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We talk with Colleen Farrell who’s doing her third year of an internal medicine residency in New York City. Fortunately, we caught her during a one-week vacation (she was supposed to be taking two), and she chatted with us about how she and her colleagues are coping. We asked her what she thought COVID-19’s larger lessons would be, and she gave an interesting, impassioned answer. Running time: 12 minutes Other interviews in this series on COVID-19: Dr. Anthony Fauci Dr. Susan Sadoughi Dr. Matthew Young Dr. Julian Flores Dr. Kristi Koenig Joe Elia: You’re listening to Clinical Conversations. I’m your host Joe Elia. We’ve come to New York City this time, at least electronically, to talk with Colleen Farrell. Dr. Farrell is a third-year resident in internal medicine at NYU in Bellevue Hospital. This July, she starts a pulmonary and critical care fellowship at New York Presbyterian-Cornell. I became aware of Dr. Farrell when a classmate of hers sent along a posting she’d made on social media. It read, in part,

San Diego County has Dr. Kristi Koenig as medical director of its emergency medical services. That’s fortunate for the county, because she’s co-edited a definitive textbook, “Koenig and Schultz’s Disaster Medicine: Comprehensive principles and practices.” We’re fortunate to have her as our guest. She’s full of sound advice on organizing a community’s response (for example, setting up “incident command” structures) and evaluating patients as new threats emerge (the well-known “three-I’s” approach — Identify, Isolate, and Inform). With the number of COVID-19 cases rising quickly there in San Diego, she’s been busy (as have all of you). Running time: 19 minutes Links: Interview from 2016 with Koenig and Schultz on the second edition of their “Disaster Medicine” Koenig, Bey, and McDonald’s article on applying the 3-i tool to novel coronavirus in Western Journal of Emergency Medicine (Jan 31 online) Other interviews in this series on COVID-19: Dr. Anthony Fauci Dr. Susan Sadoughi Dr. Matthew Young Dr. Julian Flor

This time we talk with Dr. Julian Flores, who works in a Broward County, Florida, emergency room. When he was interviewed, the count of Covid-19 cases stood at 412, less than 12 hours later, the new number was 505, as of this posting — on Friday near noon Eastern — it’s at 614. Flores is expecting the wave to hit hard there. Broward is home to Fort Lauderdale (think spring break) and Pompano Beach (think aging retirees). Couple those demographics with a lack of easy testing for the virus, and you’ve got a worrisome situation. Links of interest: NEJM Perspective article NEJM Sounding Board Running time: 13 minutes A TRANSCRIPT OF THE INTERVIEW (Please bear in mind that what follows is a conversation and not a polished essay.) Joe Elia: You’re listening to Clinical Conversations. I’m your host, Joe Elia, and I’m joined by my cohost, Dr. Ali Raja, Editor-in-Chief of NEJM Journal Watch Emergency Medicine. He’s in the Department of Emergency Medicine at Mass. General and an associate professor at Harvard Medical S

Dr. Matt Young is a first-year resident in obstetrics and gynecology in suburban Delaware. Between the day I invited him to be interviewed and the interview itself (a 36-hour span) things had changed a lot for him. Anxiety levels are up among his colleagues, and everyone in his hospital must wear a mask all the time. A ground-level view of an incipient epidemic is what we offer. Running time: 13 minutes TRANSCRIPT OF THE CONVERSATION WITH DR. MATT YOUNG Joe Elia: You’re listening to Clinical Conversations. I’m your host, Joe Elia. Like everyone else on the planet, we in the US are obsessing over the morbidity and mortality charts of the COVID-19 pandemic. We’ve done interviews with Dr. Anthony Fauci and Dr. Susanne Sadoughi and I wondered what the newcomers to clinical life are seeing through their fresh eyes. So I’ve reached out to Dr. Matthew Young, who is completing his first year of an OB/GYN residency in suburban Delaware. I know Matt from working with him on a social media project for the NEJM Group. He

We talk with Susan Sadoughi, an internist at Brigham & Women’s Hospital in Boston, about how quickly things have changed over the past week. Last week, I introduced the Fauci interview by saying that I’d heard a clinician complain that she’d spent half her time answering questions about COVID-19. This week, she’s our guest, and she’s looking back from the vantage point of a completely changed health system. She describes that change as “enormous.” She’s doing lots of telephone consultations with her patients, talking about sending her kids to be with relatives at the other end of the country, and being wistful about the sound of a cello in her hospital’s corridors. She’s learning to live with uncertainty, she tells us. Listen in, clinicians, and see whether these observations resonate with you. LINKS: Last week’s interview with Anthony Fauci Running time: 18 minutes TRANSCRIPT OF THE CONVERSATION WITH DR. SUSAN SADOUGHI (Please remember, this is a conversation and not an essay. As such, it can seem in

We have Dr. Anthony Fauci of NIAID to talk with us about COVID-19, the disease caused by the 2019 novel coronavirus (also known as SARS-CoV-2). He’s full of sound advice in the midst of a rapidly changing epidemic. We wanted to know, How do you talk with patients about this rapidly spreading infection? How do you keep informed about it? Listen in. Link: The new federal website Running time: 13 minutes TRANSCRIPT OF THE INTERVIEW Joe Elia: This is Joe Elia. If you’re like the clinician I heard from last week who said she’s spending half her time counseling patients about COVID-19, you’re probably wondering how best to discuss the problem with your patients. This time my co-host, Dr Ali Raja, and I are talking with Dr Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases about how clinicians might approach these conversations and about how both parties — clinician and patient — can best inform themselves about the developing details of this widespread illness. Dr Raja is he

Here we have an interview with Prof. Feng He, whose English is much better than my Mandarin. Thus, I’ve attached a transcript to make her ideas on salt intake (no level is too low) and blood pressure (there’s a dose-response relation with salt) more immediately available than it might be to your ears alone. She’s coauthor of an article in The BMJ — a meta-analysis — that finds the effect of salt is greater with age, and in non-white populations and those with hypertension. Links to articles mentioned and apps: The BMJ meta-analysis discussed Salt reduction in England from 2003 to 2011: its relationship to blood pressure, stroke and ischaemic heart disease mortality https://bmjopen.bmj.com/content/4/4/e004549 Formulas to Estimate Dietary Sodium Intake From Spot Urine Alter Sodium-Mortality Relationship https://www.ahajournals.org/doi/full/10.1161/HYPERTENSIONAHA.119.13117 Role of salt intake in prevention of cardiovascular disease: controversies and challenges https://www.researchgate.net/publication/3

JAMA recently published a review of some 40 papers examining the relation between malpractice liability strategies — tort reform, increased insurance premiums, etc. — and the quality of care. Apparently the efforts had no discernible effect on mortality rates, length of hospital stays, and the like. An editorial accompanying the paper sketches out a vision of where future efforts should lead, especially given the shift in U.S. medicine from private to institutional practice. The coauthor of that editorial — surgeon and law professor William Sage — is our guest. Links: Malpractice liability and health care quality article in JAMA Sage and Underhill’s editorial in JAMA Running time: 17 minutes The post Podcast 254: Old malpractice liability strategies need rethinking first appeared on Clinical Conversations.

With human papillomavirus vaccine in short supply around, moving from a three- or two-dose regimen to one dose would immediately double or treble supplies, cut costs, and simplify logistics. A careful study in Cancer by this week’s guest, Ana Rodriguez, and her colleagues adds to the evidence that single-dosing is possible and protective against pre-cancerous cervical lesions. Cancer article Cancer editorial  An earlier (2015) podcast on the question of the number of vaccine doses needed to confer protection Running time: 16 minutes The post Podcast 253: Is a single-dose HPV vaccination effective? first appeared on Clinical Conversations.

Back in November, Ali Raja and Joe Elia talked with Garen Wintemute about his Health Affairs paper regarding addressing the topic of guns with patients. Having encountered another of those weeks in which interviewees were either on vacation (richly deserved, we’re certain) or too busy to respond to Joe’s requests (get some sleep!), we’re going to offer that conversation again. We hope you’ll listen and vote — and if you do vote, please leave a comment as well. URL for November’s original podcast Running time: 19 minutes The post Podcast 252: We revisit our chat about chatting about guns first appeared on Clinical Conversations.

Intermittent fasting has salutary effects. Listen how Dr. Mark P. Mattson, co-author of a recent NEJM review on the topic, assesses the practice — and how he’s managed to skip breakfast for the past 30 years or so. Dr. Ali Raja joins Joe as co-host again this time. Links: de Cabo and Mattson’s review in the New England Journal of Medicine Michael Mosley and Mimi Spencer’s book “The FastDiet” Running time: 18 minutes The post Podcast 251: Intermittent fasting first appeared on Clinical Conversations.

It turns out that the disrespect starts even earlier — when women are questioned about their choice of a surgical specialty. Nor is the bad behavior the exclusive province of the “old guard.” We talk with Dr. Pringl Miller, a Chicago surgeon who’s compiled a collection of instructive stories from women surgeons who’ve had to dodge demeaning questions (and sometimes, flying chairs in the OR). The stories appear in the latest issue of Narrative Inquiry in Bioethics. “#MeToo in Surgery: Narratives by Women Surgeons” article in Narrative Inquiry in Bioethics Recent NEJM article on harassment in surgical residency training Time’s Up Healthcare website Patricia Dawson’s book: “Forged by the Knife: The experience of surgical residency from the perspective of a woman of color” Preeti John’s book: “Being a Woman Surgeon: Sixty women share their stories” Joan Cassell’s book: “The Woman in the Surgeon’s Body” Running time: 18 minutes The post Podcast 250: #MeToo in the OR first appeared on Clinical Conversations.

Why aren’t you able to navigate your electronic health record (EHR) as easily as you can find a recipe on, say, Google? And, what about those requirements for documenting everything? Listen to a chat with Julia Adler-Milstein, the author of an editorial that comments on a recent Annals of Internal Medicine study detailing the amount of time clinicians typically spend hunched over their EHRs during a patient visit. Links: Annals of Internal Medicine editorial Annals paper on the time clinicians spend Running time: 17 minutes The post Podcast 249: Quality time with your EHR — or just time? first appeared on Clinical Conversations.

The process of identifying super-users of healthcare and reducing the frequency of their hospitalizations — so-called “hotspotting” — was subjected to a randomized, controlled trial in Camden, NJ, the birthplace of the idea. It failed there. Those in the intervention group had a readmission rate within 6 months that was statistically identical to those getting usual care. True, the Camden patients had particularly complex social and medical problems, so that doesn’t mean that the program can’t work elsewhere. Listen to our chat with the report’s senior author, Prof. Joseph Doyle, and as well, listen to our interview with Dr. Jeffrey Brenner from 6 years ago — he’s the one who put “hotspotting” on the map. Despite the apparent failure of the trial, the Coalition still has a lot to offer. Results of the randomized trial in NEJM Interview with Dr. Jeffrey Brenner from 2013 Camden Coalition’s website Running time: 15 minutes The post Podcast 248: “Hotspotting” didn’t work in its home town — why? first appeared o

A “network meta-analysis” (we’ll explain that) finds that “test and treat” is the best way forward in managing this common condition. Patients, paradoxically, prefer immediate endoscopy to test-and-treat, but unless the patient has “alarm symptoms” (such as dysphagia, weight loss, and anemia), endoscopy is likely to add complications and costs without adding further benefit. Our guest is Prof. Alexander Ford of Leeds, senior author on the guideline-affirming study in The BMJ. Links: Article in The BMJ Physician’s First Watch summary NEJM Journal Watch Gastroenterology summary of 2017 joint U.S. – Canadian guideline The post Podcast 247: Managing dyspepsia first appeared on Clinical Conversations.

For the first time in almost a century, Americans are dying at home more often than dying in hospitals. This seems to mark a cultural change that will affect both how and where clinical medicine is practiced. Dr. Haider Warraich’s letter to the editor of the NEJM presents the numbers, and he’s agreed to talk about their implications. Links: Cross and Warraich’s New England Journal of Medicine letter (Dec. 12 issue) Warraich’s 2017 book “Modern Death” “Near Death,” a Frederick Wiseman 6-hour documentary worth finding Running time: 16 minutes The post Podcast 246: Where we die now first appeared on Clinical Conversations.

In November 2018 we interviewed two authors of an Annals of Internal Medicine study comparing the quality of diabetes care afforded by three provider types: nurse-practitioners, PAs, and MDs. They reported that there were no clinically significant differences in the intermediate outcomes — glycated hemoglobin, systolic pressure, or low-density lipoprotein cholesterol — among the groups. We’re posting that interview again for two reasons: first, this week’s planned interviewee remained unreachable, no matter my pleadings; second, listeners reacted strongly (and positively)  the first time around, and I hope newer listeners will find it as interesting. Links: URL of the original podcast Annals of Internal Medicine paper Running time: 20 minutes The post Podcast 245: We revisit a 2018 episode on NPs’, PAs’, and MDs’ performance in the primary care of diabetes first appeared on Clinical Conversations.

The anti-inflammatory colchicine is powerful and cheap. It’s thought that, because cardiovascular problems often stem from inflammation, colchicine could help prevent secondary events after MI. That’s what Jean-Claude Tardif and an international group of colleagues set out to investigate. The group reports in the NEJM that daily low-dose colchicine was associated with a lower rate of a composite endpoint than a placebo: death from cadiovascular causes, resuscitated cardiac arrest, MI, stroke, or urgent hospitalization leading to coronary revascularization. New England Journal of Medicine report Editorial commentary in NEJM Harlan Krumholz’s tweet on the report Running time: 20 minutes The post Podcast 244: Colchicine after myocardial infarction first appeared on Clinical Conversations.

Controlling hypertension lowers the relative risk for dementia and Alzheimer’s disease by roughly 15%. Given that many people have poorly-controlled hypertension, the finding that all antihypertensives are effective in bringing about this result might get your patients to be more adherent. We talk with Dr. Lenore Launer of the NIH’s Institute on Aging about her recent meta-analysis in The Lancet Neurology. LINKS: Launer’s paper in The Lancet Neurology Lancet comment on the article Running time: 16 minutes The post Podcast 243: Lowering high blood pressure lowers dementia risk first appeared on Clinical Conversations.

Tranexamic acid, which frustrates clot dissolution, has been shown to reduce death from intracranial bleeding in a large international placebo-controlled trial — “CRASH-3.” Ali Raja and Joe Elia host a lively chat with Ian Roberts, the co-chair of the trial’s writing committee, who, in addition to chastising the hosts’ seeming fascination with P-values, recounts a story from early in his training that first stirred his devotion to preventing bleeding-related death after trauma. NEJM Journal Watch Emergency Medicine summary of CRASH-3 CRASH-3 report in The Lancet Ian Roberts explains CRASH-3 on YouTube to collaborators in Malaysia Roberts presents CRASH-3 results at World Congress on Intensive Care on YouTube Running time: 23 minutes The post Podcast 242: Tranexamic acid saves lives after traumatic bleeds first appeared on Clinical Conversations.