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Demystifying Medicine One Month at a Time

Category: uncertainty (page 1 of 12)

Medical Marijuana: Not Up to the Standard

This year Oklahoma voters made a clear choice to legalize medical marijuana, joining thirty other states that permit cannabis for medicinal use.

Unsurprisingly, immediately in the vote’s aftermath, patients began asking me to ‘prescribe’ medical marijuana licenses, as the new law stipulates users must have as a precondition for legal purchase. The new law does not, however, specify qualifying diagnoses for which medical marijuana might be clinically indicated.

My answer thus far has been, “Not now. Likely never.”

This has not been a popular response. One patient looked at me as if I’d put a lump of coal in his Halloween bag.

I’m not a fan of medical marijuana for several reasons. The main issue is the lack of proven medical efficacy. I know there are thousands of anecdotes from people whose pain or anorexia has been diminished by marijuana–and I’m genuinely glad for them. But I’d like to see better powered controlled trials of cannabis products head-to-head with accepted therapeutic agents. Having the FDA weigh in on marijuana’s safety and efficacy would also go a long way toward legitimizing pot’s medicinal use.

Another major problem is smoking the stuff. If we had proven, standardized dosing of edibles, I’d be more supportive of medicinal use. But smoking anything–tobacco, marijuana, vapor juice–is not a healthy practice, and one I counsel patients to avoid. I hear the arguments about the purity of pot and how it’s ‘more natural’ than manufactured tobacco products. The bottom line is that inhaling burning plant matter into your lungs is a terrible idea–regardless of the herb.

If voters want to legalize marijuana for recreational use, I have no objection–provided we put in place a legal framework to make sure that people don’t get hurt. Standardized dosing and measures to assure product consistency would be integral. And we’d need adequate enforcement to make sure that people aren’t impaired when at work or in other situations in which their marijuana use could jeopardize others.

Putting doctors in the middle of what amounts to a political, legal, social, and economic debate steers the medical profession in a race to the bottom–and let’s face it–our profession has enough problems already without being the gatekeepers of grass.

Remember that marijuana is still scheduled by the Drug Enforcement Administration as a Class I narcotic, defined as having “no accepted medical use and high potential for abuse.” So even though medical weed is now legal in my state, I have no interest in violating or abetting violations of federal law.

In fact, as it turns out, since I work at a university, our legal counsel is of the opinion that no provider in our system shall recommend marijuana, since our institution has numerous federal grants and funding streams and must therefore comply with all federal rules and regulations.

Some have suggested that given our national opioid epidemic, marijuana can serve as a safer alternative for pain control. Since most cannabis is homegrown, and where legalized a tax revenue source–this does make medical marijuana a more appealing alternative to propping up the seemingly ubiquitous heroin/fentanyl drug cartels.

This argument makes pot part of a harm reduction strategy, which I’d be more supportive of if the evidence were stronger.

Right now I see the pot economy as a Wild West with hundreds of entrepreneurs and medical professionals looking to stake claims in this new quasi-legal economy.

Get back to me when we have more state/federal legal congruence and clarity on the stuff’s true medical benefits.

This essay originally appeared as a Doximity Op-(m)ed.

End of Life Rallies

Let’s say your loved one is at the end of life. She’s 84, with advanced cancer that is no longer treatable.

A decision has been made to put her in hospice–which is a level of care more than an actual location. [Most hospice actually occurs at home.]

The patient waxes in and out of consciousness, sometimes lucid, but mostly not.

While no one is ready for her to die, this end-of-life process brings some solace–it’s what your loved one has indicated she wants, and the time at home without aggressive, often fruitless, medical treatment, allows other friends and family members to make visits and share stories.

One afternoon, she perks up and asks for a sandwich. This is surprising, because she’s barely eaten anything in the last ten days. But we get her that sandwich!

She nibbles at it, happy, but doesn’t eat much of it.

That afternoon, she’s talkative and engaged with others in a way that she hasn’t heretofore seemed able to muster.

Is she making a comeback? Healing from her illness?

More likely, this is what is called “rallying,” and while there’s ample anecdote of its occurrence in situations like this, we have very little understanding of it.

How does it happen? As a recent NYTimes article stated:

Physiologically, experts believe that the mind becomes more responsive when a hospice patient is taken off the extensive fluids and medications such as chemotherapy that have toxic effects. Stopping the overload restores the body to more of its natural balance, and the dying briefly become more like their old selves.

It’s deceiving because we think our loved one is getting better. And while she’s more like her old self, unfortunately, it’s not bound to last. Which is why it can be upsetting for some.

Spiritually, some suggest that the dying loved one is simply readying for transition–making sure that earthly concerns will be attended to in her absence and that final goodbyes may be uttered.

I’ve seen it–and especially in elders afflicted with dementia, it can be heartening to see them rally and seem to know what’s going on–accepting their impending death, and engaging with their loved ones before drifting off.

A Surprising Reason Some Still Don’t Like Obamacare

The Affordable Care Act (“Obamacare”) has slowly become more popular as Americans discover that the law has lowered the number of people without health insurance and provided baseline benefits to millions of us (preventive care, youth coverage under parents until age 26, doing away with pre-existing conditions, etc.), without causing massive social or health care disruption.

Critics of the ACA cite ideals like letting the marketplace sort things out, rather than relying on government intervention to do so. Of course, the individual mandate, the requirement to be insured, was scaled back by the late 2017 tax reform law–such that people on the individual insurance market will be able to opt out in 2018 and beyond if they choose without penalty (even though the US Supreme Court ruled in 2012 that the mandate is constitutional).

Recently, a reader sent me a fascinating article about why some evangelical Christians also dislike Obamacare. It’s known as crucicentrism.

Not all evangelicals hold this worldview. According to a source cited in the article, about one quarter of evangelicals espouse this viewpoint.

Still–what does it mean? From the aforementioned article:

To secure a permanent place at God’s side is far more important than any short-lived torment to the body. From this perspective, then, the greatest kindness one can show others is to help them reach the salvation of the Cross.

Such a crucicentrist view on compassion explains puzzling statements by white evangelicals like Mark Green, a Tennessee state senator. “Sickness,” Green told a church group, “is one of the main avenues that bring people to religion.” In the Gospels, he said, “every person who came to Christ came to Christ with a physical need. It was either hunger or a disease.” When the government created the ACA it did a “great injustice” because, Green explained, by helping people regain their health, it had limited “the Christian church’s role” and robbed sick individuals of the opportunity “to come to a saving knowledge of who God is.” People who fell ill would now look “to the government” instead of to God.

In this worldview, suffering is seen as a pathway to faith, which will lead to salvation. And, I presume, better health.

Maybe this shouldn’t be surprising. After all, institutions have always needed members, missions, and money to maintain their existence over millennia.

But I do find this inclination shockingly uncharitable.

What do you think?

Social Hospitals?

Evolution of hospitals is a theme we’ve visited before.  A couple of years ago, these words appeared in GlassHospital:

I once had a teacher tell me, “No one should ever need to be in a hospital. Except for some cardiac conditions that require immediate care, the only people winding up in hospitals are frail elders, and those with social problems and no place to go — the mentally ill, the destitute, the homeless.” I remember feeling a bit shocked by this, but as I reflected on it, I realized he had a point. I should start with the assumption, he told me, “that almost no one really needs to be there and they’re better off at home.”

Hospitals have their origins as almshouses, places where the poor could go to seek care and sustenance. Over time, they co-evolved to become places of teaching, and in the early 20th century university-based medical schools partnered with charity hospitals in particular to train future generations of doctors.

Now a recent NY Times  op-ed  asks, “Are Hospitals Becoming Obsolete?”

Medicine has advanced so that many illnesses and procedures that used to require days in the hospital now can be treated in an office setting. It seems the more we study it, the more we realize that people do better when they convalesce in their home environments.

Another recent article discussed an additional factor contributing to the demise of hospitals: hospital at home. WHY NOT have medical care in your home, including IV therapy and even advanced procedures like dialysis if they’re available and they work?

One other line of reasoning asks about HOW we apportion hospital beds, suggesting that maybe we’ve de-commissioned too many psychiatric beds for treating people with severe mental illness. Given the horrible shooting sprees in the news recently, several commentators are asking if it’s time to re-invest in mental hospitals.

One idea here: if hospitals continue to consolidate and atrophy, perhaps we should re-purpose them to more ably handle social issues that continually confront us: nutrition, jobs, education, housing, etc., etc.–by offering services and information for people with those needs.

The question is how we structure and finance that transition.

J.P. Berkazon

It was a big story: It held the news cycle for more than 24 hours, until something about some memo sucked up all our oxygen.

It was about business. And health care.

BIG businesses doing something to TRANSFORM health care.

The announcement caused the stock prices of other big companies in the ‘health care space’ to drop.

We’re still fuzzy on the WHAT.

As to the WHO: Amazon, Berkshire Hathaway, and JP Morgan Chase. The three behemoths plan to come together to form a non-profit entity to ‘disrupt’ health care.

The WHY: health care for their > 1 million combined employees (and all over the U.S.) costs too damn much.

The headlines were breathless, e.g. Forbes: “Amazon, Berkshire Hathaway, and JP Morgan Could Disrupt U.S. Health Care and Capitalism as we Know It.”

Capitalism as we know it.

It’s a great story. It has compelling figures. I, like many, want to believe that it’s possible to disrupt our piecemeal, overwrought, and insanely expensive health care non-system.

Many others have tried. And failed.

Here’s a contrarian view on the big announcement from a seasoned observer. Is his skepticism warranted or can Amazon and friends do for health care what they’ve done in retail and web services?

What do you think? Can J.P. Berkazon crack the U.S.  health care nut?

@GlassHospital

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