1. Catch me at noon at NYU talking about uncertainty and shared decision making. 

2. At 6:30pm at the Sidewalk Bar and Restaurant at 6th and A in Manhattan I'll be reading from my new book, Making Sense of Medicine. This is part of the Prose Pros reading series. 

This material originally appeared in the Yiddish Forward; my translation is posted here with their permission.

Dear Dr. Berger, whenever I leave the subway and walk out into the sunshine, I start sneezing. Why is this? -- Isaac Bleaman, Queens, NY

Dear Isaac, 

This reflex (called the photic sneeze reflex) is found in 18 to 35 percent of the population. Its cause is unknown, though researchers have thought about it for a while (Aristotle mentions the phenomenon). Recently, there has been some suggestion that the reflex is associated with a particular genotype. As always with such investigations, however, these associations should be viewed with caution: how common is the gene, how closely related is it to the reflex, and in what proportion of those with the reflex can it actually be said to be causing the reflex?

The photic sneeze reflex is only one of a family of such reflexes, perhaps the most interesting of which is a "sated sneeze" -- which happens in some after a big meal. There have been some mechanisms thrown about; in our era, it appears to be thought that some mixing of nerve signals is involved. Purely speculatively, I'm going to guess that this sneeze is a vestigial reflex from infancy. But who knows? 

***

A friend from England asks, 
"How did you choose medicine as a career?"

There are many possible answers, but I'll relate an experience that happened to me just the other day. 

I was arguing in clinic with a patient of mine, a mother of 4 with chronic pain. She believes that narcotics are the best relief of her suffering. I partially agree, and I actually do prescribe that kind of medication to her. (Other kinds of medication, e.g., the anti-inflammatories, aren't available to her given her medicatl history.) She wants more of them, and I refuse: a higher dose, I say, can cause deleterious side effects. In plain English -- with high doses of narcotics, the cure can be worse than the disease. I don't give in, though I try to express my deepest understanding. She insists, cries and leaves disappointed.

A couple of hours later I get an email from her: "In spite of everything, you're a good doctor." (And as a matter of fact, I reconsider the matter and do increase her dose somewhat.)

Joy and tears, conflict and sympathy -- the most necessary medical equipment I own. 

I've started writing a medical advice column. Please send your questions to sholemberger@yiddish.forward.com. I hope to translate the columns here (they are originally in Yiddish). Also, please check out my new book -- MAKING SENSE OF MEDICINE. 

Dear Dr. Berger,
My 37-year-old daughter underwent a biopsy because of some liver test abnormalities -- AMA and ALP. Can you please explain what values of the tests are normal and which can indicate a problem?
Thank you,
MW

It's time for another essay about how the term "primary care provider" elides important differences between MDs, APNs, and PAs, and the phrase is a new foreign import from the bean-counters and box-checkers.

The first point I sort of agree with. Lumping categories does elide differences. The question is whether they elide *important* differences. In common conditions and much primary care, what matters more is not diagnostic expertise but longitudinal care and communicative approach. And literature shows that NP and MD care can be equivalent in such situations.

The second point is just wrong. The phrase "primary care provider" is 40 years old.

Why this piece, which does not cite the literature comparing NP and MD primary care? I think it's not about terminology but about status anxiety. As doctor-led care moves to team-based care (and, concurrently, to shared decision making), physicians have to decide what their new role is. This can be nerve-wracking. But it can provide an opportunity for open and evidence-based discussions about what primary care really means, without depending on a "recency illusion" that terms are new, or nurse practitioners are interlopers, when neither is the case.