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This transcript has been edited for clarity.

Robert Glatter, MD: Welcome. I'm Dr Robert Glatter, medical advisor for Medscape Emergency Medicine. Today, we have Dr Mikhail Varshavski, otherwise known as " Doctor Mike," who is a family medicine physician and well-known social media medical influencer.

He's joining us to discuss how he has spent the past several years debunking medical misinformation, helping to allow people and healthcare providers alike make better-informed decisions about their own healthcare during the pandemic and beyond.

Welcome, Dr Mike. It's a pleasure to have you join us.

Mikhail Varshavski, DO: Thank you so much, Dr Glatter. I'm really excited to be here to speak on a subject that I'm incredibly passionate about.

Glatter: I want to start by asking you about how you approach patients when they come to you with bits of medical misinformation and myths that don't clinically make sense.

Varshavski: The main reason why I got into posting videos on social media was because of my frustration of seeing patients being misled on something that they've seen online or even on television, thinking that was a shortcut to success for them to have a healthy outcome. In reality, that success would only come through putting in some level of effort, whether it means getting a good night's sleep; eating a healthy, varied diet; or putting in the work to go to the gym. It's very tempting for them to see a shortcut miracle cure-all supplement on social media and wonder, Why is my doctor not recommending me that?

It was my experiences during my residency that really inspired me to say, we need to do a better job in media at debunking this misinformation. I think it stemmed from the fact that there was an absence of quality, evidence-based physicians online doing it effectively.

Glatter: I think that's important. Traditional medical and healthcare systems have shied away from social media in the beginning of things. I think you're aware of this, and now it seems like every hospital is online, on TikTok, Instagram, or Facebook. That really is the way to get to the population and to reach your audience. Clearly, now that there's been this bandwagon that everyone has jumped on, as you point out, it's very important to have evidence-based and accurate information.

Could you highlight some of the most egregious examples of medical misinformation from videos that you've encountered on various social media platforms?

Spread of Outrageous Conspiracy Theories

Varshavski: For me, the scariest ones are the ones that start debunking the trust that we have with medical institutions that start spreading conspiracy theories, whether it's about the COVID-19 vaccines or COVID-19 testing. Right now, the problem of misinformation has been extremely highlighted because of the pandemic that we're in and the importance of fighting back against that misinformation.

For me, that was a goal even prior to the pandemic, but it was quickly accelerated with the need to put out accurate information. That's why, despite me being a younger doctor, the viewership on the videos educating on the misinformation that comes surrounding the vaccines are in the millions. These are millions of people that are skeptical. They don't know what to believe. They're looking for some guidance.

Recently, there was a frightening report that younger demographics are using TikTok as their main search tool. They no longer go on Google and type in "COVID-19 vaccine." They now do it on TikTok. That's very dangerous, because that's a place where I've seen misinformation thrive.

Glatter: Absolutely. If you're going to use TikTok as a search engine, that's really problematic. I think that's very important that you bring that up. This is an uphill battle. As social media evolves and they have the search capability, this is what we're dealing with.

Varshavski: We as doctors can look at a video of a social media wellness influencer talking about different types of water being more acidic than others, and that you need to drink "basic" water. We can see how ridiculous that is because we know that once the water goes into your stomach, there are gastric juices there that are so acidic that it doesn't matter if your water is a pH of 6, 7 or 8, but the average person doesn't know that. They feel like they have to spend what limited health budget they have on that water as opposed to joining a gym or buying the healthier vegetables as opposed to the processed foods in the supermarket.

It's really about guiding people with our experience but doing it in a relatable way. That's where I seem to have the most success.

Glatter: That's a very important point you just brought up: being relatable. People are sometimes flooded with statistics, data, and papers. In other videos, I believe you mentioned this - getting to the human level and connecting with patients. That's something that you are excellent at. Maybe you can expand on that.

Varshavski: As a family medicine provider, I learned early on that even if you have a patient that fundamentally disagrees with you on a given topic, highlighting that disagreement early on only serves to make the problem worse.

If I have a patient that's coming in that is vaccine hesitant, my goal isn't to flood them with misinformation and prove them wrong. It's instead to find points upon which we agree. Saying that the illnesses that we're looking to prevent with vaccines are dangerous - boom, we agreed. Talking about that their children's health is what I'm trying to optimize as best as I can - boom, we agreed on something else. It's very easy from our training (and we have very limited communications training) to just give the statistical data that we know to be true, but then the patient might not know to be true. Instead, it's finding lines of communication upon which we agree and work outward from there.

One of the biggest policy changes that I've seen happen across certain offices, both pediatric and family medicine, is stopping the practice of removing patients if they are vaccine hesitant. Before, this used to be a policy, and now what we've realized is by excluding them from our practice, we're essentially guaranteeing that they're not going to get good evidence-based care in the future.

Developing Patient Trust

Glatter: To just remove a patient because they don't agree with your views is not appropriate. I think having that open discussion is important for developing that trust and restoring that trust in mainstream medicine.

A problem I see is that many Generation Z-ers and millennials don't have family physicians or internists; they just go to urgent care centers. Without that grounding, they can't establish that relationship. That's a problem, especially with the plethora of urgent care. Maybe you can comment on this.

Varshavski: Urgent cares fill an absolute gap in care in our current healthcare debacle, if you will. Many younger folks rely on them as a quick fix for their chronic problems. Quick fixes for chronic problems are nonexistent. If it took 10 years to create a problem, it's not going to go away with a single urgent care visit. Sure, you could put a Band-Aid on the problem, but you're never going to get a solution.

That's my goal as a primary care doctor. What I try and highlight, even when I'm doing videos reacting to The Simpsons or watching the show Survivor, it's explaining in a transparent, relatable manner, using something that's very known to the audience like these shows, what my thought process is like. What I think about when a patient walks in through my door with a certain problem, the types of questions that I'll ask, the reasons for certain tests that I would run vs not run.

When patients start getting on the same page as to your mindset and your thought process, that's where you get good outcomes. It's interesting that we're speaking about this from a very medical-heavy focus vs a patient focus, because we also see that malpractice lawsuits drop when you are open and transparent with your patients, when you give your reasoning as to why right now you don't think they warrant that CT scan for their abdominal pain when they're worried about appendicitis. It's only upon them seeing your mindset and the reasoning as to why you're choosing not to order it or choosing to order it that they will they feel like they are in control of their health and they're on the same team as you, as opposed to in a very antagonistic relationship.

Glatter: Right. It's not talking above them, but talking to them as a human being and how you want to be spoken to. Let's face it, there's a large amount of medical jargon. It's scary, and it's hard to use plain English to just talk to patients. We all try to focus on that. People in the media, like yourself, have a knack and a great ability to just talk plainly and to talk normally and not use medicalese and all this jargon, which scares patients quite a bit.

Varshavski: I think I'm lucky in the sense that being a younger doctor, I haven't spent decades speaking only to other doctors and other specialists. I still am accustomed to using the common language for many of these conditions in ways that I've learned in my training.

Because of that, I feel like I have a clearer way to describe certain illnesses to patients. I remember even for myself as a med student, being in a room with one of the top cardiologists in our hospital system, they're explaining to a patient their diagnosis and the potential treatments, and everything is spot on. Science, it's all there. But then when they walk out, the patient looks at me and they say, "What did they say? I have no idea."

I kind of had to translate there, and I realized that there is a gap in this knowledge. That's not to say we need to throw away the basic sciences and medical school education. It's to say that we definitely need to find a way to incorporate better lines of communication.

Simplify Messages, but Don't Infantilize Your Audience

Glatter: I think communicating with patients, and doing media as you do, gives you the ability to connect with people and to bring things down to their level. We're by no means saying that patients are not smart or able to grasp concepts, but we just want to make them very simple, very down to earth, and things that they can relate to.

Varshavski: I also would almost push against trying to simplify or oversimplify or being paternalistic in that nature to our patients. What ends up happening in mass media communication is that if you start infantilizing your audience, they will pick up on that and they will see through it because we as humans have a naturally good BS detector.

Early on in the pandemic, the Centers for Disease Control and Prevention (CDC) and the US Food and Drug Administration (FDA) were making recommendations that were correct at the time with the evidence that we had, but they were doing it with some level of foresight into predicting what the viewers would do with that information. When you do that and you infantilize and you present the information as if you know all, that's where you start running into trouble, as we've seen.

Glatter: Science changes; it evolves. That's one of the basic tenets we learn in our medical training. The public wants the definitive answer, but often we don't have the definitive answer, and it's very frustrating. I'm sure you can relate to that.

Varshavski: That's probably the most frustrating part of debunking misinformation, because for me to prove that something doesn't work is much harder, if not impossible, than for them to just say that it works. You know, I could say, "But just by sitting here, you'll get so much stronger." For me to prove that wrong, I would have to run randomized controlled studies to prove that, whereas they can say whatever they want.

It's about explaining why I think that is not correct and take some liberties because in science, again, we can't say that this is definitely untrue, but we can say based off our scientific opinion, based on the lack of research, we're saying it's untrue.

More Medical Practices Jumping on the Social Media Bandwagon

Glatter: Many medical practices now are online, either Instagram or TikTok, and they're flooding our feeds. They, in some ways, are trying to grab Generation Z-ers or millennials who don't want traditional medical care in the office setting.

How do you feel that these medical establishments or these practices are doing right now? What's your assessment of their online presence?

Varshavski: Their online presence of encouraging people to seek out care, especially from a primary care provider, is amazing and I want that to happen more often.

Where I run into trouble is with these medical websites and practices where you essentially self-diagnose with a condition and make a request for a medication. When you start, as a patient, asking for a medication before knowing what your true diagnosis is, what the risks are for the medicine, what other potential diagnoses could be on the differential, that's where you run into trouble.

I've seen these websites pop up for a $20 visit where it's not even really a visit, and suddenly they're prescribing you finasteride for hair loss and they're prescribing you sildenafil for you to have erections. The problem with that is when those patients come into my office, I might be able to write the same prescription and I might want to write the same prescription, but at the same time, I would be doing some education or perhaps ruling out other conditions, like diabetes, and making sure that they're not having a neurologic or proinflammatory state.

There's a large amount of medicine that is missed virtually, but there's definitely utilization for certain visits. I love, with my patients who are diabetic, to have a visit to check on how their sugars are doing, if we're just going to make a small medication adjustment. As a follow-up, this could be a great tool.

It's not a great tool when a patient wants to make a virtual visit for abdominal pain. I cannot do a proper assessment with a virtual visit, and that's where we need to really be thorough and almost skeptical of the commercialization of online medicine, because it's very easy to get good reimbursement now but not very good to do a quality physical exam.

Glatter: I agree. I think access is certainly there, but making sure people have long-term follow up, as you allude to, is important. Grabbing them and giving them access is one thing, but really the finer points like you're discussing and that you just mentioned regarding medical conditions are very important.

Varshavski: I'm hoping that by watching some of my silly TikTok reaction videos or medical memes, I'm using some of the principles that a lot of the snake oil salesmen have used to pollute the medical media space and instead use it for good. All these miracle cure-all potion marketers are amazing at grabbing attention, keeping attention, and encouraging follow-through. If I can learn what they do well and use the same tactics on my YouTube channel for evidence-based medicine, I think that's a win for everybody.

I will say in the future, some of the social media platforms are going to be working with major organizations like the World Health Organization (WHO) and the National Academy of Medicine, to find better ways to verify these talking heads that are spouting medical information, whether it's right or wrong, on social media, and validate whether or not they are who they say they are.

At the end of the day, anyone can put on a white coat and say medical-sounding words. The question is, is this a real person? Do they have a license? Were they educated properly? Currently, on social media, that's very difficult to tell, but I'm hoping in the future months that problem can be at least somewhat ameliorated.

Glatter: It's almost like having an accreditation. You've been given that stamp of approval, so to speak. I think you're kind of alluding to that, that you've passed certain conditions or you have certain basic tenets and principles you adhere to, and they are trusted sites. Similar to what Twitter has done, they verify physicians, and I think in a general context, have that stamp of approval.

Varshavski: Otherwise, I feel for my patients because if they're looking up, whether it's on TikTok or Google or YouTube medical information, I actually want to encourage that. I love that they're interested about their health. I want to keep pushing that passion forward.

There are older doctors that I work with that say, "Stop going on social media, stop doing it. Don't do a Google search before you come in."

No, do it. Get your questions down on paper before you come in so that you're more prepared for the visit. Who doesn't want a more engaged patient like that? I think that only is going to yield better and better outcomes.

Restoring Public Trust

Glatter: I agree with you. Let them have the questions and pose them to you, and then you can inform them. This brings up the issue of restoring trust in mainstream medicine and by doing this, by being receptive to people who do go on social media for information (which we all do), to just validate and verify it.

Varshavski: Much of that stems from a very simple act, that I actually partnered with the WHO on, that's called Pause Before You Share. As you're aware, we have this rational mind that takes a little bit longer to kick in and takes a little bit more metabolic effort to properly think through. Then we have our emotional reasoning centers where we're quick to judge, quick to get angry, and quick to share something that outrages us.

By taking a moment before you share, you could actually stop the spread of misinformation or at least slow the spread of misinformation, because ultimately it's these factors that these algorithms use to decide what to make explode, what to share to its viewers. If we can decrease those signals on our own with certain efforts, like just taking a pause, I think that's a win for everybody.

Glatter: One thing recently I read was that people's trust in the CDC, for example, has plummeted. We all know this, obviously, with communication failures. I think reestablishing this through valid means on social media with trusted organizations like you're alluding to and physicians that represent these organizations might be a step in the right direction.

Varshavski: I think it needs to start with transparency. Transparency solves so many problems. Whether we're talking about lowering pharmaceutical costs or improving the trust that individuals have with the CDC, it needs to start with transparency and honesty and the decreasing of politicization of these topics.

That's not to say politics aren't a part of health. In fact, politics are a crucial component of public health. It's important to not villainize certain parties because, again, by villainizing someone who disagrees with you, you're essentially doing what we were talking about at the beginning of this conversation, where you have a patient that comes in with an opposing viewpoint and instead of finding points to agree upon, you're starting the conversation with the patient disliking you very much. That's essentially what happened over the past few years.

I say that from a perspective of someone that worked with the Trump administration putting out information about COVID-19, and the Biden administration. Both of them allowed me to interview Dr Fauci on my channels, and we had very open discussions. This is the point of transparency that we need to hit hardest.

Dr Fauci did not ask for my questions in advance. He did not ask to see the videos before they were published. This is a person that he doesn't know well and I'm going to ask hard questions, and that's the kind of leadership we need to continually see from these major organizations.

Glatter: I completely agree. I saw your interviews with Dr Fauci, and they were excellent. I also saw your interview with Dr Murthy, our surgeon general, and I thought that was right on point. I think getting more of these officials on social media channels to reach the public at large would be a step in the right direction because they need to hear them.

Final Advice on Social Media

Varshavski: I'm hoping that your viewers get excited about this as a potential tool to reach millions of people. I'm one person, but I see 40 patients a week in my limited part-time practice. On social media, my viewership ranges from 60 to 100 million views a month, and that's evidence-based, accurate information. I will never as a physician be able to educate that many people in my practice.

Glatter: That number - we're talking about well over one third of the US population. That's incredible, Dr Mike. I really appreciate you sharing that.

Varshavski: Thank you so much. It's not to say everyone needs to be on social media, because it's certainly not easy. Many people think it's something you could just do in your spare time. It's just like running any other business. It takes commitment, time, energy, and understanding of what works and what doesn't.

If you have a passion for it, there are ways to find out more. There are organizations that are looking to teach medical professionals how to be better at this, and I encourage everyone to seek out that information if they are passionate about it.

Glatter: Well, this has been great. I really appreciate your joining us to educate our viewers and give our audience your point of view and how you've been so successful in the world of social media. Thank you, again, for joining us. We truly appreciate it.

Varshavski: Thank you so much, Dr Glatter. Have a great one.

Robert D. Glatter, MD, is assistant professor of emergency medicine at Lenox Hill Hospital in New York City and at Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York. He is an editorial advisor and hosts the Hot Topics in EM series on Medscape. He is also a medical contributor for Forbes.

Mikhail Varshavski, DO, is a family medicine physician at the Overlook Medical Center in Summit, New Jersey. Also known as Doctor Mike, he is a well-known social media medical influencer who has over 10 million followers engaging with his every move on Instagram and his YouTube videos.

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Influencer 'Doctor Mike' Shares His Social Media Tips

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This transcript has been edited for clarity. Robert Glatter, MD: Welcome. I'm Dr Robert Glatter, medical advisor for Medscape Emergency Medicine. Today, we have Dr Mikhail Varshavski, otherwise known as " Doctor Mike," who is a family medicine physician and well-known social media medical influencer.

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Harrison’s PodClass: Internal Medicine Cases and Board Prep

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Listen to Harrison’s PodClass: Internal Medicine Cases and Board Prep on Spotify.

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Fast Five Quiz: Multiple Sclerosis Diagnosis and Workup

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Multiple sclerosis (MS) is an autoimmune chronic inflammatory disease encompassing inflammatory demyelination with axonal transection. According to the Multiple Sclerosis International Federation, as of 2020, there were 2.8 million people living with MS worldwide.

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The Hippocratic Oath is a long-standing tradition. But as the practice of medicine has evolved over the two millennia since the oath was created, the ancient text feels less and less applicable to today's medical students.

Instead of swearing by Apollo, medical school administrators, including those at Columbia, Yale, Washington University, and Mount Sinai's Icahn School of Medicine, are putting a contemporary spin on oaths, updating the language, and adding relevant context, often with input from the student body.

Although this approach sometimes encounters backlash, such as concerns about free speech, school leaders say it's worthwhile to turn oath-taking into a more meaningful and personalized experience.

And without a national oath standard - neither the American Medical Association nor the American Association of Medical Colleges has an official oath requirement or position on adapting the Hippocratic Oath - many medical schools have already adopted a more modern pledge.

"The earliest version we have of the Hippocratic Oath dates to about 150 or 200 years after Hippocrates died, and no schools use that one," says Steven Scheinman, MD, former dean at Geisinger Commonwealth School of Medicine in Pennsylvania and author of a 2018 study that analyzed oath content.

Now, schools typically use one of three primary oaths:

An "oath that bears the name of Hippocrates," which is a newer interpretation of the traditional Oath of Hippocrates;

"A Modern Oath," written in 1964 and often attributed to Dr Louis Lasagna; and

The Declaration of Geneva, first published in 1948 by the World Medical Association and updated in 2017.

When Scheinman conducted a textual analysis of 111 school oaths, he found that fewer than half used one of the three oaths during their commencement ceremonies.

Rather, the majority (about 53%) wrote a unique oath yearly or used one exclusive to the school, whereas just 9% of MD-granting schools recited customized commencement oaths in 1982 and about 25% in 2000.

Scheinman says white coat ceremonies have followed a comparable trend. In the same study, he found that most schools (70%) incorporated student-authored or school-specific white coat oaths, and just 11% used a variant of the Hippocratic Oath.

A Mix of Old and New

At the University of Pittsburgh Medical School, students recite a version of the Hippocratic Oath at white coat and graduation ceremonies, agreeing to "exercise my art solely for the cure of my patients" and "[hold] myself far aloof from wrong, corruption, and the tempting of others to vice."

But, beginning with the class of 2024, students are taking the lead in penning a unique class oath.

In the weeks before orientation, incoming first-year students meet virtually to discuss the key elements their oath should contain, develop a word cloud, and select writers to compose the draft. They also review a patient case study highlighting physicians' roles in global health.

Eventually, after several iterations, the oath is printed on reminder cards for the students to carry in their badge caddies and recite at the pinning ceremony before students embark on their clerkships.

Creating the class oath drives home the extent of physicians' evolving responsibilities, says Chenits Pettigrew Jr, EdD, associate dean for diversity, equity, and inclusion at the university.

"We're not replacing the Hippocratic Oath. We do this because we have a commitment to help students intentionally begin to acquire their professional identity, so they're not just discovering doctoring by their observations and coursework; they're given the opportunity to reflect on the commitment they're making," he says.

Specifically, the oath calls on students to honor their physical, mental, and emotional health, advocate for a more equitable healthcare system, and champion diversity in medicine and society.

Tito Onyekweli, a third-year Pitt med student involved in the writing process, says the traditional Hippocratic Oath is timeless, but modern oaths also have a place.

"We had to develop something that represented our entire class [so] we had intimate conversations with our peers to understand how their lived experiences have shaped them and will guide their practice," he says. "Our new oath represents our values and what is most relevant to our generation of medical students."

Similarly, incoming students at the University of Minnesota Medical School (UoM) collaborate with peers and faculty to write oaths for commencement and white coat ceremonies.

These oaths "build upon the intent of the Hippocratic Oath to promote humility, integrity, and beneficence" and "reflect core elements, values, and ethics the class aspires to uphold," Kat Dodge, media relations manager for the university, said in a statement to Medscape Medical News.

At last year's white coat ceremony, UoM students pledged to "care for patients with cultural competency and respect" and "strive for excellence through innovation in evidence-based medicine, respecting its utility, and acknowledging its limitations."

Meanwhile, students at Georgetown University School of Medicine in Washington, DC recite an adaptation of the Hippocratic Oath at the white coat ceremony and graduation, vowing to "abstain from everything which may be harmful or dangerous to [patients]" and promising "to esteem and revere the teachers who have trained me in the science and art of medicine."

However, in a new custom that reflects the changing times, several students subsequently take turns reading a line of the oath in their native language.

"For the class of 2026, we had a total of 24 students spanning 13 distinct languages volunteer to recite a line," says Tom Guarino, MA, CHES, assistant dean for medical student support and well-being at Georgetown. He says that this practice embodies the school's core value of "cura personalis," or care of the whole person, and demonstrates a commitment to diversity and inclusion.

Badr Abdullah, a Georgetown med student who emigrated from Oman 3 years ago, says that although it's a small step, the updated ceremony was impactful. "Knowing that I proclaimed my commitment to service to all, including those who fall outside the English-speaking community, and that they can listen and connect to it directly, was incredibly empowering," he says. "I hope that by encouraging linguistic diversity in our physicians, we can move toward providing more personalized and meaningful care to our patients."

What's an Oath Without an Education?

Despite there being less uniformity among customized oaths, many still share similarities. Respecting confidentiality, avoiding harm, and upholding the profession's integrity were included in over 80% of texts reviewed in Scheinman's study.

Lauris Kaldjian, MD, PhD, director of the bioethics and humanities program at the University of Iowa Carver College of Medicine (CCOM), found common themes in a 2018 analysis of oaths, with patient welfare, social justice, and nondiscrimination reflected in most texts.

While student-written oaths provide an opportunity for personalization, incorporating curricular content on oath-taking can deepen students' understanding of the commitment and the foundational principles that remain.

For example, CCOM offers an ethics curriculum that underscores the virtues, such as beneficence, nonmaleficence, justice, and autonomy, outlined in the school's distinct version of the Hippocratic Oath. They also offer an elective course that delves into the history of oath-taking.

When Scheinman first came to Geisinger in 2012, the school needed an oath for its inaugural class, so he assigned the responsibility to the senior students. During match week, the students studied existing oaths and their historical context.

Based on their findings, a delegation of students wrote an oath that included a commitment to "abandon my prejudices to walk with [my patients] on their journey through life and its pivotal transitions," says Scheinman. The oath was later adopted as the school's customary commencement oath, and Scheinman continued to lead an annual seminar on oath-taking throughout his tenure.

Unfortunately, Scheinman said, his study found that less than half of all schools polled integrate oath-related content into their curriculum, usually as a professionalism or bioethics course or through oath-writing sessions and lectures.

"In half of the schools, the only time the students think about an oath is when they stand up at commencement and take an oath that somebody else is telling them to take. They do it for the first time, and then they may never revisit that oath," he says.

Regardless of the pledge adopted, Kaldjian says that "medical education [should establish] a meaningful correspondence between what is professed and what is practiced."

Steph Weber is a Midwest-based freelance journalist specializing in healthcare and law.

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Med Students, Schools Put Modern Spin on Age-Old Hippocratic Oath

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The Hippocratic Oath is a long-standing tradition. But as the practice of medicine has evolved over the two millennia since the oath was created, the ancient text feels less and less applicable to today's medical students.

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This transcript has been edited for clarity.

Hi. I'm Art Caplan. I'm at the Division of Medical Ethics at the New York University Grossman School of Medicine.

Probably the most controversial ethics issue of the past year is abortion. As we all know, the Supreme Court overthrew the constitutional basis for a right to abortion, Roe v Wade, and basically said it's up to states to decide whether and how they want to restrict abortion.

Some bills are entering Congress by those who say we should have a national ban on abortion. Some states are moving to put the right to abortion into their constitution or see it voted on, as happened in Kansas and will happen in Michigan, to affirm the right to abortion.

Organizations like the Veterans Administration are saying that, at their hospitals, whether they're in states that don't allow abortion or not, they're going to permit veterans and their families (I assume) to get abortions, even if the state that the facility is in is restricted. Some places, like New York and California, are also saying that you don't have to live there if you need an abortion - that they'll try to make it possible for you to get there.

These are obviously issues and questions built on very strong feelings about the morality of abortion that divide and start heated discussions.

What I want to mention today is the ways in which the restriction of abortion influences medical practice for everyone, and has fallout that we need to be paying attention to because it has some challenges, I think, for medical professionalism that are going to come home to roost sooner or later.

I've talked to oncologists here at NYU and they point out that, for many pregnant women who are suffering from cancer, they want to quickly begin treatment for their cancer, even if it means imperiling the fetus and causing an abortion. In the states, they wonder where there are restrictions on that. Do they think that doctors are going to wait?

I've actually heard one or two reports already from oncologists in restricted states saying that until the woman gets sicker to the point where we could say her life is in danger, we're not going to start oncologic treatment on pregnant women. That puts, obviously, the life of the mom in much more jeopardy. You might lose both mom and fetus that way. I think it is a restriction with an implication on oncologic practice that, I would argue, isn't ethical.

Similarly, you have situations where many drugs might cause birth defects and have teratogenic effects on the fetus. Accutane, the commonly used acne treatment, and other treatments for skin diseases and other diseases often carry warning labels along the lines of "You need to understand that you shouldn't get pregnant if you're using this, or you're going to have to have an abortion if you use this, because the risk of having a child with a birth defect is significant."

The question is whether that will influence the willingness of doctors: "Well, I can't prescribe this for you. Abortion isn't available. Here is an option. So we're not going to be able to use this drug or this dermatologic treatment because we certainly don't want to risk a situation where you, unfortunately, have a child with a serious birth defect, but there's nothing you can do about it."

Is that going to influence how medical practice goes? How do we handle restrictions - where people create either restrictions on abortion or fetal personhood laws that say an embryo is a person from the moment of conception? How's that going to impact people who want infertility treatment?

Overall, the key issue, clearly, is whether women have the right to decide whether they want to have an abortion or end a pregnancy, and does the state have any ability to tell them that they can't make that choice, that they must carry a pregnancy to term, even in cases of rape, incest, and risk to their own health?

Roe v Wade, when it went away, reverberated out. It has implications for all manner of medical practice, whether it's in oncology, infertility, or dermatology, and I think we'd best be aware of that.

Medicine, at some point, is going to have to step up to the plate more publicly and say, "I understand that there are many who oppose abortion, but to practice medicine, we need more leeway when some of our medical practices create a situation where abortion may be the only reasonable option for someone who's getting a treatment for some other problem, illness, or disease."

I'm Art Caplan at the Division of Medical Ethics at the New York University Grossman School of Medicine. Thank you for watching.

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Post-Roe v Wade: Its Impact on Many Medical Specialties

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This transcript has been edited for clarity. Hi. I'm Art Caplan. I'm at the Division of Medical Ethics at the New York University Grossman School of Medicine. Probably the most controversial ethics issue of the past year is abortion.

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A recent study analyzing the content of TikTok videos from popular nutrition, food, and weight-related hashtags, each with 1 billion views, revealed glorification of weight loss as well as a lack of experts providing nutrition information.

Most of the content creators were revealed to be female adolescents and young adults in high school and college who lacked credentials, such as registered dietitian, doctor, or certified trainer. The distinct themes of the videos promoted the idea that intense weight loss programs are achievable and that being unable to lose weight is attributable to lack of willpower and motivation.

Having graduated from college 30 years ago, there's a lot that's new here, including the internet and TikTok and the rapid transfer of information, both inaccurate and accurate.

However, there's a lot that is disappointingly not new. We have not moved on from the idea that weight loss will provide us the self-worth and happiness that we need and crave.

Many years ago, I struggled with an eating disorder, which did one thing: It diverted my attention away from the joy of learning new things and fed my lack of self-worth until I was able to conquer it on my own. It allowed me to waste quite a bit of time focusing on the size of my thighs instead of using my mind to learn science, art, music, and languages and making strong friendships. Underlying eating disorders is certainly a battle with depression and anxiety that comes from a culture that rewards an ideal view of beauty and thinness, although this is slowly starting to change.

The fact that most of the young adults creating content about weight loss on TikTok are female continues to identify women as falling prey to ideals regarding beauty and size. The feminist movement has a long way to go.

On Repeat: Thin Is In

What will change this recurring theme of the ideal body image being thin like Twiggy, the lean supermodel from the 1960s? We may have morphed Twiggy into a similar silhouette, only more muscular - but equally unattainable.

How can we help young people develop critical thinking skills and their own personal body image ideals that reflect health at their genetic size? Here are some thoughts:

Infuse TikTok with credentialed expertise - we need dietitians and exercise specialists who can teach in a style that captures the TikTok audience while promoting evidence-based nutrition and physical activity advice.

Continue to advance the message that obesity is a disease and that environmental changes are also responsible for obesity until it becomes public knowledge. The inability to lose weight in this environment and keep it off is not a moral or motivational failing. The difference between weight loss to improve health and weight loss to achieve thinness must be distinguished here.

Develop a better marker of excess body fat than the body mass index or weight. A marker of poor health due to excess body fat could be a blood marker or fat biopsy showing inflammation, for example. Once this is established in the medical world, weight related comorbidities can be separated from cosmetic weight concerns. A separate distinction can then be made regarding medical weight loss for health reasons and cosmetic weight loss. Health at any size is a good start, but without a clear distinction between medically unhealthy and healthy weights, the field cannot move forward a clear message to the public.

The big difference between today and 30 years ago is the higher prevalence of obesity affecting our children and adolescents as well as young and older adults. The clear message from the research world is that the environment is quickly changing to promote this higher prevalence, as our genes haven't changed in this short amount of time.

Studies intimate that when faced with highly processed foods, we eat more calories than when presented with unprocessed foods. The obvious antidote to this is to adopt healthy eating patterns that avoid highly processed foods. However, a new eating disorder has emerged called orthorexia nervosa, which can be defined as a fixation on attaining optimum health by only eating unprocessed foods at all costs. Playing with your body's need to maintain a certain body weight can wreak havoc with appetite and satiety and promote overeating and shame.

Orthorexia nervosa is the modern-day (2020s) version of an eating disorder that is also affecting males in addition to females. At its worst, it can affect relationships and also lead to malnutrition, much like anorexia nervosa and bulimia nervosa. Orthorexia nervosa can be considered to be an epigenetic phenomenon because of the modern-day attention to highly processed foods and focus on healthy unprocessed foods. This has affected those with a genetic predisposition to obsessive-compulsive disorders and other depressive disorders. It affects men in greater numbers than its associated disorders anorexia nervosa and bulimia nervosa because the focus is not on food quantity, but on food quality. The focus is less on weight "perfection" and more on food "perfection."

How else can we help young adults navigate this maze of nutritional adversity? The key to food and nutrition and healthy relationships with food and health may be more focus on psychology. Depression and anxiety can lead to many dysfunctional relationships to food, exercise, drugs and alcohol. From an obesity medicine and nutrition specialist point of view, there aren't enough psychologists, psychiatrists, and social workers in the medical field who specialize in eating disorders and weight-related illnesses.

I found my own way out of an eating disorder via athletics. I grew up prior to Title IX but developed a sense of empowerment and strength via running, swimming, and biking. It also helped me burn all those calories I ate out of desperation from depression.

The science of exercise physiology is expanding because of new research exploring the cross-talk between muscles and white and brown adipose tissue. Perhaps the way out of unhealthy eating behaviors and ultraprocessed foods is additional education regarding the body weight set point along with how muscle talks to fat and vice versa. The body weight set point is determined by the brain after receiving signals from fat adipose tissue, muscle, and other organs. Understanding this will give more credence to food as medicine and exercise as medicine. It may be that we need to point the finger at highly processed foods as detrimental to our body weight set points. With highly processed foods eliminated, there will be less highly palatable foods that are nutrient poor and calorie dense to offset our natural healthy body weight set points.

Imagine there are no highly processed foods? I wonder if we can. Maybe I'm a dreamer, but there is a healthier world out there now, with so much less tobacco smoking than there was in the 1960s and before.

The cardiovascular and lung damage caused by tobacco smoking was revealed to the public via educational messaging and elimination of advertisements to smoke, especially to young people.

TikTok can promote messaging from credentialed experts educating our young people regarding healthy eating and exercise based on evidence from the literature. The processed food study referenced above showed that eating a highly processed food diet naturally caused people to eat 500 kcal more per day before experiencing fullness than an unprocessed diet did. Let's promote this information on TikTok - as long as it doesn't start a rash of orthorexia. That old adage about moderation comes to mind.

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social media and psychological wellbeing

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TikTok Time Bomb: Perpetuating Weight Loss and Diets

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A recent study analyzing the content of TikTok videos from popular nutrition, food, and weight-related hashtags, each with 1 billion views, revealed glorification of weight loss as well as a lack of experts providing nutrition information.

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This transcript has been edited for clarity.

Hi. I'm Art Caplan at the Division of Medical Ethics at New York University School of Medicine. Today, I'm talking to you from my summer home in Ridgefield, Connecticut, where it's finally, after many months of winter, turned into outdoor weather.

I'm going to talk to you today about a really interesting, quiet development in medical memorabilia. We're all familiar with the idea that people create markets in all sorts of memorabilia. Some of you may, as kids, have collected baseball cards and thought, 'Oh, if I'd only kept that collection, I'd be very wealthy today. I could have sold it to a collector." You obviously have big markets in coins, artwork, and many areas where people collect things.

Recently, Tommy John - some of you who are a little bit older may remember him as a pitcher for the Los Angeles Dodgers back in the 1970s - donated a cast from a very famous operation to the Smithsonian Museum. The operation has become known as Tommy John surgery. It basically involves transplanting a tendon to replace something damaged in the pitcher's elbow through wear and tear. You put in a new one transplanted from the other arm, or you might even use a donor tendon if one wasn't available. That reconstruction allowed Tommy John to pitch for many more years and pitch very well.

By the way, he first thought of donating his cast from this operation to the Baseball Hall of Fame, but he realized he wasn't in the Baseball Hall of Fame. Then, he and his surgeon, Frank Jobe, who pioneered this procedure as one of the world's most famous sports orthopedic surgeons, thought maybe the Smithsonian might have an interest. They did.

Out of the attic came his cast - he saved it because his Dodgers teammates had signed it after he'd had the operation - and off it went to the Smithsonian. That's good for Tommy John, and it's good for Frank Jobe, the surgeon. They sort of made history by having this really pathbreaking surgery, which many pitchers and other athletes have used since, memorialized in the Smithsonian.

I'm going to predict something else. For many more medical items - everything from scalpels to masks to images to things like tissues, say, from the first pig heart surgery - I think we're going to see a medical memorabilia market explode. We've already seen this with college athletes using their image and likeness to endorse products or to say, this is the basketball that I used at the University of Connecticut when we won our women's championship, or this is a piece of the floor from the NCAA finals, or whatever it might be. There are many markets in sports stuff, not just physical objects, but even images.

Similarly, there are many people investing not in works of art but in memes, meaning images that are put up as unique opportunities to invest on the Internet and you kind of own the original image. I think we're going to see the same thing happen in medicine. I think people are going to say, you know what, if you donate money to our medical center or our medical school, we'll give you the first whatever it is from the first pioneering surgery that was done here, or we have available images of a very exciting 100th anniversary operation done for the first time in our practice. There are many opportunities locally, nationally, and internationally that I think are going to go out there.

They will raise some ethics questions about whether that is exploiting patients. Are you taking advantage of their being involved in medical care to make money on the resale of images, tissues, casts, or other pieces of medical equipment as we saw in the Tommy John situation? Let me be clear, though, by reminding you that Tommy John donated his cast.

What I'm forecasting is in a market. It's basically saying that things that weren't seen as very valuable or were never explored as having value, just as we see in athletics, college and pro, we're going to see enter into medicine. Be careful before you throw away that mask or before you destroy something as medical waste. It may have value. It may be something you could sell. It may be something your school, your practice, or your institution suddenly wants to convert into something valuable.

I'm Art Caplan at the Division of Medical Ethics at NYU School of Medicine. Thanks for watching.

Arthur L. Caplan, PhD, is director of the Division of Medical Ethics at New York University Langone Medical Center and School of Medicine. He is the author or editor of 35 books and 750 peer-reviewed articles as well as a frequent commentator in the media on bioethical issues.

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Items From Famous Surgeries or Injuries as Memorabilia

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This transcript has been edited for clarity. Hi. I'm Art Caplan at the Division of Medical Ethics at New York University School of Medicine. Today, I'm talking to you from my summer home in Ridgefield, Connecticut, where it's finally, after many months of winter, turned into outdoor weather.

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Headlines over the past few weeks are ringing the alarm about earlier and more serious influenza (flu) and respiratory syncytial virus (RSV) outbreaks compared to previous years. Add COVID-19 to the mix and you have a dangerous mash of viruses that have many experts calling for caution and searching for explanations.

RSV and the flu "are certainly getting more attention, and they're getting more attention for two reasons," said William Schaffner, MD, professor of preventive medicine and infectious diseases at Vanderbilt University School of Medicine in Nashville.

"The first is that they're both extraordinarily early. The second is that they're both out there spreading very, very rapidly," he told Medscape Medical News.

RSV usually follows a seasonal pattern with cases peaking in January and February. Both viruses tend to hit different regions of the country at different times, and that's not the case in 2022.

"This is particularly striking for RSV, which usually doesn't affect the entire country simultaneously," Schaffner said.

"Yes, RSV is causing many more hospitalizations and earlier than any previously recorded season in the US," according to figures from the Centers for Disease Control and Prevention (CDC) on RSV hospitalizations, said Kevin Messacar, MD, PhD, an associate professor at the University of Colorado School of Medicine and a pediatric infectious disease specialist at Children's Hospital Colorado in Aurora.

Although there could be some increase in diagnoses because of increased awareness, the jump in RSV and flu cases "is a real phenomenon for multiple reasons," said Peter Chin-Hong, MD, professor in the University of California, San Francisco, Health Division of Infectious Diseases.

With fewer COVID-related restrictions, people are moving around more. Also, during fall and winter, people tend to gather indoors. Colder temperatures and lower humidity contribute as well, Chin-Hong said, because "the droplets are just simply lighter.

"I think those are all factors," he told Medscape Medical News.

Paul Auwaerter, MD, MBA, agreed that there are likely multiple causes for the unusual timing and severity of RSV and flu this year.

"Change in behaviors is a leading cause," said the clinical director for the Division of Infectious Diseases at the Johns Hopkins University School of Medicine in Baltimore. More people returning to the workplace and children going to school without masks are examples, he added.

Less exposure to these three viruses also means there was less immune boosting among existing populations, he said. This can lead to "larger susceptible populations, especially infants and younger children, due to the relative absence of circulating virus in past years."

A Leading Theory

Are we paying a price now for people following the edicts from officials to mask up, stand apart, and take other personal and public health precautions during the COVID-19 pandemic?

It's possible, but that may not be the whole story.

"When it comes to RSV, I think that theory of isolation, social distancing, mask wearing, and not attending schools is a very valid one," Schaffner said. "That's everybody's favorite [reason]."

He said he is confident that the jump in RSV cases is being driven by previous COVID public health protections. However, he's "a little more cautious about influenza, in part because influenza is so variable.

"Like people in influenza say, if you've seen one influenza season, you've seen one influenza season," Schaffner said.

"There's a lot of debate," he added. "Nobody can say definitively whether the immune deficit or debt is a consequence of not being stimulated and restimulated by the influenza virus over the past two seasons."

"A Perfect Storm"

"Now you kind of have the perfect storm," Chin-Hong said. "It's not a good situation for COVID with the variants that are emerging. For influenza, not having seen a lot of influenza the last 2 years, we're probably more susceptible to getting infected."

RSV cases rose during summer 2021, but now the weather is colder, and people are interacting more closely. "And it's very, very transmissible," he said.

Chin-Hong also predicted that "even though we don't have a lot of COVID now, COVID will probably pick up."

The rise in RSV was unexpected by some experts. "This early influenza is also a bit of a surprise and may be influenced by the fact that lots of us are going back and seeing each other again close-to-close, face-to-face in many enclosed environments," Schaffner said.

He estimated the 2022-2023 flu season started 4 to 6 weeks early "and it's taken off like a rocket. It started in the Southeast, quickly went to the Southwest and up the East Coast. Now it's moving dramatically through the Midwest and will continue. I'm quite sure to hit the West Coast if it isn't there already."

A Phenomenon by Any Other Name

Some are calling the situation an "immunity debt," while others dub it an "immunity pause" or an "immunity deficit." Many physicians and immunologists have taken to social media to push back on the term "immunity debt," saying it's a mischaracterization that is being used to vilify COVID precautions, such as masking, social distancing, and other protective measures taken during the pandemic.

"I prefer the term 'immunity gap'...which is more established in the epidemiology literature, especially given the politicization of the term 'immunity debt' by folks recently," Messacar said.

"To me, the immunity gap is a scientific observation, not a political argument," he added.

In a July 2022 publication in The Lancet, Messacar and his colleagues stated that "decreased exposure to endemic viruses created an immunity gap - a group of susceptible individuals who avoided infection and therefore lack pathogen-specific immunity to protect against future infection. Decreases in childhood vaccinations with pandemic disruptions to health-care delivery contribute to this immunity gap for vaccine-preventable diseases, such as influenza, measles, and polio."

The researchers noted that because of isolation during the pandemic, older children and newborns are being exposed to RSV for the first time. Returning to birthday parties, playing with friends, and going to school without masks means "children are being exposed to RSV, and that's likely the reason that RSV is moving early and very, very substantially through this now expanded pool of susceptible children," Schaffner said.

How Likely Are Coinfections?

With peaks in RSV, flu, and COVID-19 cases each predicted in the coming months, how likely is it that someone could get sick with more than one infection at the same time?

Early in the pandemic, coinfection with COVID and the flu was reported in people at some centers on the West Coast, Auwaerter said. Now, however, "the unpredictable nature of the Omicron subvariants and the potential for further change, along with the never-before-seen significant lessening of influenza over 2 years, leave little for predictability.

"I do think it is less likely, given the extent of immunity now to SARS-CoV-2 in the population," Auwaerter said.

"I most worry about viral coinfections...in people with suppressed immune systems if we have high community rates of the SARS-CoV-2 and influenza circulating this fall and winter," he added.

Studies during the pandemic suggest that coinfection with the SARS-CoV-2 virus and another respiratory virus were either rare or nonexistent.

Schaffner said these findings align with his experience at Vanderbilt University, which is part of a CDC-sponsored network that tracks laboratory-confirmed RSV, flu, and COVID cases among people in the hospital. "Coinfections are, at least to date, very unusual."

There needs to be an asterisk next to that, Schaffner added. "Looking back over the last 2 years, we've had very little influenza, and we've had curtailed RSV seasons. So there hasn't been a whole lot of opportunity for dual infections to occur.

"So this year may be more revelatory as we go forward," he said.

Future Concerns

The future is uncertain, Messacar and colleagues wrote in The Lancet: "Crucially, the patterns of these returning viral outbreaks have been heterogeneous across locations, populations, and pathogens, making predictions and preparations challenging."

Chin-Hong used a horse race analogy to illustrate the situation now and going forward. RSV is the front-running horse, and influenza is running behind but trying to catch up. "And then COVID is the dark horse. It's trailing the race right now ― but all these variants are giving the horse extra supplements.

"And the COVID horse is probably going to be very competitive with the front-runner," he said.

"We're just at the beginning of the race right now," Chin-Hong said, "so that's why we're worried that these three [viruses] will be even more pronounced come later in the year."

Follow Damian McNamara on Twitter: @MedReporter. For more Medscape Neurology news, join us on Facebook and Twitter.

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pediatric respiratory syncytial virus infection

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Experts Explain the 'Perfect Storm' of Rampant RSV and Flu

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Headlines over the past few weeks are ringing the alarm about earlier and more serious influenza (flu) and respiratory syncytial virus (RSV) outbreaks compared to previous years. Add COVID-19 to the mix and you have a dangerous mash of viruses that have many experts calling for caution and searching for explanations.

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by John Burton, M.D.
History

A 90-year-old woman has been a patient of the Beacham Ambulatory Care Center since 2000. Chronic conditions are pernicious anemia, osteoarthritis, and urinary incontinency. She is fully functional and fully independent. She provides care for the homebound husband who has severe COPD. They live in a row home specifically "close to the hospital" to ensure access to house calls for her husband.

In September 2000, the husband dies as a result of respiratory arrest. Her only relative is a nephew who talks with her about once a month. In October 2002, her home is broken into and our patient is raped and robbed. She was taken to a local hospital specializing in rape. Here, she is distressed, delusional, and is reported to be very emotionally distraught.

Presentation and Examination

We see the patient about 3 weeks after the rape in a community nursing home, where she was moved after a 4 day stay at the hospital. She was very distressed, delusional and confused. She slowly improved over 2 months and was discharged to a senior living building in a community in eastern Baltimore County.

In March of 2003, the patient is seen in the office. She is still very ill emotionally. She is crying, depressed (not suicidal), and stressed about her new home. She wants to move to a new Senior Housing unit because it would be on the bus route making it easier to get around. She has also hired a middle aged woman as a caregiver.

In November 2003, 9 months after moving to a new facility, she becomes acutely ill with psychotic symptoms and severe paranoia. She hallucinates that men and women are in her bed and calls others all hours of the day. She is hospitalized on a psychiatric unit and improves over about 14 days without antipsychotic medication.

One week following discharge from the hospital, symptoms rapidly recurred when she returned to the senior apartment. She was disruptive and threatened with eviction unless something was done rapidly. An emergency petition was prepared as she refused medical care. With the help of her companion, we were finally able to persuade her to take a neuroleptic drug (Haloperidol 0.025 - 1.0 mg/day) for her recurrent incapacitating hallucinations. Our office nurse and staff called her daily to guide her through the process of taking her medicines. She slowly but steadily improved and became stabilized.

Diagnosis

Post Traumatic Stress Disorder

Case Discussion

Basic Facts on Elder Rape

65% of rapes are associated with burglary

73% occur in the victims home

300,000 Elder Abuse reports in 1 year in the U.S.; 9,000 were sexual assault

Study: 28 rapes/year in Massachusetts
-Victims were ages 65-101
-50% were committed by a relative

The graph below indicates the increase in elder abuse reports since 1986.

Reference: Tatara, Toshio and Lisa Kuzmeskus. Summaries of Statistical Data on Elder Abuse in Domestic Settings for FY 95 and FY96. (Washington, DC: National Center on Elder Abuse, 1997)

Post-Traumatic Stress Disorder

Definition

PTSD is a serious disorder that results from exposure to a traumatic event. The concept was formulated during the Vietnam War. An event is considered traumatic if it is extreme, death threatening or causes serious injury, and the response involves severe fear, helplessness and horror. Clearly our patient experienced a major traumatic event.
Examples of Traumatic Events in the Elderly

Elder Abuse

Severe Accident

Natural Disaster

Terrorist Attack

Rape

Serious Illness or Surgery

Criminal Assault

War Event

Prevalence

PTSD occurs relatively commonly in elderly patients (13% - Psychother Psychosom 2003) compared to 10% in the general population. Prevalence is higher in Holocaust survivors, in patients with cancer, and in patients following heart surgery.

Key Symptoms

There are 3 cardinal symptom categories; 1) re-experiencing the event, 2) avoidance and numbing, and 3) increased arousal. *
1. Re-experiencing the event (1 must be present)

Distressing recollections

Nightmares

Physiological reactions to triggers

Psychological reactions to triggers

2. Avoidance/Numbing (3 must be present)

Avoid conversations, activities, places or people

Selective amnesia

Withdrawal, detachment, loss of interest or hopelessness

3. Increased Arousal (2 must be present)

Decreased sleep

Irritability/anger

Loss of ability to concentrate

Hypervigilance

Startle

Classification of PTSD is based on the duration of symptoms. *

Additionally, other psychological symptoms are often present including major depression (50% of cases), substance abuse or dependence, panic/agoraphobia.

Treatment

PTSD is a treatable condition and therefore it is important to recognize. Without treatment, PTSD is disabling in 50% of cases. Slightly less than 50% of patients are untreated. Informing the patient about the illness and its course through educational counseling help patients and their families cope. Cognitive therapy (a specific form of interactive counseling) requires referral to a psychologist experienced in this form of counseling.

SSRIs (antidepressants) may be necessary. The graph below is from a study by Brady, etal (JAMA 2000, 283:1837) comparing the change in Q-LES-Q* scores in patients taking an SSRI, Sertraline (n=93) versus patients taking a placebo (n=90).

*Q-LES-Q (Quality of Life Enjoyment and Satisfaction Questionnaire) measures mood, social relationships, leisure time activities, ability to function in daily life, living/housing, ability to get around, and work/hobby.

Prevention

In a study by Foa E et al (J Consult Clin Psychol. 1999; 67:194-200), investigators show the benefit of cognitive counseling by a psychologist on the severity of depression measured using the Beck Depression Inventory (BDI). These results are summarized in the graph below.

Take Home Points

PTSD is common in the elderly

PTSD can be very disabling

Recognition is key

Treatment of PTSD is effective

Additional Resources

NIH Website: http://www.nimh.nih.gov

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post traumatic stress disorder chronic condition elder rape abuse severe fear acute accident stress disaster assault withdrawal

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by John Burton, M.D. A 90-year-old woman has been a patient of the Beacham Ambulatory Care Center since 2000. Chronic conditions are pernicious anemia, osteoarthritis, and urinary incontinency. She is fully functional and fully independent. She provides care for the homebound husband who has severe COPD.

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ICU Case series - icucase 3 ( misplaced line - where??) & icucase 4 (neuro + metabolic)

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Episode 93: A 33-Year-Old with Fever, Headache, and Neck Pain

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Listen to this episode from Harrison's PodClass: Internal Medicine Cases and Board Prep on Spotify. Harrison's PodClass provides engaging, high-yield discussions of key topics commonly found on rotational and board exams in internal and family medicine.

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7 Medicines That Come from Super Toxic Critters

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In Conversation: What is behind vaccine hesitancy?

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Day in life of DOCTOR in EMERGENCY DEPARTMENT (night shift vlog)

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Many people procrastinate, some of us chronically, but why do we do that? Is there a way to counteract procrastination, and does this habit ever bring benefits? In this Special Feature, we explore the science of procrastination: What happens in the brain, what happens in the mind, and can we change it?

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What happens in the brain when we procrastinate? Medical News Today asked the experts. Image credit: Mik122/Getty Images.

Everyone procrastinates at some point in their lives. Whether it relates to paying a bill, making a doctor's appointment, completing a school project, or meeting a work deadline, it is sometimes easier to put off important tasks we may not fully enjoy and would rather accomplish some other time.

While for most people the act of procrastination may only happen every so often, for others it becomes a constant occurrence. An estimated 20% of adults in the United States are chronic procrastinators, even though research shows that high levels of procrastination in the workplace can have negative effects on employment duration and income.

And studies suggest that 75% of college students are habitual procrastinators, leading to issues including stress, anxiety, and sleeping problems.

Why do more people procrastinate than others? Is procrastination a mental health condition? And does procrastinating offer any positives or is it just a negative habit we need to kick?

Medical News Today spoke to a variety of experts to answer these questions and more about the delay tactic we are all familiar with.

According to Sharon Greene, LCSW, who specializes in treating anxiety and depression for children, adolescents, and adults at Providence Saint John's Child & Family Development Center in Santa Monica, CA, procrastination results from a struggle between a person's limbic system and prefrontal cortex of the brain.
"Your limbic system is an older part of the brain that is automatic and seeks out pleasure and/ or avoids things that cause distress," she explained to Medical News Today. "Your prefrontal cortex is a newer part of the brain that helps with planning, decision-making, and long-term goals. We all suffer at times from procrastination due to these fighting structures in our brains."
Dr. Bill Hudenko, a licensed psychologist, researcher, and professor who holds a joint appointment as a faculty member at Dartmouth's Department of Psychological and Brain Sciences and Dartmouth's Geisel School of Medicine, and global head of mental health at digital care platform, K Health, cited a study showing that people who often procrastinate have a larger - the part of the brain responsible for emotions, particularly negative ones.
"The authors also found that procrastinators have a less functional connection with the dorsal anterior cingulate cortex - a part of the brain that assimilates information and is implicated in decision-making," he continued. "While intriguing, this study highlights that procrastination is not so cut-and-dry and does not occur in just one region of the brain."
A by researchers from the Paris Brain Institute published in September 2022 found evidence suggesting the anterior cingulate cortex is where the decision to procrastinate is made. They also developed an algorithm to predict a person's tendency to procrastinate or not.

And Dr. Alex Wills, a board-certified psychiatrist and author of Give a F*ck, Actually, said other issues a person may be facing can impact how procrastination affects the brain.
"In the case of anxiety disorders, a person may become paralyzed with much activity in the amygdala - fear, despair, perfectionism, or 'paralysis by analysis'," he detailed. "With depression, processing information may become too slow when patients feel helpless or indecisive."
"[And] in the case of ADHD, there may be a neurological lack of cognitive focus due to a lack of dopamine sent to the prefrontal cortex in which the person may subjectively simply become innocently unaware of a looming deadline - until it's too late," Dr. Wills added.

Dr. Hudenko said procrastination itself is not a mental health condition. However, it can be problematic behavior if it becomes routine and causes distress.
"If someone is procrastinating due to an anxiety disorder, that anxiety can lead to other negative outcomes," he explained. "Treating the underlying anxiety that affects procrastination could help someone who is avoiding necessary tasks and may also improve other aspects of their life."
And Dr. Wills stated procrastination is often thought of as a symptom commonly found in various disorders:

"Under the anxiety spectrum, it is often found in OCPD [obsessive-compulsive personality disorder], OCD, hoarding, or PTSD [post-traumatic stress disorder] due to fears related to past trauma. In ADHD, which I consider more of a neurological or 'wiring' condition, procrastination may be a result of an inability to prioritize, stay on task, or stay focused."

"Procrastination may also be an indicator of addictive tendencies - the high of 'saving the day' from calamity by finishing an important task just before the deadline," Dr. Wills continued. "Whether someone does it all the time or not may be an indicator of one of these underlying mental health conditions."

Generally speaking, most people consider procrastination a negative habit. However, are there any positives to it?

Dr. Hudenko said there are many cases when procrastination can be beneficial, even when the person does not intend for it to be.

"Everyone can relate to procrastinating on a task because it is low impact or low value, which shows good judgment about time management and task prioritization," he explained.

"Procrastination can also help people prioritize engaging in aspects of their life that bring joy. Perhaps it's ultimately better for your mental health if you go play that game of tennis instead of getting that project done on your list. Furthermore, you might come back to that project with more energy and new insights because you stepped away to do something else!"

- Dr. Bill Hudenko

"Lastly, some people work better under pressure and perform best when they have a strict deadline, even if they didn't intend to wait until the last minute," Dr. Hudenko added.

And Dr. Wills said viewing procrastination as a "negative" or a "symptom" of other mental health diagnoses may be shortsighted.
"In my book, Give a F*ck, Actually, I celebrate the so-called 'negative' emotions and ask how these emotions may be trying to help," he said. "We can ask, 'What is procrastination teaching me about my emotional reality?'"
For those who wish to stop procrastinating, Greene suggested "rolling the tape" when thet notice themselves starting to.
"Basically visually imagining in your mind what it will feel like doing the task last minute including the stress, exhaustion, and the possibility of not completing it in time or handing in a subpar product," she explained. "For some people, this negative visualization can be enough to help them start the task."
Also, Green said giving oneself a reward after completing each step can be helpful.

"Some people also benefit from enlisting others to hold them accountable to complete each small step," she added.

Setting deadlines can be a helpful tool against procrastination when set correctly. A study from November 2021 conducted by Dr. Stephen Knowles, professor in the Department of Economics at the University of Otago in New Zealand and his team found people were more likely to complete a task with a 1-week deadline or no deadline compared to being given a 1-month deadline.

"Previous research shows that for tasks that benefit you - e.g. redeeming a voucher for a restaurant - that the longer the deadline, the lower the response rate - meaning no deadline leads to the lowest response," Dr. Knowles told MNT.

"Our research focused on a task that benefited others - e.g. completing a survey or making a charitable donation. We suspect that in our context giving people a deadline of a month gave them permission to take their time, whereas having no deadline made it seem more urgent," he added.
Based on his findings, Dr. Knowles suggested people who tend to procrastinate should set shorter deadlines rather than longer ones.
"If you are setting a deadline for someone else, you should either keep it short or not mention a deadline at all," he said.

And Dr. Hudenko said if the root of the procrastination is because an activity may take too much time, try the "chunking" method:

"Try to split things up into manageable chunks and do them over time. For example, instead of cleaning your whole house, which can feel overwhelming, just commit to cleaning the sink today and the floors tomorrow. Oftentimes when you get started on a subtask, it also makes it much easier to complete the whole thing because you prove to yourself that the task you put off isn't really as bad as you made it out to be in your head."

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Procrastination: Why do we do it, and are there any benefits?

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Many people procrastinate, some of us chronically, but why do we do that? Is there a way to counteract procrastination, and does this habit ever bring benefits? In this Special Feature, we explore the science of procrastination: What happens in the brain, what happens in the mind, and can we change it?

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Nowadays people don’t trust doctors anymore and tend to find alternative in their treatments
As a doctor I have seen a lot things that aren’t good in the medical system but sometimes there’s nothing we can do about it
In my opinion the best thing you can do ist’ trying to be the best doctor you can be.
And being the best doctor means caring about your patients, have multidisciplinary treatment,   Trying to prevent further complications and finding the better and cheapest solution and also if you have the chance to work for free maybe once a week in a free clinic.

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A medical student reached out to me recently and he had a great question which I want to answer in this podcast. To make a difference in healthcare you have many options and can have many motivations for wanting to do so. It could money, a challenge, or improved patient care. They are all valid and…

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I'm lucky that I was able to pay for my flat in cash here in Santiago de Compostela, Spain. Therefore I have no mortgage payments and don't have to pay for extra property insurance and life insurance which are mandatory in Spain when you take on a mortgage.

Spain can be a cheap country to live in. But, of course, you can also live lavishly in other cities, such as Madrid, Barcelona, and Valencia. Rent, transportation, and entertainment can really kill your budget in those cities.

In this post I wanted to talk about my household spending in Spain and compare it to living in Portland, Oregon.

Household Spending in Spain

In the US, most Americans will have the following items in their household spending categories:

1. housing (rent, mortgage, HOA, property taxes)

2. transportation (car payments, insurance, repair, gas)

3. food (groceries, eating out)

4. healthcare (insurance, office visits, medications)

5. entertainment (TV, socializing, gym membership, travel)

6. utilities (home utilities, cell phone)

In the Spain it's a little different. I'll only write about what I've observed in my city, Santiago de Compostela. Barcelona, Seville, and Madrid can be a little more like US cities since there is more wealth there.

In Spain I have the following spending categories:

1. Housing (€32/mo)

I bought this flat in cash, €90,000. I don't have any mortgage or major property taxes.

My HOA dues (community fees) are about €25/mo. Annual property taxes are €86/year. This includes property insurance.

2. Transportation (€0)

I don't need a car since SDC is small and is well connected with a bus and train system. My transportation costs are therefore $0.

I ended up buying an electric Brompton which was an unnecessary expense. I spent €3,000 on it, which about half of my annual household spending in Spain.

3. Food (€230/mo)

Groceries are cheap in SDC. There is a daily farmer's market which is cheaper than the grocery stores. I can eat well for €200/mo in groceries.

Dining out is inexpensive, as well. My friends and I dined at a fancy restaurant for €41 which included drinks, 3 main dishes, and lots of Galician bread. Not bad for 3 people.

My friends here spend far less than me on groceries. For a single dude it's easy to get by on €90/month.

4. Healthcare (€55/mo)

I pay €55/mo which is mandatory since I'm not a permanent resident of Spain. With my non-lucrative visa I'm considered a temporary resident.

I get access to both private and public care, from what I understand. I haven't had to use it yet but will report back on that when I do.

5. Entertainment (€70/mo)

People here are rather social. But they get together at a bar for a drink and that usually comes with a healthy portion of tapas. So the cost of socializing isn't high.

I have a gym membership which is €45/mo. That's the extent of my entertainment, which is probably a bit more boring than the average person's.

6. Utilities (€116/mo)

My prepaid cell plan is €10/mo. I also pay €31/mo for my home Wifi.

Water and electricity come out to around €75/mo. Electricity is €0.15/kWh here - on par with Portland, Oregon.

Total Monthly Household Spending (€503)

My monthly household spending in Spain comes out to around €500/month. This isn't me being frugal - I still have the gym membership, the dining out, organic produce, and private health insurance

But it also doesn't include random costs such as dental care, home repair, replacing a cell phone, clothes, travel, etc.

My household spending in Spain has a very low burn-rate which is ideal for someone who is pursuing a new career or needs a break from the spending/earning hamster wheel. More importantly, there is room to save in case I hit a dry spell.

Passive Income

500 euros converts to $575/month. I could earn this money by investing $230,000 in the market. My conservative index fund investing strategy should easily net me 3% annually.

If not from investments, I could earn this from renting out my Portland condo which is currently sitting empty. The going rate for my pad would be around $1,200/month and it's paid off.

Household Spending in Portland

The lowest I could get my household spending in the US was around $1,000/month - realistically, $1,500.

Now, I didn't make the move for the cost alone. It was also a decision for a better quality of life, to learn a new language, and to learn to practice medicine in a different system.

Housing would be my biggest expense in the US, even with the paid off condo. That's because of property taxes and HOA dues. Here, my biggest expense is groceries.

According to Numbeo, cost of living in Portland is about 2x as high as in SDC.

Working in Spain

I am earning my income as a digital nomad physician these days. I haven't yet tapped into my investment income.

If I choose to practice medicine here in Spain, I should be able to earn around €3,000/month. It's not a lot but neither is my household spending here in Spain.

I'm maybe among the few my age who own a paid-off house in Spain. This allows me to spend less than my peers. Which means that I would have a competitive advantage if I wanted to do something like open a cafe or a residential contracting business.

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I'm lucky that I was able to pay for my flat in cash here in Santiago de Compostela, Spain. Therefore I have no mortgage payments and don't have to pay for extra property insurance and life insurance which are mandatory in Spain when you take on a mortgage.

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"Secret" Codes Doctors Use To Talk About You // DOCTOR REACTS

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I had to go digging deep for this post because most of the information shared on forums was inaccurate. The rest is written by recruitment agencies which intentionally make the process seem complicated. So here it is, the guide for US doctors practicing medicine in Spain.

I am not sure how many US doctors practice abroad but I suspect we never hear from these individuals. They take a trip to Europe and they decide to stay. Somehow they figure out how to become a doctor there and that's that.

Becoming a Doctor in Spain

Now, you're not trying to become a doctor, you already are one. But it was interesting to read what it takes to become a doctor in Spain.

You go straight from high school and take a placement exam where you have to earn quite a high score in order to get into a medical school. It's considered to be the hardest profession to get into and the most sought-after.

Med school is a 6-year process with the first 3 years being basic sciences, along with the didactic portion of pathophysiology, microbiology, and my favorite, pharmamotherfuckingcology - which I failed in medical school.

The next 3 years are rotations and that's when you try to figure out what kind of specialist you want to be. And just like in the US you can start claiming that you're a doctor right after med school, in hopes of getting laid.

Next, you must take the MIR exam in order to place into a particular specialty. In Spain, as of this writing in 2018, geriatrics and EM and anesthesiology are the fields which have the biggest physician shortages.

Practicing Medicine in Spain

The Spanish healthcare system is considered fairly strong with most patients quite happy with it. That has been my impression so far when talking to people.

Spanish physicians, referred to as médicos, recognize that other countries don't necessarily have a better healthcare system but that doesn't stop them from leaving for other countries.

The nice thing about the EU is that once you have done your medical school and residency in one country, you can take those credentials to another country in the EU and it will be recognized. I'll get into the income side of things a little later.

These doctors get their medical licenses and can practice for the public or private system. I don't have a medical license in Spain, yet. But this article is to help me figure out how to go about it - that's how I learn most things, researching it and writing about it.

Spanish Doctors Practicing Abroad

The headline of a recent newspaper referred to the 3,500 Spanish physicians who have applied for work in other countries.

830 left to practice in the UK.

540 to France.

215 to Ireland.

200 to Germany.

125 to Portugal.

90 to the USA.

75 to the Emirates.

60 to Canada.

These numbers have increased over the past few years, mostly because the income for Spanish doctors is quite low. But some have also expressed frustration with how slow-moving the medical system is.

This is referred to as the mañana phenomenon.

Public and Private Healthcare

The majority of healthcare is public in Spain. The rest is made up of large private medical groups. Practicing medicine in Spain as a US doctor means we'll be competing in the private space, not the public. Though both are valid options.

You don't have to pay for public healthcare in Spain. But you have to pay a little every month in order to get access to private clinics and hospitals. This can range anywhere from 20-50 euros.

To give you an idea, I have a Cadillac plan for 55 € a month. For this price I have a zero copay, a zero deductible, access to public hospitals, and access to private clinics. I also have optical care but would have to pay 10 € extra a month for dental coverage.

I didn't get the dental because, from what I understand, you still have to pay 50% of the cost of the service.

Geriatrics

Geriatric care has become a big burden on the Spanish doctors. Elderly care, whether in the ER or in psychiatry, is becoming more and more time-consuming and requiring more specialized care.

I couldn't confirm this but apparently the prescription rate in Spain is high. As in, many of the elderly Spanish citizens are on multiple medications.

There is also the sentiment among physicians that these elderly individuals end up coming to the public clinics for mundane matters out of boredom.

Practicing medicine in Spain means you have to learn the culture there. And there will always be some negative sentiment towards some group. But there are also amazing healthcare being delivered in Spain.

Physician Income in Spain

As a public doctor in Spain, you can earn a gross income of 60,000 € a year. This number will vary up and down, depending on the specialty. And remember that unlike the US taxes are sky high here.

My primary care doctor friends take home around 2,200 per month and my ophthalmology, psychiatry, and hematology friends around 2,500 € a month.

I've read reports of public jobs not being reliable. You might be employed some months and be furloughed the next. That's why many workers in the private sector on the side.

One orthopedic trauma surgeon I spoke to at a bar said that he made 90,000 € a year as the head of the department, and his hours were long but nothing as bad as what his US colleagues endured.

Some physicians will work in the public sector in the morning and finish their day by working the private clinics. It's not hard to pull in north of 120,000 € for these workhorses.

A US physician practicing abroad likely isn't going to want to work 15-hour days. But it's worth discussing how medicine is practiced in these European countries.

The Clinical Workload in Spain

The need for a doctor, specifically the urgent need for a doctor, is much lower in Spain. While in the US it's common to find primary care doctors and specialists who work on weekends, here it would be uncommon.

Most of my physician colleagues in Spain have 8:00 am - 3:00 pm schedules and they are quite happy with the hours and the work.

Volumes can be high. Some doctors practicing medicine in Spain report seeing the kind of volumes we are used to seeing in the US.

The most important thing here is that the paperwork, documentation, lawsuits, and investigations are minimal. The majority of the time is spent with the patient.

And - interestingly - there is very little emphasis on customer service. This is probably aided by the fact that the Spanish culture is a very warm and friendly one, generally speaking. So I'm sure the doctors aren't giving their patients the middle finger, but science is valued higher than bedside manner.

It's the difference between going to a Jiffy Lube to have your oil plug stripped off with a smile or going to an excellent mechanic who may never make eye contact with you.

Lawsuits have gradually risen as Spain has increasingly tried to privatize healthcare. But it's still incredibly rare to hear about a lawsuit unless a doctor tried to intentionally harm a patient.

US Doctors Practicing Medicine in Spain

US doctors who attended accredited medical schools in the US and completed a residency program can practice medicine in Spain without taking any particular exam.

I just finished retaking my family medicine board exam (as of November 2020), so I'm excited not to have to take yet another test.

From my research and talking to sources here, you do not have to take the MIR or any other such test to be allowed to work as a doctor in Spain.

There is a difference between the public and private sectors - this is important to grok. If you want to work in the public sector, then you have to take a placement test to determine where in the country you'll end up for a job. If you want to work in a private clinic or open your own, you just have to have your credentials accepted by Spain, as we'll get into below.

You do not need to redo a residency, you do not have to take the MIR, or any other exam in order to start practicing. Some specialists can start practicing primary care in Spain while they wait for their credentials to be approved. This can take a year or even longer.

You may have to be supervised the first year you work. I haven't been able to get enough information on this. But it's not like you must be attached to another doctor at the hip. It's more of a mentorship.

Language Barrier

The authorities here make a big deal of language competency, but from my understanding, it's fairly easy to get to a competent speaking level within 4 months. This level is enough to pass the language exam. Of course, I'm talking about studying 6-8 hours a day - not just doodling on Duolingo. The levels are in the C1-C2 range.

The diploma you receive for your language level is what you'd submit to Madrid for your medical degree to be convalidated or for homologation.

Jobs for US Physicians Practicing in Spain

Many physicians from Latin America move over to Spain for a better income. So, there are fairly obvious paths that many of these doctors have taken; most of us just have to follow in their footsteps.

From what I have gathered here is that the Spanish people prefer to have Spanish doctors. Some believe that the quality of care they receive from Latin American doctors isn't as good.

It's becoming more normal to see older people here with obesity, diabetes, and of course, a laundry list of medications. Beta-blockers, ACE-I's, statins, metformin, and insulin are gaining traction.

As a US doctor practicing in Spain, you'll be competing with all other doctors from all other countries.

Process of Getting Licensed in Spain

The summary is below in Spanish, as I've found on other reliable websites. If someone could translate it for the rest of us, please do so in the comment section below.

1. La Solicitud cuyo formulario debe de ir debidamente cumplimentado.

2. Acreditación del pago de la tasa, Modelo 790.

3. Copia compulsada del documento que acredite la identidad y nacionalidad del solicitante.

4. Copia compulsada del título cuya homologación se solicita o de la certificación acreditativa de su expedición.

5. Copia compulsada de la certificación académica de los estudios realizados para la obtención del título, en la que consten, entre otros extremos, la duración oficial en años académicos del plan de estudios seguido, las asignaturas cursadas y la carga horaria total de cada una de ellas expresada en horas o en créditos ECTS (europeos).

6. Acreditación de la competencia lingüística necesaria para el ejercicio en España de la correspondiente profesión regulada. Esta acreditación no la necesitaría tu hijo, porque el título obtenido lo ha realizado en una universidad de lengua hispana.

The first department you'll have to wrestle with is the Ministry for Education, located in Madrid. The main website is at Ministerio De Educación Y Formación Profesional. The website changes a lot so just search for it online.

From there, you will need to find the education section. Then navigate to the University section (Universitarios) and Foreign Titles ( Títulos Extranjeros).

When I first wrote this article, everything was done over snail mail. You can supposedly submit your stuff electronically, but you may need to be present in Spain because it requires a digital certificate. You can get this from the social security office if you have an NIE number.

Next, you will need to navigate over to the homologation - homologación. If this link is broken, then just search above until you find the page.

You can also submit your application to a Spanish consulate in the US. But it's recommended that you submit it to Madrid either in person, mail it within Spain, or do it digitally.

They will need to verify all your diplomas and licenses from the USA. It can take up to 12 months for this to take place. So buckle down, and get ready.

The process is quite streamlined, but there is also a huge backlog of physicians who are waiting to get approved to work in Spain. Check out this headline below.

Homologación refers to the process of transferring all your credentials from your country to the Spanish Ministry of Education. Below I have the addresses worth having on hand.

Ministerio de Educación de España. Centro de Información y Atención al Ciudadano. Sección de Información Educativa
Calle Alcalá, 34
28014, MADRID
T: 917 018 000 (centralita), 902 21 85 00
F: (91) 701 86 48
Subdirección General de Títulos, Convalidaciones y Homologaciones, Servicio de Homologación de Títulos Extranjeros Universitarios
Calle Paseo del Prado, 28
28014 Madrid
T: (91) 420-16-94 , (91) 420-07-67

2. Register with The OMC

Next comes the OMC, about which you can read a little wiki. It's called the Organizacióon Médica Colegial De España. It's the medical college, depending on which province you're in.

This is the email I received from my local OMC below. I have attached the pdf here.

The Spanish Medical College Organization regulates the medical profession in each particular region. I'm living in Galicia, so I'd do it there.

The entire list can be found here. There are 52 regions.

The OMC will need to permit you to work in their region. They will also need to give you a particular number with which you can prescribe medication.

I believe they are also responsible for selling your practice insurance. I don't think they call it malpractice insurance - interestingly enough. It was all quite cheap.

3. Work for One Year Supervised

I referred to this above. You'll see your own patients. You'll be completely independent, but you'll be working under supervision. I'll write more on this as I get closer to it.

As of 2022, when I'm updating this post, I haven't yet gotten my medical license in Spain. In fact, I missed a great window during the pandemic when the Spanish government fast-tracked anyone who was in the pipeline.

Work Permit, Visa

Very few US physicians are trying to leave their $300k US jobs for 30k euro jobs in Spain. That's why all this information was a pain in the ass to come by.

So, the Ministry approved your medical school and residency paperwork. Then you got the local college to approve you to work after demonstrating a language competency. Next, you need a work visa to work in Spain.

Unless your region is hurting for doctors, the private healthcare system may not extend a job to you, so you'll have to resort to being an

Interestingly, the private sector often has many more jobs and is much more willing to help you get the proper work permits and visas figured out.

Private Practice in Spain

If you speak English, you'll be highly sought after in the beach cities of Spain, especially Malaga, Madrid, and Cadiz.

It's not easy finding patients for a new private practice since the advertising rules aren't what you are used to in the US. But if you can hold out long enough, you'll eventually get clients as a US doctor practicing in Spain.

Word of mouth is like Yelp here. All it takes is a few bad reviews, and people will avoid you like the plague. Probably more so in smaller cities.

My Personal Strategy

I want to get my medical license convalidated in Spain, even if I may never work in Spain. It's nice insurance to have, especially with how wonderfully things are going for me in the US.

Most medical schools in the US are recognized as valid medical schools by Spain, and my residency is in Family Medicine, so that shouldn't be a problem.

Fortunately, the jobs which are least desirable here are what I like the most. I can either work in the ER as an FP or ride in the back of an ambulance as an urgent care doctor.

After learning the language (apparently need a B2 level Spanish) and homologizing my credentials, I'll work in the public and private sectors for a year. It's not hard finding part-time gigs in the private sector.

Practicing medicine in Spain long-term would only be attractive if I open my own small private practice from 9:00 am until noon, Monday-Thursday, somewhere in Cadiz, Spain. I would add some telemedicine, which is barely happening at the major hospitals here.

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I had to go digging deep for this post because most of the information shared on forums was inaccurate. The rest is written by recruitment agencies which intentionally make the process seem complicated. So here it is, the guide for US doctors practicing medicine in Spain.

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Episode 136: Indpendent vs. Employed Physicians

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Listen to this episode from 2 Docs Talk on Spotify. Over the last several decades a shift from independent physicians to corporate-employed physicians has changed the healthcare landscape. It would make sense to consolidate and take advantage of economies of scaled to make healthcare for efficient.

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Secondary Hemostasis: Coagulation Cascade Animation [Made Easy]

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Written by Lori Zaino

Find out everything you need to know about hospitals in Spain with our guide, including treatments, costs, and more.

If you're moving to Spain, you'll be pleased to discover that the country has one of the top 20 healthcare systems in the world. The Spanish healthcare system, including hospitals in Spain, is effectively split into two parts: public and private.

The public system, Sistema Nacional de Salud (SNS), is operated on a regional level and allows all Spanish citizens to access free healthcare. The private system includes privately-owned services that are typically only accessible for patients with private health insurance. However, whichever system you use, it's important to understand how hospitals in Spain function. To help you out, our guide looks at the following:

COVID-19 in Spain

Overview of hospitals in Spain

Spain has both public and private hospitals.

In the public system, healthcare is overseen by the government of each individual autonomous community. According to the official health ministry, Spain's public medical and hospital system is rated highly. Indeed, 7 out of 10 Spanish citizens are pleased with the level of care received via the public health system. And with 467 public hospitals in Spain, visitors should be able to find a hospital if and when needed.

When it comes to public hospitals in Spain, there are different categories that provide different levels of care:

General hospitals in Spain provide essential services such as access to general practitioners, some specialized doctors, and nurses.

Mid-level hospitals have more specialists as well as access to diagnostic and more complicated treatments.

High-technology hospitals are able to treat more obscure and serious health issues. These hospitals have advanced equipment and specialized doctors.

There are also specific public hospitals and medical centers for children in Spain's larger cities such as Madrid and Barcelona.

Private hospitals in Spain are operated by private healthcare providers and are typically smaller than their public counterparts. They are also often more specialized in the range of services they provide. However, whichever type of hospital you visit, you will receive a high level of care.

It's important to remember that the vast majority of care is administered in Spanish. Depending on your region and the type of hospital, you may come across English-speaking medical professionals. However, it's always a good idea to have some basic vocabulary linked to your condition before you arrive at the hospital.

How to access hospital treatment in Spain

How you access hospital care in Spain will largely depend on your circumstances, and whether you are under the public or private systems. Generally speaking, hospitals in Spain are among the best in the world. However, there can be long waits to visit specialists and non-emergency operations within the public system. For example, in 2018, the wait time to see a digestive specialist in the public system was approximately 48 days. This is why many patients opt to pay for health insurance, gaining access to private hospitals in Spain.

As of 2021, almost 24% of the Spanish population pays for private medical insurance. Despite this, 60% of the hospitals in Spain are private. While this might sound a lot, it's important to note that in most cases, private hospitals are typically smaller and have more specified resources and fewer beds than public hospitals.

Accessing care in the public system

If you're a Spanish resident, you'll typically be assigned a healthcare center based on your registered address. This is where you can access public medical treatment through a family doctor, along with other health services and information. If you need a specialist, your family doctor will refer you to one at a public hospital or medical center. In the case of an emergency, you can visit any public hospital for treatment.

Accessing care in the private system

Within the private system, processes vary depending on your chosen insurance provider. Therefore, it's important to read up on your insurer to understand how the processes work. For example, if you need to see a specialist on your private insurance, you may be able to get an appointment directly, as opposed to going through a referral process. This will, however, depend on your individual coverage.

Health insurance providers in Spain

Private health insurance in Spain is fairly affordable compared to other countries. Expect to spend €16-€200 a month for private health insurance depending on the coverage plan. Private health insurance companies in Spain include:

For more information on everything, you need to know about getting coverage, read our guide to health insurance in Spain.

Emergency treatment in Spain

For medical emergencies in Spain, you should first call 112. Although an operator will answer in Spanish, there should be English speakers available to assist with an emergency. Alternatively, it may be possible to head straight to your nearest Spanish hospital in case of emergency and look for the Emergency Department (Urgencias) entrance.

Spanish law states that anyone with a life-threatening emergency can access treatment at a Spanish hospital, whether public or private. However, typically speaking, public hospitals have more resources and options for serious emergencies. Therefore, in case of emergency, you may prefer to head to your nearest public hospital. However, if you do hold private insurance, it may be best to go to a private hospital in case of an emergency.

For anything urgent, a helpful Spanish app to download is . This app allows users to call the emergency number, send photos of emergency situations, and more.

For all non-urgent medical queries and procedures, you should first contact your doctor or medical center.

Accessing emergency treatment as a tourist in Spain

Anyone, including tourists, can access emergency medical treatment at a public hospital in Spain if the injury or illness is deemed life-threatening or grave. EU/EEA residents visiting Spain on holiday have access to free healthcare at public medical centers if they show a valid European Health Insurance Card (EHIC). This is called the Tarjeta Sanitaria Europea in Spain.

If you're visiting from a non-EU/EEA country, it's best to get travel insurance before traveling to Spain for any smaller healthcare issues that could arise. Remember that the hospital will make a call on the severity of your situation and your eligibility for free treatment under the EHIC scheme.

For non-life-threatening situations, you should seek to make a doctor's appointment through your insurance provider or using your EHIC.

Hospital stays in Spain: what to expect

When it comes to both private and public hospitals in Spain, you can expect to receive standard care in both as many of the same doctors work at both hospitals. This means the care you receive will be largely similar. However, there can be some differences in the amenity levels in the hospitals themselves.

For example, private hospitals typically offer individual rooms for patients. However, in a public hospital in Spain, patients may have to share a room with one other occupant. This depends on the seriousness or contagiousness of the illness. Room sharing can also depend on the occupancy of the hospital at any given time.

Spanish hospital rooms typically include a hospital bed, any necessary medical supplies, and a bathroom. Usually, rooms come with a chair for a visitor. For patients sharing a room, there's a curtain or separator for privacy. Hospitals also have meal services for patients, with meals delivered to the bedside. Elite private hospitals may include extras, such as additional toiletries or other items.

Hospital costs in Spain

If you're contemplating treatment in one of the many hospitals in Spain, it's a good idea to understand what, if any, financial obligations you can expect. This differs between healthcare systems, as laid out below:

Costs at public hospitals in Spain

Treatment at public hospitals in Spain is free for Spanish citizens that show their national health card or EU/EEA visitors that show their EHIC. However, you may have to pay out of pocket for certain things like optional vaccines and certain medications. The public health system usually pays for at least part of any prescription medicine. You may need to pay the other part of that cost depending on your income.

Costs at private hospitals in Spain

When it comes to private hospitals in Spain and insurance, costs will largely depend on your insurance provider. The more affordable plans cover less, and patients may have to pay copays. A more expensive insurance plan likely covers more, and copays are lower or even non-existent. Depending on your situation, you may have to pay upfront and later request reimbursement from insurance at private hospitals in Spain.

Getting discharged from hospitals in Spain

In both private and public hospitals in Spain, the doctor decides when a patient can leave. Discharge can occur any day of the week in the morning or afternoon.

Typically, the doctor gives patients a paper stating their discharge before leaving. If a patient wants to leave earlier, they must sign that they agree to be held responsible for any secondary effects that might happen.

Hospitals in Spain give patients information about outpatient care upon discharge. Should you have any questions about this information, be sure to speak to a member of staff before you leave. Reception staff will usually help with scheduling follow-up appointments.

Visiting someone in the hospital in Spain

Many rules about visiting someone in the hospital in Spain have changed in recent years due to the ongoing Covid-19 pandemic. Pre-pandemic, visiting patients in the hospital was fairly simple and rules were often lax, ensuring you could spend quality time with your loved ones while they received treatment.

However, due to the pandemic, patients can typically only have one person accompany them to the hospital during an emergency. For longer-term stays, patients can sometimes receive visitors during specific hours. Be aware that these rules vary by hospital and, of course, are subject to change as the Covid-19 pandemic evolves.

Best hospitals in Spain

Spain's best hospitals are mainly in the country's largest and most populated cities such as Madrid and Barcelona. According to Newsweek, these are the top three hospitals in Spain:

List of hospitals in Spain

There are hospitals located throughout Spain, meaning you'll never be too far away from your nearest. Here is a list of some of the hospitals you can expect to find in some of the most popular cities in Spain.

Alicante hospitals

Barcelona hospitals

Madrid hospitals

Valencia hospitals

Here is the full list of hospitals in Spain.

Useful resources

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Written by Lori Zaino Find out everything you need to know about hospitals in Spain with our guide, including treatments, costs, and more. If you're moving to Spain, you'll be pleased to discover that the country has one of the top 20 healthcare systems in the world.

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Haematinics are the nutrients needed by the bone marrow to make blood cells in the process of haematopoiesis.

Here are the most clinically relevant haematinics deficiencies : vitamin B12 (cobalamin), vitamin B9 (folate), and iron.

Iron

Iron deficient patients can develop microcytic anaemia and may have a range of clinical features.

Most of these symptoms are related to anaemia, such as fatigue, shortness of breath, weakness and reduced exercise tolerance. Other symptoms can include pica (e.g. ice craving) and restless leg syndrome.

Typical clinical findings of iron-deficiency anaemia on examination may include:

General and conjunctival pallor

Atrophic glossitis

Angular cheilitis

Koilonychia (spoon-shaped nails) – less common

If is suspected, initial screening investigations should include:

Full blood count (FBC)

C-reactive protein (CRP)

Serum ferritin

Full blood count (FBC) and red cell parameters

These tests allow the identification and quantification of anaemia by measuring the haemoglobin (Hb) and haematocrit (Hct) mean corpuscular volume (MCV), mean corpuscular haemoglobin (MCH) and mean corpuscular haemoglobin concentration (MCHC). These may be low in iron deficiency, while red cell distribution width (RDW) may be elevated.

Serum ferritin

Ferritin is an intracellular protein that is responsible for most iron storage in the body.

There is a direct correlation between serum ferritin levels and overall iron stores in health. However, serum ferritin is an acute-phase protein, and so increases in inflammatory states, chronic kidney disease, liver disease, and malignancy.

Ferritin level of <15 μg/l is indicative of an iron deficiency in those aged >5 years.

Transferrin saturations

Transferrin is the primary serum iron transporter molecule in the body. In an iron-deficient state, the body produces more transferrin to increase the total iron-binding capacity and so acquire more iron for its cells.

Levels <16% are supportive of a diagnosis of iron deficiency.

Blood film

A blood film can be helpful if there is diagnostic uncertainty and can show morphological changes, which might support the conclusion that a patient is iron deficient.

Blood film features which make iron deficiency more likely include anisocytosis, microcytosis, hypochromia, pencil cells, target cells, and elliptocytes.

Advanced red cell parameters

They include mean reticulocyte haemoglobin concentration, percentage of red cells that are hypochromic, and reticulocyte haemoglobin equivalent.

Mean reticulocyte haemoglobin of <29 pg can be supportive of a diagnosis.

Other investigations of iron metabolism

These are not usually required to diagnose iron-deficiency anaemia but are available from most laboratories and can support the diagnosis.

Serum iron

Serum iron only measures a fraction of the iron in the blood.

Serum iron levels show diurnal variation and are sensitive to recent iron intake.

Total iron-binding capacity (TIBC)

The TIBC is calculated by taking a serum sample and adding excess iron to fully saturate the iron carrying molecules.

Transferrin

Transferrin is the main serum iron transporter molecule which can be measured in a patient’s serum.

Like TIBC, transferrin can rise in iron deficiency as the body tries to increase the total iron-binding capacity.

Soluble transferrin receptor (STFR)

In iron deficiency, these developing cells display an increased number of transferrin receptors as they try to acquire more iron, this increase can be measured in the serum.

Treatment of iron deficiency anaemia

Oral iron with vitamin C that improves the absorption of oral iron

Traditional dosing guidelines suggested aiming for 100-200mg of elemental iron a day however, more recent studies shown that dosing of around 45-80mg elemental iron is more effective and avoids gastrointestinal side effects.

A response in the haemoglobin count should be seen within a few weeks of starting therapy.

In certain scenarios, intravenous iron may be preferred. This includes patients with chronic kidney disease, inflammatory bowel disease, those intolerant of oral iron.

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Primary Hemostasis: Platelet Plug Formation [Step-by-Step Animation]

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Paediatric Clinical Examinations - The Abdomen

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Medical Departments in a Hospital - Video Lesson for Nursing Students

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I did my internship year in a private hospital, one that is very expensive
During this year In many ocasiones I saw some patients that where still  at the hospital  when in my opinion where ready to go home

ts that where still  at the hospital  when in my opinion where ready to go home
One day  when I was on call I asked one of the doctors about a particular patient that had a gastrointestinal surgery (don’t remember which) but that he was without pain, no fever, cero indications of infection, tolerating diet, he had already gone to  the bathroom, in general he was doing pretty good,.
The doctor told me that sometimes the doctor of this patient didn’t liked to go to the hospital on Sundays  so he wait until Monday to discharge his patients
I was really upset about this because he was just making the patient stayed at the hospital and spend more money without any reason
And I was sad to see how doctors  takes advantage of people when they are trusting them with their health

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Improve Article 👀

Introduction

Haematinics are the nutrients needed by the bone marrow to make blood cells in the process of haematopoiesis. Without adequate amounts of these nutrients, cytopenia(s) and related symptoms can develop. Excess amounts can also be pathological and can point to various underlying disease states.

This guide to haematinics interpretation will focus on deficiencies of the most clinically relevant haematinics: vitamin B12 (cobalamin), vitamin B9 (folate), and iron.

Other haematinics not covered in this guide include:

It is essential to consider the history and examination findings when interpreting haematinics. The relevance of results can change depending on the patient context and should be interpreted alongside a thorough clinical assessment.

You might also be interested in our medical flashcard collection which contains over 1000 flashcards that cover key medical topics.

Iron

Investigating a patient's iron status can become complicated as no single test accurately represents all stages of iron metabolism and some of the available tests can be affected by inflammation and renal disease.

Given how common iron deficiency anaemia is, it is important to understand the tests used to investigate iron deficiency and how to interpret results correctly.

When to investigate

Iron deficient patients can develop microcytic anaemia and may have a range of clinical features.

Most of these symptoms are related to anaemia, such as fatigue, shortness of breath, weakness and reduced exercise tolerance. Other symptoms can include pica (e.g. ice craving) and restless leg syndrome.

Typical clinical findings of iron-deficiency anaemia on examination may include:

General and conjunctival pallor

Atrophic glossitis

Angular cheilitis

Koilonychia (spoon-shaped nails) - less common

Initial screening investigations

If iron deficiency anaemia is suspected, initial screening investigations should include:

Full blood count (FBC)

C-reactive protein (CRP)

Serum ferritin

Full blood count (FBC) and red cell parameters

These tests allow the identification and quantification of anaemia by measuring the haemoglobin (Hb) and haematocrit (Hct) which is typically seen in iron deficiency. Although these measures do not provide any direct information about iron stores.

These findings are non-specific and may not be present in all iron-deficient patients.

For more information, see the Geeky Medics guide to full blood count interpretation.

Serum ferritin

Ferritin is an intracellular protein complex that binds iron and is responsible for most iron storage in the body.

Small amounts of ferritin are released into the serum to transport and absorb excess iron and therefore act as a surrogate serum marker for body iron storage.

There is a direct correlation between serum ferritin levels and overall iron stores in health. However, serum ferritin is an acute-phase protein, and so increases in inflammatory states, chronic kidney disease, liver disease, and malignancy.

The British Society for Haematology (BSH) guidelines suggest a serum ferritin level of <15 μg/l is indicative of an iron deficiency in those aged >5 years.

A level of <150 μg/l should act as a trigger to consider further investigations for potential iron deficiency if a patient has a concurrent inflammatory condition (acute or chronic) or renal impairment.

Therefore, CRP is suggested as part of the initial screening test, as serum ferritin within the normal range cannot exclude iron deficiency if a patient has raised inflammatory markers or a history of acute or chronic illness.

Secondary investigations

If the first screening tests are inconclusive, but the suspicion remains that a patient might be iron deficient, BSH suggest requesting secondary investigations which are listed below.

Transferrin saturations

Transferrin is the primary serum iron transporter molecule in the body. In an iron-deficient state, the body produces more transferrin to increase the total iron-binding capacity and so acquire more iron for its cells.

There is no strong evidence for a diagnostic threshold, but the BSH consensus guidelines suggest levels <16% as supportive of a diagnosis of iron deficiency if initial tests are inconclusive.

Blood film

A blood film can be helpful if there is diagnostic uncertainty and can show morphological changes, which might support the conclusion that a patient is iron deficient.

Blood film features which make iron deficiency more likely include anisocytosis, microcytosis, hypochromia, pencil cells, target cells, and elliptocytes.

Advanced red cell parameters

Given that they are relatively easy to perform, BSH suggest they can be used as part of secondary testing. Mean reticulocyte haemoglobin of <29 pg can be supportive of a diagnosis of iron deficiency and may be useful in predicting iron response in patients with chronic kidney disease.

Other investigations of iron metabolism

These are not usually required to diagnose iron-deficiency anaemia but are available from most laboratories and can support the diagnosis. Below is a list of the more common investigations.

Serum iron

Serum iron only measures a fraction of the iron in the blood. It can only measure the ferric form (Fe3+) and not the iron incorporated in haemoglobin molecules.

Serum iron levels show diurnal variation and are sensitive to recent iron intake therefore, measuring serum iron in isolation has no role in determining a patient's iron stores.

Total iron-binding capacity (TIBC)

The TIBC is calculated by taking a serum sample and adding excess iron to fully saturate the iron carrying molecules.

The TIBC is a measurement of the total iron concentration in the sample when fully saturated.

TIBC can rise in an iron-deficient state, but specificity is poor. Hence, BSH does not recommend routinely using this to assess iron stores.

Transferrin

Transferrin is the main serum iron transporter molecule which can be measured in a patient's serum.

Like TIBC, transferrin can rise in iron deficiency as the body tries to increase the total iron-binding capacity. However, transferrin is a negative acute-phase protein and so decreases in inflammatory states.

Soluble transferrin receptor (STFR)

Transferrin receptors are present on developing red cells and can be detected in their soluble form in peripheral blood.

In iron deficiency, these developing cells display an increased number of transferrin receptors as they try to acquire more iron, this increase can be measured in the serum.

Unlike ferritin, this is not affected by inflammation and so can be helpful in distinguishing anaemia of chronic disease from iron deficiency anaemia.

A rise in STFR is not specific to iron deficiency with other potential causes including haemolysis, thalassaemia, megaloblastic anaemia, and hypoxia. STFR can also be normal in mild deficiency, only becoming abnormal in more advanced stages.

Due to the lack of specificity and comparatively high cost, BSH does not recommend measuring STFR when investigating iron deficiency.

Summary table

Table 1. Interpreting iron studies.

Treatment of iron deficiency anaemia

For most patients, oral iron is a safe, effective and cheap method of treating iron deficiency. Co-administration of vitamin C improves the absorption of oral iron.

Traditional dosing guidelines suggested aiming for 100-200mg of elemental iron a day however, more recent studies performed in iron deficient, non-pregnant women have shown that once-daily dosing of around 45-80mg elemental iron is more effective and avoids many of the gastrointestinal side effects. This amount of elemental iron roughly equates to one tablet of either ferrous fumarate 210mg or ferrous sulphate 200mg. A response in the haemoglobin count should be seen within a few weeks of starting therapy.

In certain scenarios, intravenous iron may be preferred. This includes patients with chronic kidney disease, inflammatory bowel disease, those intolerant of oral iron, those needing rapid replacement due to the degree of anaemia or certain pregnant patients. The safety profile has improved with more recent formulations but there is still a risk of anaphylactoid reactions and permanent skin staining.

Vitamin B12

Testing for a patient's vitamin B12 and folate status is challenging as existing investigations are not sensitive or specific and show wide variability between different laboratories.

For this reason, routine screening is not indicated for any patient group. Instead, investigations should be performed in response to specific clinical indicators.

As vitamin B12 and folate share a close relationship in human metabolism and so present with similar features, they should be investigated simultaneously.

Clinical features of vitamin B12 deficiency

B12 deficiency often develops over years, with clinical features occurring insidiously.

In severe deficiency, subacute degeneration of the spinal cord can develop.

Importantly, not all patients with clinical vitamin B12 deficiency will have anaemia or macrocytosis.

Therefore, if a patient presents with clinical features of B12 deficiency, is in an at-risk population (see below) or has been identified to have macrocytic anaemia, investigations of B12 stores should be undertaken.

Infants can also present with faltering growth, movement disorders or developmental delay.

Causes of vitamin B12 deficiency

Causes of vitamin B12 deficiency include:

Malabsorption: pernicious anaemia, Crohn's, coeliac disease, gastric/bariatric surgery, atrophic gastritis

Dietary: vegetarians/vegans

Infection: H.pylori, giardia, tapeworm

Infants: congenital causes

Specific scenarios

Medications

Certain medications can affect serum B12 assays creating misleading results. However, they rarely lead to clinically significant deficiencies, and B12 levels should only be checked in the presence of objective features of deficiency.

Metformin, anti-convulsants, proton pump inhibitors/H2 antagonists, hormone replacement therapy/combined oral contraceptive pill, colchicine and certain antibiotics can all decrease serum B12 levels.

Gastrointestinal surgery

Patients who have undergone gastric surgery or bariatric surgery can often develop vitamin B12 deficiency.

These patients should undergo monitoring of B12 levels and receive advice on adopting a diet rich in B12 (red meat, salmon, milk, cheese etc.). Intramuscular replacement should be commenced if levels are falling despite this.

Pregnancy

A physiological reduction in serum B12 levels occurs in up to 30% of individuals by the third trimester of pregnancy, complicating assessment. If in doubt about the relevance of results, seek specialist advice.

Multiple myeloma

The presence of paraproteins can reduce serum B12, but rarely reflects clinical deficiency.

Primary testing

Serum cobalamin is the primary investigation suggested by BSH and should only be requested in the presence of objective clinical markers of deficiency. When investigating a patient for vitamin B12 deficiency, the initial blood tests should include serum cobalamin, full blood count, and a blood film.

Serum cobalamin

The most common investigation in the UK for vitamin B12 is serum cobalamin, but levels do not always correlate clinically.

It is possible to be clinically deficient in vitamin B12 with a normal range serum cobalamin level and vice versa.

False normal results can occur in the presence of very high titres of anti-intrinsic factor antibodies in pernicious anaemia. Falsely low serum levels may occur in concurrent folate deficiency or conditions listed above in the specific scenarios section.

While there is no agreed normal level, most UK labs use a cut-off of <148pmol/l as evidence of B12 deficiency if objective clinical features are present.

BSH guidelines differentiate between patients with and without objective clinical features of B12 deficiency when interpreting these results (see flowcharts below).

Full blood count (FBC) and red cell parameters

Features which might suggest a vitamin B12 deficiency include anaemia and macrocytosis.

However, it is possible to be B12 deficient with a normal full blood count. Reticulocyte counts will be low or normal as the bone marrow cannot make new cells without vitamin B12.

Blood film

A blood film can help establish the diagnosis and assess for concurrent diseases. Features on blood film are non-specific, but can include macrocytosis, hypersegmented neutrophils and oval macrocytes.

Investigating the cause

If a patient with B12 deficiency has a family history of pernicious anaemia or a personal history of an autoimmune condition, it is important to investigate for pernicious anaemia. BSH suggest screening for pernicious anaemia in patients with both clinical features and laboratory confirmed B12 deficiency.

Anti-intrinsic factor antibodies (Anti-IF)

Anti-intrinsic factor antibodies are found in pernicious anaemia and have a low false-positive rate with a high positive predictive value. They are present in 40-60% of pernicious anaemia cases. False-positive results can occur following recent B12 injections.

Anti-gastric parietal cell antibodies

Anti-gastric parietal cell antibodies are less specific, being found in 10% of the background population who do not have pernicious anaemia. However, they are found in up to 80% of patients with the disease.

Summary charts of BSH guidance

Secondary testing

Depending on the clinical presentation, secondary testing may be required. Secondary testing is indicated if a patient presents with convincing clinical features of vitamin B12 deficiency (e.g. macrocytic anaemia and glossitis or neurological symptoms) but has normal serum cobalamin levels.

Secondary testing for B12 deficiency includes:

Total plasma homocysteine: raised in B12 deficiency but can also be elevated in folate deficiency, B6 deficiency, renal disease, and hypothyroidism.

Plasma methylmalonic acid: raised in B12 deficiency and in renal disease, haemoconcentration and small bowel overgrowth.

Holotranscobalamin: more sensitive but not available in all labs. It is low in vitamin B12 deficiency.

Table 2. Interpreting secondary tests for B12 deficiency.

Treatment of B12 deficiency

In the United Kingdom, guidelines for the treatment of B12 deficiency suggest using intramuscular (IM) vitamin B12 injections with the dosing and frequency depending on symptoms and response:

If no neurological symptoms: 1mg IM three doses a week for 2 weeks, then every 3 months

If neurological symptoms present: 1mg IM alternate days until no further improvement in symptoms (minimum 3 weeks), then every 2 months

Once treatment is commenced, an increase in reticulocyte count should occur in the first 7-10 days.

Folate

Both forms are absorbed in the terminal ileum, and half of the body's folate is found in the liver. It is often measured simultaneously with vitamin B12 as they share a close relationship in human metabolism with similar clinical features in deficiency.

As folate is important in DNA synthesis, the rapidly dividing cells of the body are those first affected.

Symptoms of folate deficiency can include those related to anaemia (shortness of breath, fatigue, weakness etc.), and mouth ulcers/glossitis. Therefore, folate levels are generally measured in similar scenarios to vitamin B12.

An isolated folate deficiency is rare, if a patient is deficient in both folate and vitamin B12 they should receive B12 replacement before initiating folate replacement due to the risk of precipitating subacute degeneration of the spinal cord.

Causes of folate deficiency

Causes of folate deficiency can be categorised into conditions that either inhibit absorption, increase secretion or those increasing the body's requirements for folate:

Dietary: diet deficient in folate-rich foods (legumes, broccoli, asparagus, brown rice, folate fortified foods)

Alcoholism: alcohol intake >80g/10 units a day

Gastrointestinal disorders: coeliac or any disorder affecting the small bowel

Pregnancy: preferential delivery of folate to foetus rather than mother's tissues, deficiency in utero increases the risk of neural tube defects

Haematological disorders: increased red cell destruction (sickle cell anaemia, haemolytic anaemias) and those with abnormal haematopoiesis

Exfoliative skin disorders (e.g. psoriasis)

Medications: anti-epileptics

Primary testing

If folate deficiency is suspected, the initial tests should include a serum folate level and a full blood count.

Serum folate

The serum folate level is the most useful initial screening test. No internationally recognised level defines deficiency, but a level <7nmol/l is generally used. Below this level, the risk of megaloblastic anaemia sharply increases.

Therefore, there is a grey area from 7-10nmol/l, in which case a treatment trial may be helpful.

Serum folate is not a perfect test as several conditions can cause false results.

Falsely low levels can occur in anorexia, acute alcohol intake, pregnancy, anti-epileptic therapy, and post-haemodialysis. Falsely high levels can occur if the test is performed too soon after oral folate ingestion.

Full blood count/blood film

Secondary testing

If the clinical suspicion of folate deficiency is high but serum folate is in the normal range, BSH guidelines suggest considering secondary testing. These can include:

Red cell folate: lots of laboratory variables limiting use, time-consuming and expensive

Plasma total homocysteine: high in folate deficiency but non-specific as can be raised in B12 deficiency, B6 deficiency, renal disease and hypothyroidism

Treatment of folate deficiency

If a patient is folate deficient, it is important to assess for concurrent vitamin B12 deficiency.

If a patient is deficient in both folate and B12, they should be started on B12 replacement first to avoid precipitating or worsening neurological features of B12 deficiency.

The usual treatment of folate deficiency is folic acid 5mg once daily for 3-4 months unless the cause of the folate deficiency is chronic (e.g. haemolysis) in which case a longer duration of treatment might be required.

Reviewer

Dr Tom Fail
Haematology SpR
Editor

Dr Chris Jefferies

References

Fletcher, A., Forbes, A., Svenson, N., Wayne Thomas, D. (2022), Guideline for the laboratory diagnosis of iron deficiency in adults (excluding pregnancy) and children. Br J Haematol, 196: 523-529.

Devalia, V., Hamilton, M.S., Molloy, A.M. and (2014), Guidelines for the diagnosis and treatment of cobalamin and folate disorders. Br J Haematol, 166: 496-513.

Camaschella C. (2015) Iron-deficiency anemia. New England journal of medicine. May 7;372(19):1832-43.

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Haematinics Interpretation | Iron Studies | Geeky Medics

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Improve Article 👀 Haematinics are the nutrients needed by the bone marrow to make blood cells in the process of haematopoiesis. Without adequate amounts of these nutrients, cytopenia(s) and related symptoms can develop. Excess amounts can also be pathological and can point to various underlying disease states.

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Common prescription reasons are drawn from the NIH Drug Information Portal and drug manufacturer websites.

Download these combined lists (XSLX) in a single Excel file.

Limitations

The ranks in these combined lists are based only on the rankings in the lists submitted to the Drug Price Transparency Program by the insurance companies based on pharmacy and medical benefits. If a drug is near the top of one of the Combined Top 25 lists, that's because it is near the top of many of the insurance companies' lists as well. The combined lists are not based on any quantitative data such as numbers of enrollees, prescription counts, or dollar amounts.

A detailed description of the method used to create the combined lists can be found at the end of the program's report (PDF).

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Common prescription reasons are drawn from the NIH Drug Information Portal and drug manufacturer websites. Download these combined lists (XSLX) in a single Excel file. The ranks in these combined lists are based only on the rankings in the lists submitted to the Drug Price Transparency Program by the insurance companies based on pharmacy and medical benefits.

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10 Most Prescribed Medicines Around the World and Their Uses - Blogs - Makati Medical Center

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Medicines and the process of combining ingredients to treat conditions have long been a part of human history, dating back to ancient Mesopotamia, as evidenced by the cuneiform clay tablets. The ancient materials describe the process of making salves (ointment) and other concoctions using various…

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Clinical Case Presentation: Pediatric/ Pediatric Ward/ Family-Centered  P3-2 Group 6

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The chart shows the number of men and women studying engineering in Australia throughout the years 1992 to 2012
We can observe that  there are a lot more male students  than females accounting for at least twice the number in all years
There’s a pattern where the number of men decreased while the women increased through the years
There was an important increase in female students, tripling the number of students in 20 years , which shows  women are becoming more interested in careers  stereotyped for men. Career choosing for women is not what it used to be, where most of the time they didn’t even had the choice of studying the university.
The role imposed by society is not as strong as before and men and women have more freedom to pursue the career they want.

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It is widely accepted in modern culture that people should divide their daily diet into three large meals - breakfast, lunch, and dinner - for optimal health. This belief primarily stems from culture and early epidemiological studies.

In recent years, however, experts have begun to change their perspective, suggesting that eating smaller, more frequent meals may be best for preventing chronic disease and weight loss. As a result, more people are changing their eating patterns in favor of eating several small meals throughout the day.

Those who advocate for eating small, frequent meals suggest that this eating pattern can:

improve satiety, or feeling full after a meal

increase metabolism and body composition

prevent dips in energy

stabilize blood sugar

prevent overeating.

While a few studies support these recommendations, others show no significant benefit. In fact, some research suggests it may be more beneficial to stick with three larger meals.

Here is what the research says.

Early epidemiological studies suggest that increased meal frequency can improve blood lipid (fats) levels and reduce the risk of heart disease. As a result, many experts advise against eating fewer, larger meals a day.

Over the years, some studies have supported these findings, suggesting that people who report eating small, frequent meals have better cholesterol levels than those who consume fewer than three meals per day.
In particular, one 2019 cross-sectional study that compared eating fewer than three meals per day or more than four meals per day found that consuming more than four meals increases HDL (high-density lipoprotein) cholesterol and lowers fasting triglycerides more effectively. Higher levels of HDL are associated with a reduced risk of heart disease.
This study observed no differences in total cholesterol or LDL (low-density lipoprotein) cholesterol. It is important to note, however, that this is an observational study, meaning it can only prove association, not causation.

Additionally, one review published in the American Heart Association's journal concluded that greater eating frequency is associated with a reduced risk for diabetes and cardiovascular disease, according to epidemiological studies.

There is a commonly held notion that more frequent meals can help influence weight loss. However, the research on this remains mixed.

For example, one compared eating three meals per day or six smaller, more frequent meals on body fat and perceived hunger. Both groups received adequate calories to maintain their current body weight using the same macronutrient distribution: 30% of energy from fat, 55% carbohydrate, and 15% protein.
At the end of the study, researchers observed no difference in energy expenditure and body fat loss between the two groups. Interestingly, those who consumed six smaller meals throughout the day had increased hunger levels and desire to eat compared to those who ate three larger meals per day.
Although calorie intake was controlled in both groups, researchers hypothesized that those who consumed frequent meals would be more likely to consume more daily calories than those who ate less frequently.

Results of another large observational suggest that healthy adults may prevent long-term weight gain by:

eating less frequently

eating breakfast and lunch 5 to 6 hours apart

avoiding snacking

consuming the largest meal in the morning

fasting for 18-19 hours overnight.

Moreover, according to the United States Department of Agriculture (USDA) Scientific Report of the 2020 Dietary Guidelines Advisory Committee, due to inconsistencies and limitations in the current body of evidence, there is insufficient evidence to determine the relationship between meal frequency and body composition and the risk of overweight and obesity.

Does eating frequent meals boost metabolism?

Small, frequent meals are often touted as a cure-all for obesity. Many believe that eating every 2 to 3 hours can help boost metabolism.

Digestion of food does require energy. This is known as the thermic effect of food (TEF). However, it does not appear that meal frequency plays a role in boosting metabolism.

In fact, some studies suggest fewer, larger meals may increase TEF more than eating frequent meals.

Although evidence to support increased meal frequency in the general population remains mixed, several experts believe that eating small, frequent meals can benefit athletes.

According to the International Society of Sports Nutrition, athletes who follow a reduced-calorie diet may benefit from eating small frequent meals with adequate protein because it can help preserve lean muscle mass.

When prioritizing total daily calorie intake, limited evidence suggests that, in athletes, a higher meal frequency may increase performance, support fat loss, and improve body composition.

People who eat more frequently are more likely to have better diet quality. Specifically, those who consume at least three meals per day are more likely to have a greater intake of vegetables, greens, legumes, fruit, whole grains, and dairy.

These individuals are also more likely to consume less sodium and added sugars than those who consume two meals per day.
Similarly, another 2020 study published in the British Journal of Nutrition found that increased meal frequency - approximately three meals per day - is associated with higher diet quality.
Researchers found that snack frequency and diet quality varied depending on the definition of snacks.

Based on the presented studies, no substantial evidence supports one eating pattern over the other. Yet many of these studies also have limitations.

For example, there is no universally accepted definition of what a meal or snack consists of. This can have an impact on study outcomes.

With that said, both eating patterns can be beneficial as long the primary focus is on healthful eating habits.

Who should consume small, frequent meals?

A review published in Nutrition in Clinical Practiceshows that certain populations may benefit from six to 10 small, frequent meals. These include people who:

experience early satiety

are trying to gain weight

have gastroparesis

have gastrointestinal symptoms such as nausea, vomiting, or bloating.

If your goal is to lose weight, it is important to be mindful of your portion sizes. Be sure to stay within your allotted daily calorie needs and divide them among the number of meals you consume.
For example, if you need 1,800 calories to maintain your weight and choose to eat six small meals daily, each meal should be around 300 calories.

Small, frequent meals often come in the form of ultra-processed foods and snacks that fall short in many vital nutrients your body needs. Thus, it is essential to focus on the quality of the foods you consume.

Who should consume fewer, larger meals?

People who may benefit from three larger meals per day include:

those who have difficulty practicing portion control

those who tend not to eat mindfully

people who live busy lives and may not have time to plan and prepare several nutritious mini-meals a day.

Again, keeping diet quality in mind and prioritizing whole foods is essential. Fewer meals mean fewer opportunities to get in key nutrients the body needs.

While we do not have strong evidence to support the importance of meal frequency, substantial evidence supports the overall health benefits of following a well-balanced, nutrient-rich diet.

According to the Dietary Guidelines for Americans 2020-2025, a healthy diet should:

emphasize fruits, vegetables, whole grains, and low-fat or fat-free milk or dairy products

include protein from various sources, including seafood, lean meat and poultry, eggs, nuts, seeds, soy products, and legumes

stay within your allotted calorie needs

limit added sugars, cholesterol, trans fats, and saturated fats.

Evidence is mixed about the importance of food frequency. While there is no solid evidence to suggest that one eating style is superior to the other, both can offer health and wellness benefits if you follow a healthy eating pattern.

Thus, it ultimately comes down to personal preference and which approach works best for you. Additionally, if you have certain health conditions, one style may benefit you over the other.

As always, consult your healthcare provider before making any significant changes to your diet.

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Meal frequency and portion size: What to know

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It is widely accepted in modern culture that people should divide their daily diet into three large meals - breakfast, lunch, and dinner - for optimal health. This belief primarily stems from culture and early epidemiological studies .

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Zero-calorie artificial sweeteners may not be as harmless as they seem. Carmen Martínez Torrón/Getty Images

A massive study involving French citizens that spanned more than a decade evaluated their use of artificial sweeteners.

The observational study periodically checked the participants' food and drink intake and had the participants regularly report on their health.

By the end of the study, the researchers learned that the participants who consumed higher levels of artificial sweeteners experienced cardiovascular disease events at a higher rate than participants who did not consume artificial sweeteners.

While artificial sweeteners may seem like a good alternative to sugar to reduce caloric intake, a study published in suggests there may be a connection between such sweeteners and an increased risk for cardiovascular disease (CVD), including stroke.

The research, conducted by the French National Institute for Health and Medical Research, is not the first study to suggest a connection between artificial sweeteners and increased risk for heart disease, however, it is the largest to date. The study included data from more than 100,000 participants.

When people try to cut sugar out of their diets, for reasons such as trying to lose weight or trying to control their blood sugar, they may turn to artificial sweeteners.

Artificial sweeteners have been around for more than 100 years. Saccharin, for example, which is found in the sugar substitute Sweet'N Low, was first discovered in 1879. Since then, researchers have discovered numerous other artificial sweeteners, including sucralose, aspartame, stevia, and xylitol.

There has almost always been controversy surrounding artificial sweeteners. As the Harvard School of Public Health notes, concerns include the development of type 2 diabetes and weight gain but the evidence is varied and inconclusive.

Despite the concerns, the Food and Drug Administration considers the approved sweeteners generally safe to use, as long as people do not exceed the acceptable daily intake for each type.

For example, with sucralose (which is found in Splenda), a 132-pound person could consume 23 packets before going over the recommended limit.

The study began in 2009 with the launch of the NutriNet-Santé e-cohort. People interested in participating in " the world's largest nutrition study " could sign up online.

More than 170,000 signed up for the study, and the researchers narrowed down their field to 103,388. The chosen participants included people 18 years of age and older, as well as people who filled out questionnaires related to "diet, health, anthropometric data, lifestyle and sociodemographic data, and physical activity."

The average age of the included participants was 42 years, and the majority of the participants were females (79.8%).

Throughout the following years, researchers periodically gathered information from the participants such as all food and beverages consumed during a 24-hour period. To make sure the participants were being accurate with their food logs, the researchers required them to submit photos.

Additionally, participants also reported their artificial sweetener consumption. The researchers wanted to know the amount and sweetener brand.

Approximately 37% of the participants reported using artificial sweeteners, with the participants divided into non-consumers, lower consumers (artificial sweetener intake below the median), and higher consumers (artificial sweetener intake above the median). The participants consumed an average of 42.46 mg/day. They consumed the following artificial sweetener types:

aspartame

acesulfame potassium

sucralose

cyclamates

saccharin

thaumatin

neohesperidine dihydrochalcone

steviol glycosides

salt of aspartame-acesulfame potassium

The researchers also collected other health information from the participants throughout the duration of the study, including information from "any new health events, medical treatments, and examinations." Additionally, the participants provided documentation of any reports of CVD.

At the end of the study, the researchers compared the number of cardiovascular events that people who consumed artificial sweeteners experienced to the number of events that people who did not consume these sweeteners experienced.
The researchers found that people who were higher consumers of artificial sweeteners had an increased risk of cardiovascular disease compared to non-consumers.
Participants reported 1,502 cardiovascular events during the follow-up, including 730 coronary heart disease events and 777 cerebrovascular disease events.

Higher consumers of artificial sweeteners experienced 346 events per 100,000 person-years and non-consumers experienced 314 events per 100,000 person-years.

3 particularly problematic sweeteners
"Our results indicate that these food additives, consumed daily by millions of people and present in thousands of foods and beverages, should not be considered a healthy and safe alternative to sugar, in line with the current position of several health agencies," write the authors.
The authors noted that they do not believe the occasional use of artificial sweeteners is as problematic as daily use. "Occasional artificial sweetener consumption is not likely to have a strong impact on CVD risk, and so even if some consumption might have been missed, it would probably have had a low impact on the study results."

Additionally, the authors noted that three artificial sweeteners in particular were associated with higher risks.
According to the authors, "Aspartame intake was associated with increased risk of cerebrovascular events, and acesulfame potassium and sucralose were associated with increased coronary heart disease risk."
Speaking to Medical News Today about the study, Dr. Jeff Gladd, integrative medicine physician and chief medical officer at Fullscript, a care delivery platform for integrative medicine, noted that while artificial sweeteners sparingly would not likely pose health issues, using them regularly can possibly cause some problems.

"No calorie artificial sweeteners such as aspartame, saccharin, and sucralose are commonly added to many 'diet' and 'sugar-free' processed foods like pastries, pudding, candy, soft drinks, and more," said Dr. Gladd.

"Considering that artificial sweeteners are typically found in highly processed foods, I recommend limiting your consumption of them altogether. Some safer alternatives include natural options such as allulose, monk fruit, and stevia which do not seem to carry the same concerns," he added.

"[R]esearch suggests that heavy use of artificial sweeteners may actually lead to weight gain and obesity, and according to some animal trials, consuming artificial sweeteners may alter the gut microbiota and potentially increase one's risk of certain cancers, although more research is needed to substantiate these claims."
- Dr. Jeff Gladd

"While prospective studies like this are not confirmed proof of causation, this potential connection in combination with associations of consumption with obesity and gut microbiome concerns should add to the motivation to limit their intake," he said.
Dr. Vicken Zeitjian, a cardiologist at the University of Texas Health Science Center at San Antonio, Texas, also spoke with MNT about the study.

"The link between artificial sweeteners and coronary artery disease/stroke is not surprising given the fact that artificial sweeteners are associated with diabetes, hypertension, hyperlipidemia, hypertriglyceridemia, and obesity," said Dr. Zeitjian.

Dr. Zeitjian noted that the study may not be able to be applied to all populations, however, said "it does give us insight that artificial sweeteners may be implicated in coronary heart disease and cerebrovascular disease."

"We live in an era where we focus on prevention, and therefore this study shows that controlling risk factors from a dietary standpoint may have reduced incidence of heart attacks and strokes."
- Dr. Vicken Zeitjian

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Cardiovascular disease: 3 artificial sweeteners linked to higher risk

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A massive study involving French citizens that spanned more than a decade evaluated their use of artificial sweeteners. The observational study periodically checked the participants' food and drink intake and had the participants regularly report on their health.

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Can You Diagnose It? Practice Clinical Case [USMLE, Medical Students, Nursing]

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Clinical Case Presentation in English - Medical English Listening Skills

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People in harmonious relationships may start thinking in synch, according to new research. Hinterhaus Productions/Getty Images

Although research suggests several factors may contribute to a harmonious relationship, what predicts marital satisfaction is not fully understood.

Research also indicates that long-term couples often begin to think and behave similarly, leaving many unanswered questions about how this might play a role in marital satisfaction.

A recent study from Stanford University in collaboration with researchers in China has uncovered evidence that shared brain activity may predict marital happiness.

Their findings also provide insights into the neurobiological foundation of human marital bonding.

Marital satisfaction and romantic compatibility have been the subject of research for decades. Yet, scientists are only beginning to understand why some couples report happiness within a relationship and others do not experience this type of relationship satisfaction.

So far, research has identified several factors that may contribute to an individual's happiness in their relationship. For example, a 2016 systematic review of research found that religion, sex, and communication impacted marital satisfaction. Interpersonal factors and mental health also played a role, along with occupation, length of the marriage, age, and the number of children a couple had.
In addition, over time, harmonious couples often begin to think and behave in similar ways. For instance, a 2021 study found evidence of personality synchrony over time within older adult couples.
Still, scientists have yet to fully understand if this synchronicity between romantic partners indicates greater relationship satisfaction.

However, a new study from Stanford University researchers in collaboration with scientists in China has uncovered more insight into marital satisfaction.
Specifically, they found that heterosexual married partners who reported higher marital satisfaction also had synchronized brain activity when viewing marriage-related images.
Moreover, in contrast to other research, the scientists found no significant association between marital satisfaction and age, sex, personality traits, or marriage length.

The research appears in the Proceedings of the National Academy of Sciences (PNAS).

The study authors hypothesized that measuring marital satisfaction might be possible by looking at the brain's response to marital and socially relevant cues.
They also proposed that since growing evidence indicates neural activity in partnered individuals becomes increasingly synchronized over time and shared life experiences, these synchronicities might contribute to greater marital satisfaction.
To investigate this theory further, the scientists recruited 35 heterosexual couples in China who had been married for at least a year. The researchers also included randomly selected male-female pairs that were not married.

First, the research team determined whether behavioral or personality factors predicted marital happiness by having study participants complete several questionnaires on marital satisfaction and adult attachment. The participants also completed the Big Five Personality Inventory.
Then, the participants underwent fMRI scans of the brain while viewing relationship-related and object-related movie clips. The scientists hoped to identify whether married couples showed more brain activity synchronization than randomly selected male-female pairs.
The scientists analyzed the data by computing intersubject synchronization (ISS) between married couples. The team also used dimensional and categorical analyses to determine whether the ISS between married couples was associated with marital satisfaction.

In addition, the researchers also examined what role the default mode network (DMN) - a brain network linked to thoughts, emotions, or beliefs about oneself and others - played in marital happiness.

Specifically, the team looked at whether ISS in the DMN was related to specific factors of marital satisfaction, including personality, communication, and conflict resolution.

The analysis showed that married couples who reported greater marital satisfaction were more likely to show activity in similar parts of the brain when they watched the relationship-related movie clips. However, this synchronized neural activity did not happen when they viewed object-related images, regardless of reported marital satisfaction.
Moreover, happily married couples showed more synchronized brain activity than randomly paired couples.
In a Stanford Medicine article, study author Dr. Vinod Menon, a professor of psychiatry and behavioral sciences at Stanford University, said, "we found that the links between marital happiness and behavioral measures, like personality tests, were quite weak."

In the article, Dr. Vinod explained that "married couples overall, compared with random couples, had more similar brain activity independent of levels of satisfaction. On top of that, you get additional synchronization in those who self-report to be more satisfied in their marriage."

Individuals come together and create pair bonds due to many complex factors. But when and how a couple develops synchronized thinking is not fully understood.

"We don't know whether there [are] selection-based behaviors arising from similar brain activity in a relationship, or whether couples evolve over time to develop similar anticipatory and predictive brain representations," Dr. Menon explained in the Stanford Medicine interview.

Dr. Jared Heathman, board certified psychiatrist with Your Family Psychiatrist in Houston, Texas, told Medical News Today:

"Married couples often think the same, which is called synchronized thinking. This type of thinking can be something that brings couples together. People often choose partners that are similar to them. Synchronized thinking can [also] be a learned response that occurs after a couple has been together for a long period of time."
Interpreting the study results, Dr. Heathman added, "my thoughts on this are that in a relationship, both partners move toward a similar line of thinking regarding needs, wants, and hopes. Both partners influence each other."
"Although both partners are in sync about marriage, they may have different views and perspectives on some various topics, thus explaining why they did not have similar brain activity when viewing non-relationship related images," he added.

Dr. Monica Vermani, clinical psychologist and author of A Deeper Wellness: Conquering Stress, Mood, Anxiety and Traumas, told MNT:

"Couples with similar thinking styles and personalities often come together easily, cohabit well, and easily live in harmony. On the other hand, some people come together because, [...] they lack certain traits in themselves, and seek out partners who possess the traits they lack in order to attain a sense of balance."

"In successful partnerships where these dynamics are in play, both individuals respect, admire, and learn from one another. Over time being together, they are often challenged and inspired to learn from and acquire the traits they admire in their partner."
- Dr. Monica Vermani

Regarding the study's results, Dr. Vermani suggests that "brain similarities confirm shared perceptions, thought patterns, ways of processing emotion, anger, interpersonal and social interactions, and even analytical versus emotional reasoning."
"Such neurological/brain activity commonalities can be strong predictors of marital satisfaction," she concludes.

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Happy marriage and synchronized brains: What's the link?

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Although research suggests several factors may contribute to a harmonious relationship, what predicts marital satisfaction is not fully understood. Research also indicates that long-term couples often begin to think and behave similarly, leaving many unanswered questions about how this might play a role in marital satisfaction.

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Alternative medicine is a term used to refer to medical practices outside traditional medicine that don’t have proven fundaments.
As a doctor I always advice people to seek medical professional help when needed.
Doctors are trained for years to identify and treat deceases whereas alternative practitioners don’t. It’s well known that the emotional  state of the patient  may impact the treatment's outcome so alternative medicine can help by making them feel better but just as a complement.

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Saoirse Ronan pronouncing Irish names jomarch Stephen Colbert

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Saoirse Ronan pronouncing Irish names jomarch Stephen Colbert❤️ Help me Grow Channel ❤️ Subscribe my channel Celebrity Bizz🌻Donate me: https://www.buymeacof...

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Discharging patients from a hospital is a complex task. An essential part of this process is the documentation of a discharge summary. A discharge summary is a clinical report prepared by a health professional at the conclusion of a hospital stay or series of treatments. It is often the primary mode of communication between the hospital care team and aftercare providers. It is considered a legal document and it has the potential to jeopardize the patient's care if errors are made. Delays in the completion of the discharge summary are associated with higher rates of readmission, highlighting the importance of successful transmission of this document in a timely fashion.

This guide will help you to understand what's necessary to include and give you a structure to effectively write discharge summaries. It gives a detailed description of each section that may be included in a typical discharge summary. Each section illustrates key pieces of information that should be included and aims to explain the rationale behind each part of the document.

In practice, each summary is adapted to the clinical context. As such, not all information included in this guide is relevant and needs to be mentioned in each discharge summary. In addition, different hospitals have different criteria to be included and you should always follow your hospital's or medical school's guidelines for documentation.

You might also be interested in our OSCE Flashcard Collection which contains over 2000 flashcards that cover clinical examination, procedures, communication skills and data interpretation.

Patient details

Important information to include regarding the patient includes:

Patient name: full name of the patient (also the patient's preferred name if relevant)

Date of birth

Unique identification number

Patient address: the usual place of residence of the patient

Patient telephone number

Patient sex: sex at birth (this determines how the individual will be treated clinically)

Gender: the gender the patient identifies with

Ethnicity: ethnicity as specified by the patient

Next of kin/emergency contact: full name, relationship to the patient and contact details

GP details

This section should be completed with the details of the General Practitioner with whom the patient is registered:

GP name: the patient's usual GP

GP practice details: name, address, email, telephone number and fax of the patient's registered GP practice

GP practice identifier: a national code which identifies the practice

Hospital details

Discharging consultant: the consultant responsible for the patient at the time of discharge

Discharging specialty/department: the specialty/department responsible for the patient at the time of discharge

Date and time of admission and discharge

Discharge destination: destination of the patient on discharge from hospital (e.g. home, residential care home)

Presentation

History and examination findings

Include a focused summary of the patient's presenting symptoms and signs:

"Mrs Smith presented to A&E with worsening shortness of breath and ankle swelling. On arrival, she was tachypnoeic and hypoxic (oxygen saturation 82% on air). Clinical examination revealed reduced breath sounds and dullness to percussion in both lung bases. There was also a significant degree of lower limb oedema extending up to the mid-thigh bilaterally."

Investigations

Include salient investigations performed during the patient's admission:

"Blood tests revealed a raised BNP. An ECG showed evidence of left-ventricular hypertrophy and echocardiography revealed grossly impaired ventricular function (ejection fraction 35%). A chest X-ray demonstrated bilateral pleural effusions, with evidence of upper lobe diversion."

Include any investigations that are still pending:

"A renal tract ultrasound has been requested and will be performed in the next 2 weeks. We will write to you with the results."

Diagnoses

This section should include the diagnosis or diagnoses that were made during the patient's stay in hospital:

"Mrs Smith was reviewed by the Cardiology team who confirmed a diagnosis of congestive heart failure."

If no diagnosis was confirmed, use the presenting complaint and explain no cause was identified:

"No clear cause was identified for the patient's chest pain at this time."

Diabetes: type 1, type 2, steroid-induced, gestational

Myocardial infarction: NSTEMI, STEMI

Pneumonia: bacterial, viral, aspiration pneumonia

Septicaemia: causative organism and source (e.g. E.Coli urosepsis)

Gastroenteritis: viral, bacterial

Management

"Mrs Smith required oxygen and intravenous diuretic therapy for the first 24 hours of her admission. She was then weaned off oxygen and commenced on regular oral furosemide (40mg OD) which is to be continued after discharge. At discharge, Mrs Smith's symptoms were much improved and she was able to mobilise independently with only mild shortness of breath on exertion."

Complications

Document any complications that occurred during the patient's hospital stay:

"Mrs Smith developed a stage 2 acute kidney injury after initiation of diuretic therapy, however, this resolved with dose titration and careful fluid balance management. Her baseline creatinine at discharge was 74 μmol/ L."

Procedures

This section must include all operations or procedures that the patient underwent:

Date of procedure(s): the date the procedure(s) was/were performed

Procedure: the procedure performed (e.g. laparoscopic appendectomy)

Complications related to the procedure: details of any intra-operative complications encountered during the procedure, arising during the patient's stay in the recovery unit or directly attributable to the procedure (e.g. injury to surrounding structures, secondary wound infections, etc)

Specific anaesthesia issues: details of any adverse reaction to any anaesthetic agents including local anaesthesia (e.g. difficult intubation, allergic reaction to a particular anaesthetic agent)

Future management

Treatments (e.g. medication, surgery, etc)

Hospital follow up

Referrals made by the hospital (e.g. referral to chronic pain team)

Example: "We have discharged Mrs Smith on regular oral Furosemide (40mg OD) and we have requested an outpatient ultrasound of her renal tract which will be performed in the next few weeks. We will review Mrs Smith in the Cardiology Outpatient Clinic in 6 weeks time. After review from our social worker and occupational therapist, we have arranged a once-daily care package to assist Mrs Smith with her activities of daily living."

Clearly document any actions you would like the patient's GP to perform after discharge:

"Could you please arrange for Mrs Smith's U&Es to be assessed in 2 weeks time, to ensure her creatinine and electrolytes remain stable on her new diuretic regime. Should you have any questions or concerns in the meantime, please don't hesitate to contact our team."

Medication changes

"Amlodipine INCREASED to 10mg once daily to improve blood pressure control."

"Citalopram 20mg once daily COMMENCED due to low mood."

"Furosemide 40mg once daily STOPPED due to acute kidney injury."

Medications to take home

Regular medications

As required (PRN) medications

For each medication, you should include details regarding the following:

Name: usually, generic drug names are preferred, but in some cases using the specific brand name is more appropriate (e.g. epilepsy medication)

Form: capsule, drops, tablet, lotion, etc

Route: oral, inhaled, topic, intravenous, etc

Frequency: once daily, twice daily, as required, etc

Duration: x days, long-term, etc

Indication: e.g. congestive heart failure

Additional instructions: review date, monitoring requirements, etc

This section should outline any allergies or adverse reactions that the patient experienced. It should be as specific as possible and include the following:

Causative agent: the agent (food, drug or substances) that caused an allergic reaction or adverse reaction

Description of the reaction: this may include the manifestation (e.g. rash), type of reaction (allergic, adverse, intolerance) and the severity of the reaction

Date first experienced: when the reaction was first experienced

Information for the patient

Most discharge letters include a section that summarises the key information of the patient's hospital stay in patient-friendly language, including investigation results, diagnoses, management and follow up. This is often given to the patient at discharge or posted out to the patient's home.
"You were admitted to hospital because of worsening shortness of breath and swelling of your ankles. We performed a number of tests which revealed that your heart wasn't pumping as effectively as it should have been. As a result, we have started you on a water tablet called Furosemide, which should help to prevent fluid from building up in your legs and lungs. You should continue to take the Furosemide tablet as prescribed, however, if you become unwell, you should see your GP as this tablet can potentially damage your kidneys if you become dehydrated. We plan to review you in 6 weeks time, in the Cardiology Outpatient Clinic and we will send your appointment details out in the post. We have also asked your GP to take some blood tests to check your kidney function in around 2 weeks time. In the meantime, should you have any concerns or questions, you should see your GP."
This section includes personal information about the healthcare provider completing the discharge summary:

Other sections that may be included

Assessment scales

This section identifies any assessment scales used when clinically evaluating the patient. Some examples of assessment scales commonly used include:

New York Heart Association (NYHA) Functional Classification

Cognitive function (e.g. MMSE)

Mood assessment scales

Malnutrition Universal Screening Tool (MUST)

Social context

Home circumstances:

Who the patient lives with (e.g. lives alone, lives with a partner, lives with family)

Details of the patient's residence (e.g. house with stairs, bungalow, flat, residential care, etc)

Occupational history:

Current and/or previous relevant occupation(s) of the patient

Special requirements

Document if the patient has any special requirements:

Transport arrangements (e.g. ambulance with oxygen)

Language (e.g. preferred language, need for an interpreter)

Advocate requirements

Participation in research

This is to clearly identify patients who are involved in a clinical trial.
This may include:

Whether participation in a trial has been offered, refused or accepted

Name of the trial

Drug/Intervention tested

Enrolment date

Duration of treatment and follow up

A contact number for adverse events or queries

Legal information

This section describes the care of the patient from a legal perspective. Some examples of the types of information it may include are shown below.
Consent for treatment record:

Whether consent has been obtained for the treatment
Mental capacity assessment:

Whether an assessment of the mental capacity of the (adult) patient has been undertaken, if so, who carried it out, when it was carried out and the outcome of the assessment
Advance decisions about treatment:

Whether there are written documents, completed and signed when a person is legally competent, that explains a person's medical wishes in advance, allowing someone else to make treatment decisions on his/her behalf late in the disease process

Location of these documents

A copy of the document itself

Lasting or enduring power of attorney or similar:

Record of individual involved in healthcare decision on behalf of the patient if the patient lacks capacity
Organ and tissue donation:

A record of whether a patient has consented for organ or tissue donation.
Consent relating to a child:

Consideration of age and competency

Record of the person with parental responsibility, or appointed guardian where a child lacks competency

Consent to information sharing:

Record of consent to information sharing, including any restrictions on sharing information with others (e.g. family members, other healthcare professionals)

Use of identifiable information for research purposes

Safeguarding issues:

Any legal matters relating to the safeguarding of a vulnerable child or adult (e.g. child protection plan, a child in need plan, protection of a vulnerable adult)

Safety alerts

This section illustrates if the patient poses a risk to themselves, for example, suicide, overdose, self-harm, self-neglect. Also include if the patient is a risk to others, including professionals or any third party.

Patient and carer concerns

This section should include a description of any concerns of the patient and/or carer.

1. Health and Social Care Information Centre, Academy of Medical Royal Colleges. Standards for the clinical structure and content of patient records [Internet]. London: Health and Social Care Information Centre, Academy of Medical Royal Colleges; 2013 p. 37 - 44. Available from: [LINK]

2. UpToDate [Internet]. Uptodate.com. 2019 [cited 28 January 2019]. Available from: [LINK]

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How to Write a Discharge Summary | Discharge Letter | Geeky Medics

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This article explains how to structure and write a hospital discharge letter (a.k.a. discharge summary) in an OSCE setting.

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25 year old Female patient was admitted to the surgery floor on February 3, 2022 with the diagnosis of Lipodistrophy for a liposuction. During surgery they liposucted 500cc of abdominal fat, surgical finding of scarring fibrosis, total bleeding of 300cc, without complications. Next day the patient had good general state, assisted ambulation, urination and evacuation were present, the patient withstands oral soft diet,  referred pain Eva 4/10 in surgical wound, labs... Physical exploration: tender abdomen with bandage, dressing in surgical wound with little bleeding, without signs of infection. For good evolution it was decided the patients discharged.

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25 year old Female patient was admitted to the surgery floor on February 3, 2022 with the diagnosis of Lipodistrophy for a liposuction. During surgery they liposucted 500cc of abdominal fat, surgical finding of scarring fibrosis, total bleeding of 300cc, without complications. Next day the patient had good general state, assisted ambulation, urination and evacuation were present, the patient withstands oral soft diet,  referred pain Eva 4/10 in surgical wound, labs... Physical exploration: tender abdomen with bandage, dressing in surgical wound with little bleeding, without signs of infection. For good evolution it was decided the patients discharged.

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A technician at Northfield Laboratories in Evanston, Ill., holds two bags filled with PolyHeme in 2004. The company's clinical trial of the blood substitute drew criticism for operating under an exemption from informed-consent requirements. (AP Photo/M. Spencer Green)

Michael Hickson, a father of five living in Texas, was one of millions of Americans who contracted covid-19 in 2020. The 46-year-old African American, who had become a quadriplegic after having a heart attack while driving in 2017, died in June at St. David's South Austin Medical Center, six days after the hospital ended treatment for him. Before his death, Michael's wife, Melissa, met with his attending physician, who she says decided against the further treatment she had requested because he had no "quality" of life.

As Harriet A. Washington writes in her new book, " Carte Blanche: The Erosion of Medical Consent," Hickson's story speaks to some of the urgent legal and societal issues of medical ethics. Among these is the decision to withhold treatment, one of the key ways in which Washington sees the imperative of informed consent slipping away. As she writes, "Withholding care from those deemed to have a poor quality of life or those for whom treatment is assumed to be futile, the policies rob patients of their right to consent." Such issues have become unavoidable during the coronavirus pandemic, but they play out against a background of related medical ethics questions that Washington ably considers.

Throughout "Carte Blanche," which focuses primarily on experimental research, Washington explores issues such as whether patients in nursing homes are adequately informed of the risks, and how nonconsensual medical testing has long disproportionately targeted African Americans, soldiers and the incarcerated. Washington's thesis is that medical consent is generally breaking down and that this crisis is exacerbated in the realm of experimental research by the fact that many Americans have only a vague understanding of consent, thinking it revolves primarily around signing a legal document to the affirmative. It is much more than that, she says. "Informed consent helps to enforce ethical principles of autonomy, beneficence and justice, and the signed form is only one piece of evidence buttressing a researcher's claim that she has explained everything a subject reasonably needs to know in order to make the best decision about whether he wants to participate."

Washington, the author of works such as " Medical Apartheid " (2006), which focused on the history of medical experimentation on Black Americans, draws on her earlier research, as well as media reports and historical cases both largely unknown and notorious. She discusses the Nuremberg Code, the set of ethical guidelines for human research produced in the aftermath of Nazi-era experimentation, and the Tuskegee study, which ran from 1932 to 1972 and withheld treatment for 600 Black men diagnosed with syphilis who thought they were receiving care. As Washington shows, it's a history that exemplifies the many ways African Americans, Jews and other marginalized groups have been subjected to abusive research experiments - often without their knowledge or consent.

A medical ethicist who lectures in bioethics at Columbia University, Washington also shares more recent stories of individuals and their families who found themselves within the gradations of what it means to "consent" to medical treatment or an experimental study. She finds that some were unable to consent because of their conditions. She cites others, such as those in the military, who received experimental drugs after being coerced or threatened with reprisal if they did not consent. Some were simply deceived into consenting. A disproportionate number of people in these scenarios were African American.

Taken in isolation, each of these examples is deeply disturbing. In aggregate, they lay bare systemic failures that effectively rob vulnerable individuals of their agency and expose them to potential harm. That has, as Washington shows in the opening chapters of her book, become especially clear during the coronavirus pandemic. The quest to care for the surge of infected patients, especially in nursing homes but also in hospitals where resources have been stretched thin, has placed in stark relief related decisions surrounding informed consent and care.

Washington looks at the case of a Texas nursing home doctor who reportedly gave hydroxychloroquine to dozens of patients in April 2020, shortly after the U.S. Food and Drug Administration gave the anti-malarial drug an emergency-use authorization to treat covid-19, despite the paucity of supporting data. Some of those patients suffered from dementia, which made them unable to offer informed consent. Washington points out that the physician also did not elicit informed consent from some designated family members. Acknowledging the crisis clinicians faced in such environments, Washington writes, "The staggeringly high rates of coronavirus infection in nursing homes filled with susceptible elderly certainly constitutes an emergency, but it does not present an excuse for abandoning ethical behavior, especially when caring for the powerless who cannot effectively express their own opinions about their medical fate nor advocate for themselves."

Washington also discusses examples of patients who were unknowingly pulled into medical trials while receiving treatment. In 2006, Martha Milete was shot in the chest by burglars in her Detroit home. Bleeding heavily, she was given an artificial blood cell substitute called PolyHeme, made by Northfield Laboratories, while en route to the hospital in an ambulance. Like more than 700 others around the country, she had been enrolled - unwittingly and without consent - in a Phase 3 clinical trial on PolyHeme use for victims of traumatic injury from 2003 to 2006. That study drew widespread criticism because it operated under decade-old regulations allowing clinical emergency research under an exception from informed-consent requirements.

At the hospital, Milete remembers people who were not part of her medical team repeatedly drawing her blood. Outraged when she learned they were researchers, she ordered them to stop. Washington asked her if anyone from the hospital or research team had told her she had been enrolled in the experiment. Milete replied: "No, my daughter told me. The medical staff never told me. . . . There was a coordinator who kept telling nurses to 'take more blood, take more blood.' She was in cahoots with the research people."

PolyHeme, Washington says, "provided an example of how a study could be legal yet unethical." As she points out, that research also had a troubling racial dimension, one that resonates throughout much of the book: Thirteen of the cities that ultimately completed the PolyHeme trial, or 65 percent, had Black populations considerably higher than the national African American representation of 13 percent, and some had disproportionately high Hispanic populations as well.

"Carte Blanche" is particularly bracing when it highlights such racial disparities, and even more so when weaving together decades-old stories with topical ones from today. The echoes of the past reinforce the grave need to stop what Washington views as the creeping erosion of consent. Laypeople, in particular, will find the book a tight and informative historical overview of the ways informed consent has been evaded, but they may also be heartened by the systemic reforms Washington says are needed to restore its central place in American medical research and care.

She advocates, for example, for resolving financial conflicts of interest within institutional review boards, which monitor biomedical research involving human subjects, and for the formal education of medical research subjects through coursework. Washington says eschewing "newspeak" is also vital, noting, "The honest sharing of information and debate concerning human medical experimentation that must inform any decision about consent is rendered impossible by the corruption of the language and semiotics adopted by researchers, their institutions, and by too many ethical experts." In this regard, especially, her book is a welcome step in the right direction.

By Harriet A. Washington

Columbia Global Reports

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Review | A bioethicist warns that informed consent is endangered

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Michael Hickson, a father of five living in Texas, was one of millions of Americans who contracted covid-19 in 2020. The 46-year-old African American, who had become a quadriplegic after having a heart attack while driving in 2017, died in June at St. David's South Austin Medical Center, six days after the hospital ended treatment for him.

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