From:

Medical News Today

Almost 60 per cent of US medical schools do not meet recommendations for nutrition education for med students, producing physicians – the first port of call for nutrition advice for many consumers – who may have inadequate nutrition knowledge. Twenty years ago the National Academy of Sciences (NAS) reported that 21 hours of education in nutrition was required but found that many medical schools did not offer nutrition courses.

The 1985 NAS report said: Nutrition education programs in US medical schools are largely inadequate to meet the present and future demands of the medical profession. A new survey, published in The American Journal of Clinical Nutrition (Vol. 83, pp. 941S-944S), re-examined the state of nutrition education in 106 medical schools. The two-page survey contained 12 questions, with respondents – usually the person responsible for the nutrition teachings – indicating in which year of study that students were taught and in which context (eg nutrition, physiology, biochemistry).

The respondents were also asked whether current nutrition education was sufficient or if more was needed. Remarkably, less than one half (41 per cent) of the responding schools provided the minimum 25 hours or more recommended by the NAS in 1985, said lead author Kelly Adams from the University of North Carolina at Chapel Hill. Also surprising was the finding that 17 schools (18 per cent) required only [less than or equal to] 10 hours of nutrition instruction, she said.

The researchers also found that during the clinical years (third to fourth year) 36 per cent of schools offered less than five hours of teaching nutrition. Eighty-eight per cent of the instructors questioned also indicated that the students needed more tuition. Thus, it appears that we are producing a pool of physicians who feel largely unprepared to counsel their patients about nutrition, concluded Adams. Other surveys in the literature have reported that physicians feel unprepared to deal with the growing problem of obesity, with 32 per cent of US adults clinically obese.

Shockingly, the number of overweight children is reported to have tripled since 1980. With the rising epidemic of obesity in the US population and the knowledge that prevention is more likely to be successful than treatment, it is clearly imperative to ensure that medical students are adequately prepared, wrote the researchers.

Dr. Daniel Fabricant, vice president of scientific affairs for the industry association, the National Nutritional Foods Association, applauded the authors of the study, but said that it seemed to confirm what many in the research community have long believed to be true. There is an ever increasing amount of good science that demonstrates how very important nutritive factors, like the use of dietary supplements, are for not only maintaining health, but in preventing disease.

Based on the study, information on nutrition, diet and supplementation cannot be accurately provided to the public by their physicians, which means that the public, who works longer hours and has more demands on their time than ever, making it harder to find good information, suffers the most. Fabricant said that the NNFA hoped that such studies would be the impetus for major wholesale changes in medical education to implement curriculum and instructors that provide the tools to best serve the public with. Additionally, if the majority of physicians are not properly educated on these topics is it really surprising that many stories appearing in journals/publications geared towards physicians are misinterpreted and sometimes misleading?

The American Medical Association refused to comment on the study since it was published in a non-AMA journal.

From nytimes.com

Not long ago, I took care of an elderly man with congestive heart failure. A few days into his stay in the hospital, he told me he was not going to make it out alive. “I am going to die here,” he whispered, as if letting me in on a secret.

I tried to reassure him: on the scale of disease I normally treat, his case was relatively mild. But then he became sicker.

His bloated legs dripped fluid, soaking his bed sheets and puddling on the tile floor. His blood pressure dropped. He became delirious. I was perplexed by the precipitous downturn. What did my patient know that I did not?

After several days of keeping round-the-clock vigil in the intensive care unit, his wife of nearly 50 years could no longer bear his suffering and requested hospice care. A few hours before he died, groggy from morphine, he managed to summon a few moments of lucidity. Gripping his wife’s hand, he said to her, “You’re doing the right thing.”

Every day in medicine there are examples of patients who know they are about to die, even if no one else does. They often have a feeling of impending doom before a catastrophic event like a heart attack or a fatal infection, and though doctors don’t know how to explain it, most of us take it seriously.

When we talk about instinct in medicine, we usually talk about expert clinicians grasping diagnoses in ways that seem to defy analytical explanation. These doctors appear to know almost intuitively which data to focus on and which to ignore. Of course, their decision-making is based on experience and deductive reasoning (and perhaps on evidence, too), yet it seems almost mystical.

I will never forget the time in medical school when we presented a baffling case to the chief of medicine. He made a diagnosis of primary pulmonary hypertension within seconds, on the basis (he claimed) of the loudness of the second heart sound, an incredible feat of observation and logical synthesis.

This sort of diagnostic intuition is becoming rare in the current era of technological medicine. Patients today often receive a battery of tests even before a physician examines them. The results, usually expressed in numbers that give a misleading impression of absolute precision, tend to lull doctors into a sort of laziness that has atrophied instinct.

On the other hand, doctors’ prognostic instincts have always been poor. In my work as a critical care cardiologist, I am often asked to predict how long someone is going to live. I know how useful such projections can be to patients and their families, but I rarely, if ever, venture a guess because they are so often inaccurate. (I am usually too optimistic.)

So it amazes and baffles me when patients have a sixth sense about their own deaths. Last year, my team cared for a woman who told us calmly on morning rounds that she had a feeling she was going to die that day.

A few hours later she complained of belly pain, and when a tube was inserted through her nose and into her stomach, old digested blood — “coffee ground” secretions — came up. Her blood count plummeted, and within a few hours she had spiraled into shock and multiple organ failure, even before we could get a CAT scan to see what was going on. It was totally unexpected, one of the most rapid noncardiac deaths I have ever witnessed.

I don’t know how my patient was seemingly able to predict her own demise. Perhaps high levels of circulating adrenaline caused a reaction similar to a panic attack; I don’t know. But I have learned over time to take such intuitions very seriously.

Sometimes, morbid instincts derive from other sources. In 2007, The New England Journal of Medicine had the story of a cat named Oscar who lives in a nursing home in Providence, R.I., and seems to have an uncanny sense for when elderly residents are about to die.

He goes to their rooms, curls up beside them — even those residents for whom he has previously shown little interest — and purrs. Staff members at the facility have learned that this is a telltale sign of impending death, having witnessed this behavior in the deaths of at least 25 patients. “This is a cat that knows death,” one doctor said. “His instincts that a patient is about to die are often more acute than the instincts of medical professionals.”

No doubt there are more such animals. But I have learned that the best instincts in medicine derive from the patients themselves. Their intuitions about their own health may be denigrated by doctors. But we must learn to pay attention to them. As my patients have taught me, they often hold the vital clue.

Sandeep Jauhar is a cardiologist on Long Island and the author of the recent memoir “Intern: A Doctor’s Initiation.”

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From wsj.com

Did you feel healed the last time you went to the doctor?
My bet is no. If you were lucky, maybe you got 10 minutes with the doctor. In not much more time than you might have spent in a fast food drive-thru, the doctor wrote a prescription, ordered a battery of lab tests and sent you off for a thousand dollars worth of imaging studies.
Somewhere along the line too many doctors stopped being healers and became prescribers and technicians.

We became business people and started thinking in terms of relative value units — the coin of the medical finance realm — as much as how to make patients better. We took seminars in medical coding, so we could talk the same lingo as the government and the insurance companies.

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The changes in medicine are at odds with many of the values that defined the profession I joined.

A healer takes time to understand you. That understanding leads to a more accurate diagnosis at less expense. A healer makes patients feel welcome, understood and encouraged by their visit, even if their health isn’t perfect.

The right dose of empathy is every bit as important as the proper strength for a pill. I can’t put my finger on a day the profession was transformed. But the change is driven home every time a health insurance company calls me a “provider” instead of a doctor. Sure, the switch in name is partly a nod to nurse practitioners and other non-M.D.s who treat patients. Yet the rise in the ranks of these alternative caregivers seems to me to have more to do with concerns about economics than about patients.

The modern physician pushes the paper around, convincing the insurance clerks to pay. The sad fact is the documentation of your visit and paperwork for referrals likely take your doctor as much time as seeing you.

As I look around I see plenty of doctors suffering from compassion fatigue. I don’t consider myself a burned-out family doctor. Delivering kids and watching them grow up brings me as much satisfaction as ever.

Still, I know how much harder it has become to get things done compared with when I started practice a decade ago. I have to fight insurance companies more to get the drugs and treatments I think my patients need. I have to refer patients to bigger groups of specialists, and the quality of their service has gone down.

I also have to see more patients to cover my overhead, and there are months when the practice isn’t profitable.

Getty ImagesBeing in private practice lets me do things my way, though there is always a cost. I can spend my own time and money on something that fits my idea of what a doctor should be doing. I sometimes listen especially closely to the heart of an anxious patient and do a more thorough exam than absolutely required so that my reassurance may have more impact. Having a healing attitude means having a little fun when you can. Sometimes I answer the practice phone when my secretary is at lunch and just tell the patient to come on over. That really surprises them. Every day, I call several patients at home with their test results or to check up after an office visit.

We are seeing an increase in patients losing jobs, losing medical coverage and just needing someone to care.

One free clinic in the area has seen a jump in requests for assistance from 100 people per month to 100 people every four days.
I spent extra time this month with a young woman with an unplanned pregnancy who drove 40 miles to the office because no other practice in the area would take her public assistance.

Recently, I provided free care to a man with depression. He’d just lost his house, his usual job and his health insurance. At his new job, he makes $8 an hour without benefits. There is no federal bailout in sight for him.

From usatoday

Physician David Newman has written a book about the secrets your doctor keeps from you. But he’s not talking about “secret cures” that sell books on alternative medicine. Instead, his new book, Hippocrates’ Shadow: Secrets From the House of Medicine (Scribner), is all about the secrets that hide in plain sight in medical journals and hospital hallways:

• Doctors don’t know as much as you think they do. For example, they don’t know what causes most cases of back pain or what makes it better.
• Doctors do know that many of the tests, drugs and procedures they order and prescribe either do not work or have not been proved to work. Case in point: They keep prescribing antibiotics for colds and bronchitis.

HEALTH BLOG:The doctor will see you now

• Doctors disagree, often, about everything, including whether that chest X-ray you just had really shows pneumonia.
• Doctors like ordering tests better than they like listening to you.

“These doctors are not bad human beings,” says Newman, a New York City emergency department physician who also has studied philosophy, worked as a paramedic and served at an Army hospital in Iraq. He now trains medical students and residents at Columbia University and St. Luke’s/Roosevelt Hospital Center.

Time limits, lawsuit fears and the demands of insurers deserve some blame for the truth gap, he says, but medical training and traditions play big roles.

Take the antibiotic problem. Studies show half of patients who go to a doctor with a cold are prescribed an antibiotic. Colds are caused by viruses; antibiotics kill only bacteria.

“Doctors think patients want a prescription,” Newman says. They also know, he says, that patients feel better once they get that “magic pill.”

But doctors should know, he says, that patients are just as satisfied when physicians take a few minutes to listen, explain why antibiotics won’t help and suggest some symptom relief — relief that won’t come with side effects such as diarrhea, yeast infections and allergic reactions.

Likewise, he says, doctors don’t like to admit that many test results are not as black and white as they appear. Communicating shades of gray is harder, he says, and not taught in medical school. And while patients assume doctors rely on science, “it’s not uncommon for the decisions we make to be entirely based on opinion,” Newman says.

Letting patients in on secrets like those would allow them to make better, more healthful choices, he says.

Other doctors will argue with some of Newman’s views. For example, he says routine mammograms don’t save lives, a conclusion at odds with those of the American Cancer Society, the National Cancer Institute and other medical groups.

But the idea that Americans get worse medical care than they realize — often because they get too many, not too few, tests, drugs and procedures — is gaining ground.

Think about this summer’s recommendation from the U.S. Preventive Services Task Force that men over 75 should stop getting blood tests for prostate cancer (because they are more likely to be harmed by prostate cancer treatment than to die from the disease). Or read Overtreatment, a 2007 book by former health journalist Shannon Brownlee, just out in paperback. She writes that the biggest problem is doctors and hospitals “get paid more for doing more.”

Whatever the causes, part of the cure must be straight talk, Newman says: “There is a lot of personal responsibility in this. It’s all about patients and doctors communicating.”