Uninsured and underinsured

	Atul Gawande (@Atul_Gawande)
8/20/18, 6:13 AM Nearly half of all Americans in fair or poor health — 46.4% — are uninsured or have affordability problems despite having coverage. ⁦‪@DrewAltman‬⁩ axios.com/not-just-unins…

“Dopesick: Dealers, Doctors, and the Drug Company That Addicted America”

Fewer than 50 pages into Beth Macy’s “Dopesick: Dealers, Doctors, and the Drug Company That Addicted America,” one of the many opioid users she talks to — this one a mother in Virginia — explains how her addiction started in the early 2000s, after routine gallbladder surgery. “The doctor didn’t force me to take them,” she said of OxyContin and Percocet, two powerful painkillers she was instructed to take concurrently. But her doctor, she assumed, was a “high-standard person, someone you’re supposed to trust and believe in.”

If you want a glimpse into how the opioid crisis began, the woman’s words are a good place to start. She was aware of her own choice in the matter, but her physician instructed her to double up on highly addictive narcotics. An expert, someone supposed to know better, had betrayed her trust.

Books like “Pain Killer,” by Barry Meier, a reporter for The New York Times, and “Dreamland,” by the journalist Sam Quinones, have covered the opioid crisis in detail, but they appeared before the 2016 election, when the places in the country most affected by the epidemic went for Drumpf. With “Dopesick,” her third book after “Factory Man” and “Truevine,”Macy has waded into a public health morass that has also become a political minefield. Commentators on the left have pointed out the gaping discrepancy between the sympathy extended to today’s opioid users, who are mainly white, and the brutal, racist handling of the war on crack.

“Dopesick” touches on these political developments, but its emphasis lies elsewhere. Macy’s strengths as a reporter are on full display when she talks to people, gaining the trust of chastened users, grieving families, exhausted medical workers and even a convicted heroin dealer, whose scheduled two-hour interview with the author ended up stretching to more than six hours. (continues)

How to Quantify a Nurse’s ‘Gut Feelings’

"I had a nagging sense that something was wrong, but I couldn’t articulate it."
By Theresa Brown (Ms. Brown is a hospice nurse.)

At the start of my shift, at 7 a.m., my patient, newly admitted a few days before for a blood cancer, was talking and acting normally. By the end of my shift, 12 hours later, she had grown confused and her speech was garbled. A CT scan revealed bleeding in her brain. She was sent to intensive care and died the next day.

This was years ago, but the case still haunts me. I believe that moving faster on her treatment might have prevented her sharp decline. But the medical team didn’t share my sense of urgency, and no obvious red flags signaled a coming emergency. Without a worrisome clinical value or test result to point to, my concern alone wasn’t persuasive.

Every nurse likely knows the feeling. The patient’s vital signs are just a little off, she seems not quite herself, her breathing is slightly more labored. But on paper she looks stable, so it’s hard to get a doctor to listen, much less act.

In such situations nurses invoke “gut feelings,” but they actually aren’t feelings at all — they are agglomerations of observations and experiences that over time have turned into finely tuned clinical judgment. The idea is that working at the bedside has honed nurses’ perceptions to be especially alert to brewing trouble. (continues)

Why Doctors Should Read Fiction

Last week, Sam Kean wrote about a new paper in Literature and Medicine. The paper, he explained, argues that “certain literary exercises can expand doctors’ worldviews and make them more attuned to the dilemmas real patients face.”

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As a physician who teaches both ethics and creative writing to medical students and house officers, I appreciate the value of using fiction and narrative to enhance the training of future physicians. These tools are certainly helpful in cultivating humanistic and compassionate doctors. However, medical school is rather late in the game to introduce these techniques. Ideally, admissions committees at medical schools should be looking for students who are imaginative and who are already reading literature, including literature about illness and physician-patient relationships. One might argue for altering medical school admissions requirements accordingly—for instance, replacing required courses in Newtonian physics with those that foster creativity and emotional understanding. As a physician, I am often asked to listen to my patients’ stories with empathy; in contrast, not once have I ever had to calculate the trajectory of a patient to be shot out of a cannon.

Jacob M. Appel, M.D., J.D., M.P.H.
Assistant Professor of Psychiatry and Medical Education
Director of Ethics Education in Psychiatry
Mount Sinai School of Medicine 
New York, N.Y.

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	The Atlantic (@TheAtlantic)
8/5/18, 5:32 PM Letter: Literature should be a medical school admissions requirement on.theatln.tc/ooFciqp

The annals of literature are packed with writers who also practiced medicine: Anton Chekhov, Arthur Conan Doyle, William Carlos Williams, John Keats, William Somerset Maugham, and on and on. As doctors, they saw patients at their most vulnerable, and their medical training gave them a keen eye for observing people and what makes them tick.

But if studying medicine is good training for literature, could studying literature also be good training for medicine? A new paper in Literature and Medicine, “Showing That Medical Ethics Cases Can Miss the Point,” argues yes. In particular, it proposes that certain literary exercises, like rewriting short stories that involve ethical dilemmas, can expand doctors’ worldviews and make them more attuned to the dilemmas real patients face.

(continues)