente Medical Center reported on the real-world experience of 657 people who started PrEP between 2012 and 2015. Over 99% were men who have sex with men, 84% reported multiple sexual partners, and 30% had HIV-positive partners. Together they were observed for over 388 person-years of PrEP use.

The big news: Exactly zero patients contracted HIV infection! That's huge.

The problem is, the popular conversation about it has been over the top. From The Washington Post to FoxNews and the Huffington Post, people have been saying it's "100% effective" and lots of other undeserved superlatives.

PrEP works, this study was great, but there is real danger in all of this over-hype.

Read more in my new post over at TheBodyPro

Posted on September 19, 2015 .