Clinical Conversations

Running time: 18 minutes
In California, Garen Wintemute and his group find evidence that people are willing to discuss gun safety with their clinicians, especially when there may be danger of harm present. That willingness extends across gun owners and non-owners. So why aren’t more clinicians doing it?
The findings appear in Health Affairs.
Links to the article & further resources:
Health Affairs article
Wintemute’s essay in Annals of Internal Medicine on gun violence
Another Annals article on preventing gun-related death and injury
The post Podcast 241: Talking about guns with patients first appeared on Clinical Conversations.

Running time: 23 minutes
Paula Byrne set out to understand what the available data tell us about how many people are taking statins for primary prevention — and how much good is it likely doing them?
Also, how do you discuss their possible harms and benefits with patients?
Links:
Paula Byrne and colleagues’ analysis in The BMJ
Kausik Ray meta analysis in JAMA Internal  Medicine
Kausik Ray 2010 Clinical Conversations interview
NEJM Journal Watch General Medicine comparison of statin guidelines
The post Podcast 240: Overuse of statins for primary prevention of cardiovascular events first appeared on Clinical Conversations.

Running Time: 18 minutes
Veterans Day will be here soon, and this episode introduces you to Patrick Tripp, a writer and radiation oncologist. He’s taken conversations with some of his patients and published thumbnail profiles of several in a remarkable essay in the London Review of Books (that’s right, it’s not a medical journal).
The patients all happened to be veterans of the war in Vietnam. There are no biomedical insights here — or are there? At the very least, you are reminded that the people in the exam room all have stories to tell, and if you have the luxury of listening to them you may just learn more about their true chief complaint.
Patrick Tripp’s London Review of Books essay
The post Podcast 239: Talking with veterans first appeared on Clinical Conversations.

Running time: 21 minutes
A white paper from the Office of the Assistant Secretary for Preparedness and Response (ASPR) advises clinicians, health planners, and emergency responders that the old ways of responding to mass casualty events no longer hold. Wounded people arrive in Ubers and Lyfts at hospitals that are unprepared to be trauma centers. It’s best to practice (sending out an email to the staff doesn’t count) so that everyone in the hospital knows what to do and where to go when chaos strikes.
Ali Raja and Joe Elia talk with Paul Biddinger, one of the contributors to “Mass Casualty Trauma Triage: Paradigms and Pitfalls.”
And by the way, you may think you know how to use a tourniquet, but you probably don’t. Follow the link (below) to Stop the Bleed.
Links:
ASPR white paper
Stop the Bleed home page
Boston Marathon interviews:
Ron Walls, Brigham & Women’s Hospital
Alasdair Conn, Massachusetts General Hospital
Andrew Ulrich, Boston Medical Center
Brien Barnewolt, Tufts Medical Center
NEJM Journal Watch Emergency Medicine summary of the white paper
The post Podcast 238: Preparing for the unthinkable chaos of a mass-casualty event first appeared on Clinical Conversations.

Running time: 18 minutes
JAMA has just published an analysis of the latest findings regarding waste in the nation’s $3.5 trillion annual health “co-pay.” And with 25% of that — some eight hundred billion dollars — characterized as wasted, you’d think there would be stacks of competing cost-saving proposals to consider, especially regarding administrative costs. There aren’t.
An editorial comment on all this by our guest, Don Berwick, reminds us that one person’s wasteful spending is another’s lavish income. The question is, with all that money left on the table, what are we foregoing as a country?
Dr. Berwick has thoughts, and he kindly agreed to share them with us.
JAMA article by Shrank et al.
JAMA editorial by Berwick
The post Podcast 237: U.S. health spending — where is the outrage? first appeared on Clinical Conversations.

Running time: 20 min.
Recently, Lancet Digital Health ran a meta-analysis concluding — if cautiously — that “deep learning” (more familiarly known as artificial intelligence) can be considered “equivalent to healthcare professionals” in image-based diagnoses.
In an editorial commentary on the analysis, Tessa Cook says, in effect, “not so fast!” And she discusses the reasons behind that caution with us in this episode.
Dr. Cook’s commentary in Lancet Digital Health
The meta-analysis on which she was commenting
The post Podcast 236: Is an AI better at diagnosis? first appeared on Clinical Conversations.

Running time: 18 min.
Laura Hawks and colleagues undertook a study of forced sexual initiation — that is, a woman’s first episode of vaginal intercourse (and it’s forced when it wasn’t voluntary on her part).
Using government survey data on some 13,000 women of reproductive age, Hawks compared the women whose sexual initiation was voluntary with those whose wasn’t. It turns out that there were longer-term medical consequences apparently associated with the circumstance. Listen in.
Links:
JAMA Internal Medicine article
JAMA Internal Medicine editorial
The post Podcast 235: Forced sexual initiation and its clinical aftermath first appeared on Clinical Conversations.

Running time: 21 minutes
A national sample of early- to midcareer pediatricians shows that women are lagging behind men in compensation, and another study from the sample shows that they’re not getting much help with the housework, either.
We talk with two of the authors of these studies and get their advice on what to do next — besides emptying the dishwasher and folding some laundry, gentlemen.
Links:
Pediatrics article on earnings
Pediatrics article on housework help
Pediatrics editorial on the two articles
The post Podcast 234: Pay for women pediatricians lags first appeared on Clinical Conversations.

Using “Vitamin H” (haloperidol) or newer antipsychotics to treat delirium in hospitalized patients should be off the menu, writes Edward Marcantonio in an Annals of Internal Medicine editorial.
Dr. Marcantonio agrees with the authors of a systematic review who conclude that “current evidence does not support routine use of haloperidol or second-generation antipsychotics to treat delirium in adult inpatients.” In his commentary entitled “Old Habits Die Hard,” he writes “the findings presented are sufficient to stop this clinical practice.”
Links:
Annals of Internal Medicine editorial
Marcantonio’s “Clinical Practice” article in NEJM in 2017
The post Podcast 233: Antipsychotics are no solution to delirium during hospitalization first appeared on Clinical Conversations.

You surely remember “O-chem” — those late-night undergraduate hours spent grappling with benzene rings and alkanes and all the rest. Well, it turns out that drug makers were paying close attention to things like racemic mixtures and enantiomers. The manufacturers usually release their products as racemic mixtures and then, when patents are about to expire, an enantiomer appears. Voila! New drug, new price!
Dr. Joseph Ross and his crew looked at the implications to Medicare spending of all this. They published an interesting letter in the Annals of Internal Medicine detailing how much money the system could save if we stuck with the racemic mixtures. How much? Well, on the order of $15 billion over 5 to 6 years.
Links:
Annals of Internal Medicine letter
NEJM Journal Watch Pediatrics and Adolescent Medicine coverage of albuterol vs. levalbuterol
The post Podcast 232: Basic organic chem and drug pricing first appeared on Clinical Conversations.