The observation of art and the art of observing individuals with physical differences.

Astute observation is a fundamental skill in medical care because not only it is crucial for the detection of patients' emotions (which is a prerequisite for empathy) but also it can often yield diagnoses at first sight. The Germans call this technique "augenblickdiagnose," and indeed, gestalt diagnosis together with systematic review is used by dysmorphologists to identify syndromes. Artists have traditionally excelled at skilled observation since it is necessary for realistic portrayal of the human form. Thus, not surprisingly, they have also often depicted syndromes and defects in artworks, decades or even centuries earlier than their medical counterparts' description. Although physicians should avoid overdiagnosing or medicalizing what may be ethnic variations, personality traits, or just artistic style, this commentary will review how syndromes and various physical differences have been represented in artworks. It will then provide practical tips on how to become better observers. The historical relationship between artists and physicians provides context for our mutual diagnostic and interpretative pursuits.

When Disease Strikes Leaders: What Should We Know?

Diseases of heads of state can affect national policy. Yet, cases of cover-up are numerous and involve not only dictatorships but also open and democratic societies. No system of full disclosure is currently in place to ensure that the public has access to all the information needed to establish whether a candidate to the presidency or an elected leader can discharge the powers and duties of the office. Hence, this essay reviews how the illnesses of democratically elected heads of state have changed history; addresses how to ensure greater transparency, so that leaders will not only be unable to conceal incapacitating disabilities, but also be removed from office once impaired; and lastly discusses how illness does not necessarily imply incapacitation, even though separating the two might often be difficult. These are issues of great relevance to national politics and medical ethics. They are particularly important as the 2020 presidential election is underway, and four out of the five leading candidates are well into their 70s.

Out of Touch.

This Viewpoint discusses the role of touch in medical tradition and its importance in medicine today.

The Art of Observation and the Observation of Art: Zadig in the Twenty-first Century.

Astute observation is a fundamental component of the art of medicine. Yet most schools and residencies offer little formal teaching of this skill, with some outsourcing the entire subject matter to art museums and instructors. Curiously, it was nineteenth century medicine that may have provided the conceptual framework for what is now known as Visual Thinking Strategy, the technique used by many art-based programs in order to teach observation. We suggest that the time is ripe for medicine to regain ownership of the teaching of this skill, not only because it may enhance clinical care but also because only the eyes of a skilled physician can best interpret crucial medical details. To this end, we shall revisit both the method of Zadig, which William Osler practiced and taught to his students, and its application to the observation of art first pioneered by the Italian physician Giovanni Morelli. As an example of this skill, we shall use focused observation to decode a fifteenth century portrait that hangs at the Philadelphia Museum of Art, thus turning a seemingly non-descript Renaissance painting into a treasure trove of personal, social, and medical information.

Medical Students' Exposure to the Humanities Correlates with Positive Personal Qualities and Reduced Burnout: A Multi-Institutional U.S. Survey.

BACKGROUND: Literature, music, theater, and visual arts play an uncertain and limited role in medical education. One of the arguments often advanced in favor of teaching the humanities refers to their capacity to foster traits that not only improve practice, but might also reduce physician burnout-an increasing scourge in today's medicine. Yet, research remains limited. OBJECTIVE: To test the hypothesis that medical students with higher exposure to the humanities would report higher levels of positive physician qualities (e.g., wisdom, empathy, self-efficacy, emotional appraisal, spatial skills), while reporting lower levels of negative qualities that are detrimental to physician well-being (e.g., intolerance of ambiguity, physical fatigue, emotional exhaustion, and cognitive weariness). DESIGN: An online survey. PARTICIPANTS: All students enrolled at five U.S. medical schools during the 2014-2015 academic year were invited by email to take part in our online survey. MAIN MEASURES: Students reported their exposure to the humanities (e.g., music, literature, theater, visual arts) and completed rating scales measuring selected personal qualities. KEY RESULTS: In all, 739/3107 medical students completed the survey (23.8%). Regression analyses revealed that exposure to the humanities was significantly correlated with positive personal qualities, including empathy (p < 0.001), tolerance for ambiguity (p < 0.001), wisdom (p < 0.001), emotional appraisal (p = 0.01), self-efficacy (p = 0.02), and spatial skills (p = 0.02), while it was significantly and inversely correlated with some components of burnout (p = 0.01). Thus, all hypotheses were statistically significant, with effect sizes ranging from 0.2 to 0.59. CONCLUSIONS: This study confirms the association between exposure to the humanities and both a higher level of students' positive qualities and a lower level of adverse traits. These findings may carry implications for medical school recruitment and curriculum design. "[Science and humanities are] twin berries on one stem, grievous damage has been done to both in regarding [them]... in any other light than complemental." (William Osler, Br Med J. 1919;2:1-7).

Enhancing and sustaining empathy in medical students.

BACKGROUND: Empathy is an important component of physician competence that needs to be enhanced. AIM: To test the hypotheses that medical students' empathy can be enhanced and sustained by targeted activities. METHODS: This was a two-phase study in which 248 medical students participated. In Phase 1, students in the experimental group watched and discussed video clips of patient encounters meant to enhance empathic understanding; those in the control group watched a documentary film. Ten weeks later in Phase 2 of the study, students who were in the experimental group were divided into two groups. One group attended a lecture on empathy in patient care, and the other plus the control group watched a movie about racism. The Jefferson Scale of Empathy (JSE) was administered pre-post in Phase 1 and posttest in Phase 2. RESULTS: In Phase 1, the JSE mean score for the experimental group improved significantly (p < 0.01); no change in the JSE scores was observed in the control group. In Phase 2, the JSE mean score improvement was sustained in the group that attended the lecture, but not in the other group. No change in empathy was noticed in the control group. CONCLUSION: Research hypotheses were confirmed.

The Moral Lessons of Covid-19: A Call for Renewal.

The Covid-19 pandemic struck physicians at a time of unprecedented dissatisfaction and burnout, providing a stress test whose lessons might guide structural changes in healthcare. While selflessly rescuing patients from death, many doctors were exposed to unacceptable risk, with little protection for themselves, and, by extension, for their families and patients. This essay examines the basis and limits of duty to treat in a time of crisis and explores how these experiences could leave doctors morally stressed and even compromised. We question whether a physician-patient relationship that treats patients' safety and well-being as separate from their doctors' personal and professional values, needs, and dignity is the best way to deliver care. Such questions predated coronavirus but were brought to the forefront because of the epidemic. As physicians process their experiences, we hope to begin a deeper moral and social conversation that might help us be better prepared for future crises.

Mazzini at 150: the Italian death of a London exile.

The year 2022 will mark the 150th anniversary of the death of Giuseppe Mazzini, the spiritual father of the Italian Republic and one of the best political minds of the nineteenth century. In this review, we revisit the events surrounding Mazzini's death, based on a report published in 1872 by Dr. Giovanni Rossini, the Italian physician who cared for him during his last days in Pisa. The detailed clinical information provided by Dr. Rossini suggests quite strongly that Mazzini's most likely cause of death was gastroesophageal cancer complicated by aspiration pneumonia. Surprisingly, there are no published medline entries concerning the cause of death of this Italian patriot and revolutionary, who spent 41 years of his life in exile, was admired by Dickens, Meredith and Carlyle, and is considered not only one of the founding fathers of Italy but also one of the visionaries behind the idea of a United Europe.

Early vs late tracheotomy for prevention of pneumonia in mechanically ventilated adult ICU patients: a randomized controlled trial.

CONTEXT: Tracheotomy is used to replace endotracheal intubation in patients requiring prolonged ventilation; however, there is considerable variability in the time considered optimal for performing tracheotomy. This is of clinical importance because timing is a key criterion for performing a tracheotomy and patients who receive one require a large amount of health care resources. OBJECTIVE: To determine the effectiveness of early tracheotomy (after 6-8 days of laryngeal intubation) compared with late tracheotomy (after 13-15 days of laryngeal intubation) in reducing the incidence of pneumonia and increasing the number of ventilator-free and intensive care unit (ICU)-free days. DESIGN, SETTING, AND PATIENTS: Randomized controlled trial performed in 12 Italian ICUs from June 2004 to June 2008 of 600 adult patients enrolled without lung infection, who had been ventilated for 24 hours, had a Simplified Acute Physiology Score II between 35 and 65, and had a sequential organ failure assessment score of 5 or greater. INTERVENTION: Patients who had worsening of respiratory conditions, unchanged or worse sequential organ failure assessment score, and no pneumonia 48 hours after inclusion were randomized to early tracheotomy (n = 209; 145 received tracheotomy) or late tracheotomy (n = 210; 119 received tracheotomy). MAIN OUTCOME MEASURES: The primary endpoint was incidence of ventilator-associated pneumonia; secondary endpoints during the 28 days immediately following randomization were number of ventilator-free days, number of ICU-free days, and number of patients in each group who were still alive. RESULTS: Ventilator-associated pneumonia was observed in 30 patients in the early tracheotomy group (14%; 95% confidence interval [CI], 10%-19%) and in 44 patients in the late tracheotomy group (21%; 95% CI, 15%-26%) (P = .07). During the 28 days immediately following randomization, the hazard ratio of developing ventilator-associated pneumonia was 0.66 (95% CI, 0.42-1.04), remaining connected to the ventilator was 0.70 (95% CI, 0.56-0.87), remaining in the ICU was 0.73 (95% CI, 0.55-0.97), and dying was 0.80 (95% CI, 0.56-1.15). CONCLUSION: Among mechanically ventilated adult ICU patients, early tracheotomy compared with late tracheotomy did not result in statistically significant improvement in incidence of ventilator-associated pneumonia. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00262431.

The Archetypes of Medicine: A Job Description for the 21st Century.

Medicine is facing an identity crisis, one that might find resolution by revisiting a past rich in multifaceted individuals who transcended the strict definition of 'doctor', excelled in other fields of human endeavor, and showed us different ways of being physicians. This paper reviews 12 archetypes that have been part of the profession since its inception, but that, as of late, might have been forgotten. Our goal is to elicit discussion and introspection, with the premise that being a physician ought to be something larger than being a mere technician. If our premise is accepted, then the next step would be to identify those personal traits that made those archetypes possible, so that we can start both recruiting for them and then nurturing them during training.

Intravenous morphine for breakthrough (episodic-) pain in an acute palliative care unit: a confirmatory study.

The aim of this prospective cohort study was to confirm the safety of intravenous morphine (IV-M) used in doses proportional to the basal opioid regimen for the management of breakthrough pain and to record the nurse compliance on regularly recording data regarding breakthrough pain treated by IV-M. Over a one-year period, 99 patients received IV-M for breakthrough pain during 116 admissions. The IV-M dose was 1/5 of the oral daily dose, converted using an equianalgesic ratio of 1/3 (IV/oral). For each episode, nurses were instructed to routinely collect changes in pain intensity and emerging problems when pain became severe (T0), and to reassess the patient 15minutes after IV-M injection (T15). Nurses were unaware of the aim of the study and just followed department policy. In total, 945 breakthrough events treated by IV-M were recorded and the mean number of events per patient per admission was eight (95% confidence interval (CI) 6.9-9.5). The mean dose of IV-M was 12mg (95% CI 9-14mg). In the 469 events (49.6%) with a complete assessment, a decrease in pain of more than 33% and 50% was observed in 287 (61.2%) and 115 (24.5%) breakthrough events, respectively. The mean pain intensity decreased from 7.2 (T0) to 2.7 (T15). In eight episodes, no changes in pain intensity were observed and a further dose of IV-M was given. The remaining patients did not require further interventions. No clinical events requiring medical intervention were recorded. In this confirmatory study, IV-M was administered for the management of breakthrough pain in doses proportional to the basal opioid regimen to all patients, including older patients and those requiring relatively large doses. This did not result in life-threatening adverse effects in a large number of patients and was effective in most cases. The role of nurses is of paramount importance in monitoring and collecting data and gathering information for audit purposes on the unit.

Medical treatment for inoperable malignant bowel obstruction: a qualitative systematic review.

The use of symptomatic agents has greatly improved the medical treatment of advanced cancer patients with inoperable bowel obstruction. A systematic review of studies of the most popular drugs used in the medical management of inoperable malignant bowel obstruction was performed to assess the effectiveness of these treatments and provide some lines of evidence. Randomized trials that involved patients with a clinical diagnosis of intestinal obstruction due to advanced cancer treated with these drugs were reviewed. Five reports fulfilled inclusion criteria. Three studies compared octreotide (OC) and hyoscine butylbromide (HB), and two studies compared corticosteroids (CSs) and placebo. Globally, 52 patients received OC, 51 patients received HB, 37 patients received CSs, 15 patients received placebo, and 37 patients received both placebo and CSs. On the basis of these few data, the superiority of OC over HB in relieving gastrointestinal symptoms was evidenced in a total of 103 patients. The latter studies had samples more defined in terms of stage and inoperability, and had a shorter survival in comparison with studies of CSs (less than 61 days, most of them less than 20 days). Data on CSs are less convincing, due to the methodological weakness of existing studies. This review confirms the difficulties in conducting randomized controlled trials in this population.

Switching from transdermal drugs: an observational "N of 1" study of fentanyl and buprenorphine.

The aim of this study was to confirm that the concomitant presence of transdermal fentanyl (TTS FE) and buprenorphine (TTS BU) may be feasible without important consequences, using doses presumed to be equianalgesic. A prospective "N of 1" study was carried out in a sample of volunteers with cancer pain receiving stable doses of TTS FE or TTS BU, with adequate pain and symptom control. In the study design, each patient provided data before and after a switch from one opioid to the other and then back to the previous one. Sixteen patients receiving daily stable doses of 0.6 or 1.2mg of TTS FE were switched to TTS BU using an FE-BU ratio of 0.6-0.8. After three days, the TTS BU patch was removed and TTS FE patch was placed for another three days. Six patients receiving TTS BU were switched to TTS FE and then rotated back to TTS BU with the same dosing considerations. No statistical differences in changes in pain and symptom intensity during switching and between the two different sequences were observed. No significant changes in rescue doses of oral morphine were reported at the same intervals. Cancer patients receiving stable doses of TTS FE or TTS BU can be safely switched to the alternative transdermal opioid. Further studies should be performed to gather data about the use of TTS BU with other opioids, at different doses, and in different clinical conditions.

Intrathecal treatment in cancer patients unresponsive to multiple trials of systemic opioids.

The aim of this study was to evaluate the clinical response to a combination of intrathecal morphine and levobupivacaine in advanced cancer patients who were highly opioid-tolerant, being previously treated with multiple opioid trials unsuccessfully. Initial intrathecal morphine dose was calculated from the previous opioid consumption using a morphine oral-intrathecal ratio of 100:1. Then, doses of both drugs were modified during the treatment according to the clinical needs and balanced with adverse effects. Fifty-five patients were assessed during admission, before starting the intrathecal treatment, during the titration phase, and followed up to death, by frequent phone contacts or visits, as available. Pain and symptom intensities were recorded before starting the intrathecal treatment (T0), at time of hospital discharge (T dis), and then at 1 month (T1), 3 months (T3), 6 months (T6) intervals, and the last observation, at least 1 week before death (T death). Fifty-five patients were selected for starting an intrathecal treatment. Thirty-two patients were males. The mean age was 60 years (95% CI 57-63), and 65.4% of patients were under 65 years. The most frequent indication was the presence of adverse effects and poor pain control. Complete data with adequate follow-up until death were available in 45 patients. Statistical differences in pain intensity were found at the different time intervals examined until death. Statistical decreases in the intensity of drowsiness and confusion were found until 1 month after starting intrathecal therapy. Statistical differences were found in daily intrathecal morphine doses, with a 3-fold increase at time of hospital discharge. Subsequently, further increases in doses were not significant. Conversely, systemic opioids, expressed as oral morphine equivalents, significantly decreased at all the intervals examined until death. Early complications included mild bleeding in 2 patients, without consequences, headache in 4 patients, bladder catheterization in 6 patients, reoperation for bleeding or changes of catheter position in 4 patients, unrelated death in 1 patient, and stroke in another 1. Late complications included local infection in 2 patients, and discontinuation of intrathecal therapy due to spinal compression. In patients who had received multiple trial of opioids and routes of administration, the intrathecal treatment started with an oral-intrathecal morphine conversion ratio of 100:1, and local anesthetics at the most convenient clinical doses provided a long-term improvement of analgesia, with a decrease in adverse effects and opioid consumption until death.

A prospective randomized study of corticosteroids as adjuvant drugs to opioids in advanced cancer patients.

This randomized controlled study evaluated the role of corticosteroids as adjuvants to opioid therapy in 76 advanced cancer patients with pain who requiring strong opioids. Patients were divided in 2 groups. Group O received conventional opioid treatment. Group OS received dexamethasone (8 mg orally) along with conventional treatment. Pain and symptom intensity, sense of well-being, and opioid escalation index and distress score were recorded at weekly intervals until death. No differences in pain intensity, opioid consumption, and opioid escalation index were found in 66 patients who survived 33 to 37 days. Corticosteroids did not provide significant additional analgesia to opioids, but persistently decreased opioid-related gastrointestinal symptoms for the patients with limited survival and improved the sense of well-being for some weeks. Corticosteroid-related toxicity was minimal. Further studies with an increased sample size are necessary to detect any minimal difference in analgesia between the two groups.