How to stem the incipient epidemic of hypertension

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On November 13, 2017, an epidemic of hypertension broke out and could rapidly affect tens of millions of Americans.  The epicenter of the outbreak was traced back to the halls of the Anaheim, CA, convention center where the annual meeting of the American Heart Association was taking place.

The pathogen was released in a special 488-page document labeled “Hypertension Guidelines.”  The document’s suspicious content was apparently noted by meeting personnel, but initial attempts to contain it with an embargo failed and the virus was leaked to the press.  Within minutes, the entire healthcare ecosystem was contaminated.

At this point, strong measures are necessary to stem the epidemic.  Everyone is advised not to click on any document or any link connected to this virus.  Instead, we are offering the following code that will serve both as a decoy and as an antidote for the virulent trojan horse.

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You eat as you are

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Here’s the typical story we come across every day:

Jack was overweight and had a terrible cardio-metabolic profile.  Jack changed his diet: he eliminated X, Y, Z and added more A, B, and C.  He’s now lost 30 pounds and he feels fantastic.  His numbers are also perfect: his HDL is through the roof, his LDL is undetectable, and his A1c is smack in the normal range.

Todd was overweight and had a terrible metabolic profile.  Todd changed his diet but he did not eliminate X, Y, or Z.  In fact, he did the opposite.  He increased his intake of X, Y, and Z but eliminated A, B, and C.  He’s now lost 30 pounds and he feels fantastic.  His numbers are also perfect: his HDL is through the roof, his LDL is undetectable, and his A1c is smack in the normal range. 

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I refuse to tell you what to eat

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Note: I first published this on the website of Athletic Heart SF, my cardiology practice.

A recent tweet from JAMA, the journal of the American Medical Association, urged me and other doctors to “include nutrition counseling into the flow of [our] daily practice.”

Along with the tweet came a link to an article that outlines “relatively small” dietary changes, based on the latest Dietary Guidelines for Americans, that can “significantly improve health.”

My response to the tweet was swift and knee-jerk.  I will not do it.  I simply will not.  I refuse to follow dietary guidelines or recommend them to my patients.

“What are you saying?!” “Are you the kind of self-interested doctor who only treats disease and cares nothing about prevention?!”  I imagine my outraged critics erupting in a chorus of disapproval.

Is my reaction unwarranted?  After all, the recommendations themselves seem sensible enough:  Eat fast food less often; drink fewer sugary sodas; consume more fruits and vegetables.  What’s not to like?

Unhealthy guidelines

I don’t know.  Perhaps it’s dietary guideline fatigue.

For more than 40 years, the nutrition experts have instructed us with guideline after guideline, food pyramid after food pyramid.  But what have they got to show for?  The obesity epidemic followed the introduction of dietary recommendations, and some doctors even blame those recommendations for causing the epidemic!

The blame may be far-fetched, but there’s something un-natural and perhaps even unhealthy about dietary guidelines.

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Good health care news from America

My dispatch to Switzerland

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I was kindly asked to provide an article for Courrier du Medecin Vaudois, the French language journal of the medical society of the canton of Vaud.  The article was published as part of an issue on the theme of ‘America First against Obamacare.’ Below is an English version of the piece.

Health care in the United States: The surprising good news

On the surface, the news from America about health care seems rather grim: cost and dissatisfaction keep rising, reforms are stalling, and, for some, even life expectancy may be declining.  If that wasn’t bad enough, President Trump issued a tweet on March 25 predicting that “Obamacare will explode.”

For a small but growing number of doctors and patients, however, the future is surprisingly hopeful. 

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Direct primary care for the poor

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A third-year family medicine resident inquires about the direct primary care model (DPC) and caring for the poor. (more…)

Book review: How Doctors Think

By Kathryn Montgomery

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Kathryn Montgomery’s How Doctors Think: Clinical Judgment and the Practice of Medicine is an excellent book that was brought to my attention by Dr. James Gaulte in the comment section of my post on phronesis.  Indeed, much of Montgomery’s monograph deals with the Aristotelian concept of practical wisdom applied to clinical decision-making.

The author is Professor of Medical Humanities and Bioethics and Professor of Medicine at Northwestern University Feinberg School of Medicine.  Her book is too rich to cover deeply in a short review, but I’d like to highlight some of its major strengths as well as a few minor weaknesses.

In the first part of the book, Montgomery thoroughly demolishes the notion that medicine is applied science.

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A prospective medical student asks for advice

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A prospective medical student wrote me this, and below is my response: (more…)

Maintenance of board certification

Who is thriving and who is struggling?

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Nov-Dec-15-Web 1This article first appeared in the November/December issue of San Francisco Medicine, the magazine of the San Francisco Medical Society. That issue was dedicated to the theme of ‘Thriving in Medicine.’ For other blog posts on the topic of MOC, see here.

Up until recently, obtaining and maintaining a specialty board certificate seemed essential for a physician intent on having a thriving medical career.  Doctors and the public alike widely viewed board certification as a proof of proficiency that distinguished those with advanced training and expertise.

To maintain board-certified status, certificate holders were quite willing to be subjected to a decennial examination, and some doctors even looked forward to preparing for the test and to an opportunity to systematically review their field of expertise.

In a few short years, however, any positive sentiment regarding maintenance of certification (MOC) exercises seems to have all but evaporated.

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Medical friendship at the end of life

As hard as it sounds

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Pat, a non-physician reader, writes:

I read your two articles on friendship for more explicit clues on how to deliver very bad news, and wondered if you would consider publishing something on this topic as part 3 of this series. My prompt is a close friend with cancer, and she’s not getting better. At her last visit, the message she took home was: “there’s not much more we can do for you other than more chemotherapy, and we’re not even sure that it will do any good.”   This was a complete and sudden loss of hope.

Two thoughts come to mind.

The first is from Viktor Frankl. In Man’s Search for Meaning he says: “Those who know how close the connection between the state of mind of a man – his courage and hope, or lack of them – and the state of immunity of his body will understand that the sudden loss of hope and courage can have a deadly effect.”

The second is from Atul Gawande’s book, On Being Mortal. He describes two approaches to giving bad news. Dr. Informative supplies hard cognitive information: cold facts, descriptions, outcome possibilities, statistics. A doctor’s other approach might be to look for an opportunity to start the conversation with “I’m worried” and then continue with the patient in an “ask, tell, ask” process. In this approach, the direction of travel becomes clear more gently and perhaps gives the patient a little more time to walk into the possibility than being crashed into it.

…I would be especially interested to read your views from the doctor’s side in the context of your two blogs on the friendship dimension in the doctor-patient relationship.

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The physician as entrepreneur

Warning: not a post about "disruptive innovators"

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Frank Knight, risk and uncertainty

In this article, I wish to introduce the reader to the theory of entrepreneurship advanced by Frank Knight (1885-1972), and show that the common, everyday work of the physician could be considered a form of entrepreneurial activity in the Knightian sense.

Knight was an influential American economist.  He is best known for his book Risk, Uncertainty, and Profit in which he proposed to distinguish risk and uncertainty as follows:

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