Ruminations at the breakfast table

Lately, I’ve become engrossed in reading “The Autocrat of the Breakfast Table.” First serialized in the nascent Atlantic Monthly and subsequently brought out in book form in 1858, Oliver Wendell Holmes’ humorous musings include any number of aphorisms about life and health, purportedly shared in dialogue over the first meal of the day in a boardinghouse.

“Just as we find a mathematical rule at the bottom of many of the bodily movements, just so thought may be supposed to have its regular cycles.  Such or such a thought comes round periodically, in its turn.” (p. 56)

“Keep any line of knowledge ten years and some other line will intersect it,” Holmes observes. (p. 223)

I recently received a blanket mailing from the manufacturer of a type of infant formula touting its indication in the treatment of gastroesophageal reflux (GER) in the “happy spitter.” The communiqué referenced a clinical article on diagnosis and treatment of GER and gastroesophageal reflux disease (GERD) in children published in the May 2013 issue of Pediatrics. I read this article in its entirety twice: first, to glean the clinical information; and second, to relish the authors’ recommendations not to treat uncomplicated GER in spitty infants who were otherwise thriving and well.

According to the authors, “GER is considered a normal physiologic process that occurs several times a day in [more than 50% of] healthy infants.” As such, little is required in the way of treatment apart from parental education, anticipatory guidance, and reassurance.

A key issue is distinguishing between clinical manifestations of GER and GERD in term infants, children, and adolescents to identify patients who can be managed with conservative treatment by the pediatrician and to refer patients who require consultation with the gastroenterologist.

The authors emphasize that “lifestyle changes” should be regarded as “first-line therapy in both GER and GERD, whereas medications are explicitly indicated only for patients with GERD.”

The new guidelines strike a note of caution when discussing the dramatic increase in past years in the number of PPI [proton pump inhibitor] prescriptions written for pediatric patients, particularly infants… Overuse or misuse of PPIs in infants with reflux is a matter for great concern. [These medications] in the so-called “happy spitter” should be avoided by all pediatric physicians.

I was pleased to read this update in the light of similar cautionary comments that I had expressed four years ago in the Yale Journal for Humanities in Medicine, “Ruminating on GERD.” Hopefully, these “new” guidelines will provide “high-value, high-quality care without risk to patients or unnecessary direct and indirect costs.”

The words of the autocrat of the breakfast table ring true: “Keep any line of knowledge ten years and some other line will intersect it.”

Oliver Wendell Holmes, Sr.

Oliver Wendell Holmes, Sr.

Minimal Medicine

Sometimes I wonder whether we as a society have not over-medicalized life. We spend so much of our time browsing health columns, monitoring vital signs, ruminating on our symptoms, consulting our doctors. Many of us have become so health conscious that we balk at deviating from the straight and narrow path. When it comes to our health, we have become risk averse.

Even those of us who spend their days in clinical practice recognize that medicine does not encompass all of life.

Perhaps we need to learn to practice minimal medicine.

These thoughts ran through my head as I read Mark Bittman’s final NYT Minimalist culinary column. Over a span of thirteen years Bittman authored nearly 700 weekly columns for the NYT Dining section. As it turns out, the culinary arts share a good deal with medical practice.

“I discovered that you never cook with someone else without learning something,” Bittman writes. “In every case, there’s a two-way transfer of knowledge. If they know less than you do, you grow from teaching. If more, of course, you grow from learning.”

Bittman’s words bring to mind Sir William Osler’s description of medical teacher and student: “the pupil and the teacher working together on the same lines, only one a little ahead of the other. This is the ideal toward which we should move.” After 25 years of practice, Osler observed, “I have learned … to be a better student, and to be ready to say to my fellow students, ‘I do not know’.”

Osler reckoned that “no man can teach successfully who is not at the same time a student.”

Here’s Bittman musing again: “Usually, I was either taught to make something or I modeled it myself, as best I could. I refused to buy into the notion that there was a ‘correct’ way to prepare a given dish; rather, I tried to understand its spirit and duplicate that, no matter where I was cooking.”

Osler advocated that “the practical shall take the place of didactic teaching.” To acquire the skills necessary to perform medical procedures, students are encouraged to “see one, do one, teach one.” In 1867 the physician Oliver Wendell Holmes argued that the “most essential part of a student’s instruction is obtained … not in the lecture-room, but at the bedside.”

Bittman maintains that, “as Jacques Pépin once said to me, you never cook a recipe the same way twice, even if you try.”

How true. And you never perform a physical examination or surgical procedure in exactly the same way. There are always confounding factors which necessitate workarounds and thinking outside the box.

Medical practice, like cooking, is always a compromise. Like their culinary counterparts, clinicians “almost never have the time, the ideal ingredients or equipment, or all of the skills we’d like.”

“Shop avidly, keep a full refrigerator and pantry,” Bittman advises; “pull things out and get to work.”

Where would the good clinician be without a well-stocked surgery?

“My growing conviction that the meat-heavy American diet and our increasing dependence on prepared and processed foods is detrimental not only to our personal health but to that of the planet has had an impact on my life.”

A nutshell of sound dietary advice, one every practicing clinician should take to heart.

Bittman concludes: “What I see as the continuing attack on good, sound eating and traditional farming in the United States is a political issue.”

What I see as the continuing attack on good sound traditional medical practice has lately become a political issue as well.