Can American Democracy Pass The Trump Stress Test?

BY MIKE MAGEE

As we enter a new and potentially historic week, with a former President doing his best to reignite a Civil War in our nation, we do well to take a breath and reread James Madison’s words from Federalist No. 51. But first, a few words of history.

When it came to checks and balances in this new national experiment in self governance, the Founders, while establishing three co-equal branches, left one of those branches the task of defining by practice its own power and influence.

The new Constitution in 1787 awarded one branch, the elected Congress, the daunting power to impeach, convict and remove representatives or appointed federal officials for due cause up to the President himself. But it also empowered a second branch, the Executive, through its President, veto power to check legislative excesses and the privilege of initiating appointments to the federal judiciary. Only the third branch of the government, the Judiciary, was left deliberately “elastic,” destined to grow into “the triangle of power.”

Thirteen years later, on February 17, 1801, Congress was forced to break a tie in the Electoral College vote, resolving a Constitutional crisis and declaring a victor in one of “the most acrimonious presidential campaigns” in U.S. history. Thomas Jefferson was awarded the victory, and John Adams acquiesced and was sent packing a month later. But two days before he departed, Adams unloaded multiple appointments of circuit justices and justices of the peace which the U.S. Senate quickly confirmed on March 3rd. In the rush, Adam’s Secretary of State, John Marshall (soon to become Chief Justice Marshall of the Supreme Court under President Jefferson) didn’t have time to complete a final necessary step, delivering the commissions, to some of the appointees.

When Jefferson took office on March 4th, and saw the opportunity to block some judgeships on the technicality, he instructed his new Secretary of State, James Madison, to not deliver the commissions. One of those prospective new judges, a Maryland businessman, William Marbury, after trying to unlock his commission for several months, filed a lawsuit in December, 1801 demanding that his commission be delivered through a “writ of mandamus.” ( “an order from a court to an inferior government official ordering the government official to properly fulfill their official duties or correct an abuse of discretion.”)

Eventually the case came to the Supreme Court and John Marshall delivered the unanimous verdict on February 24, 1803 in Marbury v. Madison

In short, William Marbury did not get his judgeship, but not because he didn’t deserve it. He did, and the decision said as much. But the Court also recognized that the authority that Section 13 of the Judiciary Act of 1789 had granted the Court to issue “writs of mandamus” (and effectively force Secretary of State Madison to deliver the appointment) was unconstitutional. 

This was because Article III of the U.S. Constitution  (signed September 17, 1787) made clear that the Supreme Court had “original jurisdiction over cases only where a U.S. state is party to the lawsuit.” As legal experts have explained: While the decision “limited federal court’s jurisdiction, it cemented the Court’s status as the ultimate interpreter of the Constitution.”

William Marbury’s loss became our nation’s gain. Our third branch of government, in finding its voice, defined its own powers. As Justice Marshall wrote “It is emphatically the province and duty of the Judicial Department to say what the law is…a Law repugnant to the Constitution is void.” As law historian Lawrence Friedman wrote, “Here for the first time John Marshall in the U.S. Supreme Court dared to declare an act of Congress to be unconstitutional.”

Donald Trump, for a time, sat himself in the middle of America’s triangle of power. From his seat as President, he installed himself as “a Golden Idol” and had a commanding view of the Executive branch of government. By aligning with the Federalist Society, the Christian Right and Mitch McConnell, he was able to stack the Judiciary and deliver a promised reversal of Roe v. Wade. But that federal overreach, which included rejecting  50 years of precedent and compromising women’s freedom and autonomy over their own bodies, fueled a resounding 2020 Trump defeat and Republican statewide under-performance in the 2022 Mid-term elections.

It also triggered a first ever President-led armed insurrection on January 6, 2021. But in a real-life “Democracy stress test,” this may be the moment when our three branches of government finally deliver a message to all Americans that no man is above the law. 

First, our citizenry pried the Executive branch free of Trump in 2020. 

Second, our Judiciary, including state and federal courts, have rejected nearly 100 bogus cases led by unethical lawyers on Trump’s behalf, and are nearing multiple indictments of a now, unprotected and disgraced former President. 

Third,  a Republican led Congress has been forced to privately cooperate on real issues, while publicly feigning continued fealty to Trump and a small band of Trump look-alike’s intent on driving their party over the cliff.

So what did James Madison, author of Federalist No. 51, have to say about all this? 

On February 8, 1788, he wrote: “If men were angels, no government would be necessary. If angels were to govern men, neither external nor internal controls on government would be necessary. In forming a government which is to be administered by men over men, the great difficulty lies in this: you must first enable government to control the governed; and in the next place oblige it to control itself.”

Trump is a stress test, and our nation is rising to the challenge. We are gradually, slowly and painfully, learning to “control ourselves” by enforcing our laws. Democracy is a work in progress.

Mike Magee MD is a Medical Historian and author of CODE BLUE: Inside the Medical-Industrial Complex.

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THCB Spotlight: Glen Tullman, Transcarent & Aneesh Chopra, Carejourney

I just got to interview Glen Tullman, CEO Transcarent (and formerly CEO of Livongo & Allscripts) & Aneesh Chopra, CEO Carejourney (and formerly CTO of the US). The trigger for the interview is a new partnership between the two companies, but the conversation was really about what’s happening with health care in the US, including how the customer experience needs to change, what level of data and information is available about providers and how that is changing, how AI is going to change data analytics, and what is actually happening with Medicare Advantage. This is a fascinating discussion with two real leaders in health and health techMatthew Holt

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THCB Gang Episode 122, Thursday March 30

Joining Matthew Holt (@boltyboy) on #THCBGang on Thursday March 16 at 1PM PT 4PM ET are Olympic rower for 2 countries and DiME CEO Jennifer Goldsack, (@GoldsackJen); patient safety expert and all around wit Michael Millenson (@mlmillenson); benefits expert Jennifer Benz (@Jenbenz); and our special guest health economist VP of Research at Trilliant HealthSanjula Jain @sanjula_jain.

If you’d rather listen, the “audio only” version is preserved as a weekly podcast available on our iTunes & Spotify channels — Matthew Holt

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AI: Not Ready, Not Set – Go!

By KIM BELLARD

I feel like I’ve written about AI a lot lately, but there’s so much happening in the field. I can’t keep up with the various leading entrants or their impressive successes, but three essays on the implications of what we’re seeing struck me: Bill Gates’ The Age of AI Has Begun, Thomas Friedman’s Our New Promethean Moment, and You Can Have the Blue Pill or the Red Pill, and We’re Out of Blue Pills by Yuval Harari, Tristan Harris, and Aza Raskin.  All three essays speculate that we’re at one of the big technological turning points in human history.

We’re not ready.

The subtitle of Mr. Gates’ piece states: “Artificial intelligence is as revolutionary as mobile phones and the Internet.” Similarly, Mr. Friedman recounts what former Microsoft executive Craig Mundie recently told him: “You need to understand, this is going to change everything about how we do everything. I think that it represents mankind’s greatest invention to date. It is qualitatively different — and it will be transformational.”    

Mr. Gates elaborates:

The development of AI is as fundamental as the creation of the microprocessor, the personal computer, the Internet, and the mobile phone. It will change the way people work, learn, travel, get health care, and communicate with each other. Entire industries will reorient around it. Businesses will distinguish themselves by how well they use it.

Mr. Friedman is similarly awed:

This is a Promethean moment we’ve entered — one of those moments in history when certain new tools, ways of thinking or energy sources are introduced that are such a departure and advance on what existed before that you can’t just change one thing, you have to change everything. That is, how you create, how you compete, how you collaborate, how you work, how you learn, how you govern and, yes, how you cheat, commit crimes and fight wars.

Professor Harari and colleagues are more worried than awed, warning: “A.I. could rapidly eat the whole of human culture — everything we have produced over thousands of years — digest it and begin to gush out a flood of new cultural artifacts.”  Transformational isn’t always beneficial.

Each of the articles points out numerous ways AI can help – and in some cases, already is helping – solve important problems.  Even though Professor Harari and his colleagues are the most concerned, they admit: “A.I. indeed has the potential to help us defeat cancer, discover lifesaving drugs and invent solutions for our climate and energy crises. There are innumerable other benefits we cannot begin to imagine.”

All three essays, in fact, reference how AI could help revolutionize health care in particular; Mr. Gates devotes an entire section of his essay to how AI will improve health and medical care, while Mr. Friedman discusses at length AI’s role in understanding protein folding, which has crucial roles in drug discovery.

Exciting times.  Peter Lee, Microsoft’s Corporate Vice President, Research, tweeted:

https://platform.twitter.com/widgets.js

Of course, not every industry is going to be equally ready.  Take healthcare.  Joyce Lee, M.D. (aka Doctor as Designer) bemoaned:

https://platform.twitter.com/widgets.js

Healthcare is trying to use 21st century technology in a system with 19th century institutions (e.g., hospitals) and 20th century regulations (e.g., telehealth licensing restrictions).  AI is going to be ready for healthcare long before healthcare is ready for it.

————-

The problem is, of course, much bigger than healthcare.  As Mr. Friedman laments: “Are we ready? It’s not looking that way: We’re debating whether to ban books at the dawn of a technology that can summarize or answer questions about virtually every book for everyone everywhere in a second.”

Professor Harari and colleagues are even more doubtful: “Social media was the first contact between A.I. and humanity, and humanity lost.”  And that was with what they correctly call “primitive” AI; imagine, they say:

What would it mean for humans to live in a world where a large percentage of stories, melodies, images, laws, policies and tools are shaped by nonhuman intelligence, which knows how to exploit with superhuman efficiency the weaknesses, biases and addictions of the human mind — while knowing how to form intimate relationships with human beings?

 Scary, indeed.

The U.S. did a terrible with recognizing how automation – more than outsourcing – took away hundreds of thousands of factory jobs over the past few decades, and we’re even more ill-prepared for when AI comes for all those white collar and “creative” jobs.  Such as in healthcare.

More than jobs are at stake, according to Professor Harari and colleagues:  

The time to reckon with A.I. is before our politics, our economy and our daily life become dependent on it. Democracy is a conversation, conversation relies on language, and when language itself is hacked, the conversation breaks down, and democracy becomes untenable.

No, we’re not ready, especially, as Mr. Gates says: “Finally, we should keep in mind that we’re only at the beginning of what AI can accomplish. Whatever limitations it has today will be gone before we know it.”  Professor Harari and colleagues go even further: “We have summoned an alien intelligence. We don’t know much about it, except that it is extremely powerful and offers us bedazzling gifts but could also hack the foundations of our civilization.”

Wow.

—————

AI is not like just a faster computer. It is not even like the introduction of the PC or the smartphone. This is, as the above authors have said, potentially more like mastery of fire, use of the wheel, development of the steam engine, or the advent of man-made electricity.  AI will change society as we’ve known it, in ways we can’t predict.

All three essays are dubious that market forces alone are going to result in AI that has the best outcomes for society, as opposed to for a select few.   Mr. Gates’ main priority is: “The world needs to make sure that everyone—and not just people who are well-off—benefits from artificial intelligence.”  To do that, Mr. Friedman believes: “We are going to need to develop what I call “complex adaptive coalitions” — where business, government, social entrepreneurs, educators, competing superpowers and moral philosophers all come together to define how we get the best and cushion the worst of A.I.”

But we don’t have the luxury of time. Professor Harari and colleagues urge: “The first step is to buy time to upgrade our 19th-century institutions for an A.I. world and to learn to master A.I. before it masters us.” 

I’m not sure our technology obtuse legislators or our for-profit orientation are ready for any of that.  So have fun playing with GPT-4 or Bard, but this is not a game. AI’s implications are world-changing.

Kim is a former marketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor.

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Matthew’s health care tidbits: The drug model for DTx was wrong

Each time I send out the THCB Reader, our newsletter that summarizes the best of THCB (Sign up here!) I include a brief tidbits section. Then I had the brainwave to add them to the blog. They’re short and usually not too sweet! –Matthew Holt

If you were to look at pharmaceuticals in the US you might make three observations. 1) They are the most important way health conditions are helped, cured or eradicated. 2) The way they are delivered to patients (via pharmacies) is very badly integrated with the health care delivery system. 3) They are way too expensive.

OK, so those are my observations not yours but I think you’ll agree they’re all true.

Now I am going to tell you that we’ve developed a technology that lives in your phone that has the same impact as a drug, if not better. It will cure your depression, insomnia, pain, even maybe Alzheimer’s. And because it is a software product, not a drug you ingest, it has no (or at least few) dangerous side effects. And because it’s software and easy to distribute to millions of people, it can be cheap. Wouldn’t it be a great idea for the people managing health conditions—a patient’s clinical care team—to directly integrate this technology into the care they are delivering?

Some of the people building these technologies agreed, but most of them decided that they liked the current model of prescription pharmaceuticals. They built these cool technologies and decided to distribute them via physician prescriptions and charge for them like pharmaceuticals. To do that, they had to get FDA approval for their “Prescription Digital Therapeutics” (DTx) via expensive clinical trials. Additionally, of course, they hoped to get government-backed monopoly status–called patents in the pharma business.

In general in health care, the FDA regulates things that go into the body and may cause damage. The rest of clinical medicine has great latitude for experimentation, technique and technology development, and allows others to copy what works.

The companies heading down the Prescription DTx route also used the business model of regular pharma and biotech companies. They raised large amounts of money up front, applied for patents, went through the FDA clinical trial process, and hoped to charge significant amounts per patient once their DTx were approved and prescribed.

None of them seemed to care that if they succeeded, their DTx would necessarily only be accessed by a small population at great cost. None of them seemed to notice that their DTx were usually an electronic distillment of teaching, patient advice, coaching therapy or other activities that look more like extensions of traditional clinical care, as opposed to ingested pharmaceuticals.

Many of these companies are now in deep trouble. They raised money when it was cheap or even, like Pear and Better Therapeutics, took advantage of the SPAC vehicles to IPO. Now they have found that they cant get their DTx through the FDA process quickly enough or aren’t seeing the prescribing numbers they needed to make their products a success. Since the digital health stock crash, it’s very hard for them to raise more money. Pear Tx this week announced it was trying to sell itself.

My hope is that we get a reset. I want digital therapies that are extensions of clinical care to be widely used and widely available as part of the care process, and for their care to be integrated into clinical care –rather than to be prescribed and then delivered by some third-party. And, because they are software and software scales, I want them to be cheap. Hopefully that is the future of DTx.

On second thoughts, that wouldn’t be a bad future for regular pharmaceuticals either!

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Elia Stupka, Angelini Ventures

I’ve been friends with Roberto Ascione for many years. Roberto is a keen Napoli fan who on the side runs the Healthware Group and also the Frontiers Health Conference that I’ve been going to for many years (and where Jess DaMassa is co-MC). Recently Healthware acquired the media company pharmaphorum and hired star reporter (and another friend) Jonah Comstock, ex MobiHealthNews and HIMSS Media. This is THCB’s second cross-posting with pharmaphorum.Matthew Holt

Nils Bottler, who recently joined Angelini Ventures as Principal, is an avid skier, surfer, and digital health investor based in Berlin. In a new podcast, he spoke with Paul Tunnah, pharmaphorum founder, about his career, the German start-up landscape, and where Angelini Ventures aims to have an impact.

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THCB Gang Episode 121, Thursday March 23

Joining Matthew Holt (@boltyboy) on #THCBGang on Thursday March 16 at 1PM PT 4PM ET are futurist Ian Morrison (@seccurve); writer Kim Bellard (@kimbbellard); Suntra Modern Recovery CEO JL Neptune (@JeanLucNeptune); and Olympic rower for 2 countries and all around dynamo DiME CEO Jennifer Goldsack, (@GoldsackJen).

The video will be below. If you’d rather listen to the episode, the audio is preserved from Friday as a weekly podcast available on our iTunes & Spotify channels

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Throw Away That Phone

By KIM BELLARD

If I were a smarter person, I’d write something insightful about the collapse of Silicon Valley Bank. If I were a better person, I’d write about the dire new UN report on climate change. But, nope, I’m too intrigued about Google announcing it was (again) killing off Glass. 

It’s not that I’ve ever used them, or any AR (augmented reality) device for that matter. It’s just that I’m really interested in what comes after smartphones, and these seemed like a potential path. We all love our smartphones, but 16 years after Steve Jobs introduced the iPhone we should realize that we’re closer to the end of the smartphone era than we are to the beginning. 

It’s time to be getting ready for the next big thing.  

—————

Google Glass was introduced ten years ago, but after some harsh feedback soon pivoted from a would-be consumer product to an Enterprise product, including for healthcare. It was followed by Apple, Meta, and Snap, among others, but none have quite made the concept work. Google is still putting on a brave face, vowing: “We’ll continue to look at ways to bring new, innovative AR experiences across our product portfolio.”  Sure, whatever.

It may be that none of the companies have found the right use case, hit the right price point, adequately addressed privacy concerns, or made something that didn’t still seem…dorky. Or it may simply be that, with tech layoffs hitting everywhere, resources devoted to smart glasses were early on the chopping block. They may be a product whose time has not quite come…or may never.   

That’s not to say that we aren’t going to use headsets (like Microsoft’s Hololens) to access the metaverse (whatever that turns our to be) or other deeply immersive experiences, but my question is what’s going to replace the smartphone as our go-to, all-the-time way to access information and interact with others? 

We’ve gotten used to lugging around our smartphones – in our hands, our purses, our pants, even in our watches – and it is a marvel the computing power that has been packed into them and the uses we’ve found for them. But, at the end of the day, we’re still carrying around this device, whose presence we have to be mindful of, whose battery level we have to worry about, and whose screen we have to periodically use. 

Transistor radios – for any of you old enough to remember them – brought about a similar sense of mobility, but the Walkman (and its descendants) made them obsolete, just as the smartphone rendered them superfluous.  Something will do that to smartphones too.

What we want is all the computing power, all that access to information and transactions, all that mobility, but without, you know, having to carry around the actual device. Google Glass seemed like a potential road, but right now that looks like a road less taken (unless Apple pulls another proverbial rabbit out of its product hat if and when it comes out with its AR glasses). 

—————-

There are two fields I’m looking to when I think about what comes after the smartphone: virtual displays and ambient computing. 

Virtual displays: when I refer to virtual displays, I don’t mean the mundane splitting your monitor (or multiple monitors) into more screens. I don’t even mean what AR/MR (mixed reality) is trying to accomplish, adding images or content into one’s perception of the real world. I mean an actual, free-standing display equivalent to what one would see on a smartphone screen or computer monitor, fully capable of being interacting with as though it was a physical screen. Science fiction movies are full of these.

I suspect that these will be based on holograms or related technology. The displays they render can appear fully life-like. You’ll use them like you would a physical screen/device, not even thinking about the fact that the displays are virtual. You may interact with them with your hands or maybe even directly from your brain.

They’ve historically required significant computing power, but this may be changing and might not even be a constraint even if it doesn’t, due to ambient computing.  

Ambient computing: We once thought of computers as humans doing calculations. Then they became big, room-sized machines. Personal computers brought them to a more manageable (and ultimately portable) size, and smartphones made them fit to our hands. Moore’s Law continues to triumph.

Ambient computing (aka, ubiquitous computing, aka Internet of Things – IoT) will change our conceptions again. Basically, computers, or processors, will be embedded in almost everything. They’ll communicate with each other, and with us. As we move along, the specific processors, and their configuration, may change, without missing a beat, much as our smartphones switch between cell towers without us (usually) realizing it. AI will be built in everywhere. 

The number of processors used, which processors, and how they’re used, will depend on where you are and what task you want done. The ambient computer may just listen to your direction, or may project a screen for you to use, depending on the task. You won’t worry about where either is coming from.

In that new world of virtual screens and ambient computing, carrying around a smartphone will seem as antiquated as those 1950’s mainframes. Our grandchildren will be as astounded by smartphones as Gen Z is by rotary phones (or landlines in general).

That’s the kind of advance I was hoping Google Glass would help bring about, and that’s why I’m sad Google is calling it quits.   

—————-

Healthcare is proud of itself because it finally seems to be embracing telehealth, digital medicine, and EHRs. Each is long overdue, none are based on any breakthrough technologies, and all are being poorly integrated into our existing, extremely broken healthcare system. 

What healthcare leaders need to be thinking about is what comes next. Healthcare found uses for Google Glasses and is finding uses for AR/MR/VR, but it is still a long way from making those anywhere close to mainstream. Smartphones are getting closer to mainstream in healthcare, but no one in healthcare should assume they are anything but the near-term future. 

What is possible – and what is required – when there are no physical screens and no discrete computers? 

Hey, I’m still waiting for my holographic digital twin as my EHR. 

Kim is a former marketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor.

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Interview with Ogi Kavazovic, CEO of House Rx

Ogi Kavazovic, CEO of House Rx joined Matthew Holt to explain how his company is trying to ungum the specialty pharmacy market. Its a huge market with a few huge oligopolies in charge of it, and Ogi thinks there is room to work directly with the clinics responsible for most patients using injectables and provide them a better and cheaper experience. Last year they raised $30m in a round led by Bessemer, but as Ogi says there’s along way to go!

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Two Patients With More Than One Diagnosis

BY HANS DUVEFELT

I have written many times about how I have made a better diagnosis than the doctor who saw my patient in the emergency room. That doesn’t mean I’m smarter or even that I have a better batting average. I don’t know how often it is the other way around, but I do know that sometimes I’m wrong about what causes my patient’s symptoms.

We all work under certain pressures, from overbooked clinic schedules to overfilled emergency room waiting areas, from “poor historians” (patients who can’t describe their symptoms or their timeline very well) to our own mental fatigue after many hours on the job.

My purpose in writing about these cases is to show how disease, the enemy in clinical practice if you will, can present and evolve in ways that can fool any one of us. We simply can’t evaluate every symptom to its absolute fullest. That would clog “the system” and leave many patients entirely without care. So we formulate the most reasonable diagnosis and treatment plan we can and tell the patient or their caregiver that they will need followup, especially if symptoms change or get worse.

Martha is a group home resident with intellectual disabilities, who once underwent a drastic change in her behavior and self care skills. She even seemed a bit lethargic. A big workup in the emergency room could only demonstrate one abnormality: Her head CT showed a massive sinus infection. She got antibiotics and perked up with a ten day course of antibiotics.

A month later, her condition deteriorated again. It was on the weekend. This time she had a mild cough. Her chest X-ray showed double sided pneumonia. She got antibiotics again and started to feel better.

When I saw her in followup, she was still coughing a little, and she wasn’t her usual happy self. Her lungs were clear. I asked her caregiver if they had done a head CT the last time she was in the ER. I saw no mention of it in the ER report.

“I’m pretty sure they did”, he said.

I retrieved it from the statewide Maine Health InfoNet site. It described that all the sinuses were infected and only slightly improved from the earlier study.

Martha is now on a much longer course of antibiotics, because a sinusitis often takes a lot longer to clear up than most pneumonias. I sometimes compare this to getting the contents of an egg out through a tiny hole in the shell (I never did learn how that is done). And, a sinusitis can sometimes cause pneumonia because of postnasal drip.

I saw another case the other day where I think I was able to piece things together.

Gretchen had seen another provider for headaches. She had migraines in her youth but they stopped after she had her first child. My colleague ordered a brain MRI to make sure there wasn’t something more malignant going on. It showed what the radiologist described as a possible migrainous angiopathy.

By the time I ended up seeing her, she had had the migraine for over a week and she had taken daily doses of over-the-counter remedies, so I figured that she now had an element of withdrawal headache. Normally I prescribe prednisone in such cases, but Gretchen told me she has had severe psychiatric side effects from steroids before.

I asked her to wean off the OTC medications and started her on topiramate. Gradually her headaches got better. Then, a few days later we got a phone call, saying her migraine had come back with a vengeance. It was late in the day and she had been vomiting. She went to the ER and they gave her IV fluids, metoclopramide and something for pain.

I saw her in followup and she was better but very worried, telling me her headache was starting to build again.

Then she told me something that jolted my brain I to action.

“Whenever I start to hurt on the side of my nose where I had the surgery, the headache comes on.”

“What kind of surgery”, I asked.

“I had a big cyst removed, se-ba-cious I think it was called.”

“Can you take your mask off”, I asked. I had not seen her uncovered face before.

She did and there was a big scar.

“What kind of pain do you have there”, I asked. Is it steady or, like, pulsating?”

“It’s like jabs and jabs, like someone is sticking needles in there.”

I pulled the monofilament from my pocket and started touching her over the three branches of the trigeminal nerve on each side of her face.

“Does this feel the same on both sides of your face?”

“No, it’s different.”

I took a deep sigh and explained:

“This looks like a nerve pain, a neuralgia, in the nerve that reaches the skin outside your sinus there, and also in the other two branches that go to the forehead and the jaw. It’s called the trigeminal nerve and it comes directly from the brain. I wonder if that is what has made your migraines come back after all these years.”

“Can you stop this from getting full blown”, she asked.

“I probably can’t stop the neuralgia very quickly. Most neuralgia medications take a while to,start working, but I’ll send in a prescription for Imitrex. Take one as soon as you get home and you can take one more later today if you have to. Then call me tomorrow and let me know how you are doing.”

The next day she told me she was headache free after just one Imitrex, and the neuralgia was barely noticeable.

I’m curious how she will do in the long run, and I’m curious if the trigeminal neuralgia is somehow related to the surgery she had there.

Like I’ve said before, curiosity is a powerful antidote to burnout.

Hans Duvefelt is a clinician, writer, and author of “A Country Doctor Writes.”

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