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Sensible Medicine
Common sense and original thinking in bio-medicine
A platform for diverse views and debate
Common sense and original thinking in bio-medicine
A platform for diverse views and debate
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Why are mRNA injections still in use?
I have not finished listening to this episode yet but the first discussion about shortening training really hit a nerve. I do think that the preclinical time could be shortened but I am reticent to take away any clinical time. As it is, the med school with which I am affiliated has dropped 3rd year clerkships down to 39 weeks with multiple intercessions and a month off to study for boards. The med students are spending 3-6 weeks in a specialty, there are rotations on which they do not take overnight call nor do they work on the weekends, and then they are expected to make a career decision. The 4th year is about 18 months long but there are multiple breaks for board studying and interviews. They seem to have much less clinical exposure prior to starting residency.
For the past few years, there has been the added educational hit of virtual med school during covid. Our first and second year residents came in with very limited patient interactions, team work experience, and overall clinical exposure. They want to do a good job but many are behind in their knowledge base and skills. I am hopeful that this will improve with the next few classes but we will see.
I do not think that we can say that residents have proficiency after seeing "X" numbers of cases. Yes, 99 patients follow the script but you have to see those 99 to recognize the 1 that does not. I am 20 years out and am still humbled daily by uncommon presentations, clinical courses, and challenging patients. And then there is the issue of autonomy. With hospitalists and nocturnists and fellows, how often does the senior resident really get to be the decision maker for a patient. Yes, they may know the right answer on rounds but that does not always translate to creating the appropriate treatment plan in the middle of the night. Nor to having the confidence and triage skills to care for large numbers of patients with little to no supervision. There are absolutely residents who could be done in fewer years but they are not the majority.
I would prefer to see tracks (ie for general practice vs academics vs fellowship bound) rather than shorter training.
I did a college to med school program back in the day that was 3 years of college and then automatic skip to the interview/early admission to the affiliated med school. It worked well and shaved a year off the training. Completely agree that adding more time does not provide significant value. Of course, I would also like a lively debate about board recertification - as you progress in your career, your focus narrows, yet you are expected to know everything in your specialty whether your practice is general or focused. Really enjoy learning a bunch of stuff just to pass boards every 10 years!
Laura, I think the current 3+4 program works for a small group of people who are extremely mature and focused. However, I much prefer students and residents who took time off between college and med school and had "real life" experiences. They tend to have a better work ethic and a sense of the world outside of academics. Taking the break also lets people decide if medicine is really the path they want to pursue. I talk to so many students who have an idealized vision of the medical profession and are then crushed when the reality is so different.
Board certification is a good topic. Do you still have to test every 10 years? Peds moved to quarterly questions several years ago and it is bearable, kind of. My biggest issue with recertification is the insane amount of money that we have to pay for this privilege. It is a total racket!
Every 10 years for infectious disease. They are trying a new thing with online questions but honestly, after being in practice for 34 years and taking my boards three times, I don’t feel that I need to pay all the money and spend all of the time to “prove” myself one more time...I can find something else to do at this point. They are going to lose a lot of us to early retirement because we are so sick of it.
Get ‘em Vinay!
I'm in an unusual program, so fellowship training is something I consider quite important. My current residency in Preventive Medicine and Public Health has me only in clinic for the equivalent of one full day a week (the rest being spent on my MPH or various other educational or public health endeavors), so I wouldn't feel comfortable going into addiction medicine without a fellowship.
In the broader context, I agree that we waste a lot of time in medical training. The Australian system (where I spent some of my schooling) has all medical grads do the equivalent of a transitional year before applying to specialty training, which I do think makes some sense. In the current system, your career path is largely decided by things that happen before you have much in the way of patient care experience. I wonder if we might be able to transition the largely useless fourth year of medical school into more of a paid internship model.
I also wonder if we could cut out some of the basic science stuff. One proposal I've seen is to have the equivalent of a preclinical education standardized across professions, so medicine, dentistry, veterinary medicine, etc. etc. would all do some basic science, get one credential, and then differentiate into learning domain-specific knowledge. I would much rather see that than see med schools rushing through trying to teach the basics that advanced students already know and the nontraditional students can't keep up with.
Not so much about Long Covid as much as about post Covid observations.
During the height / onset of the pandemic, I was working as a Home health PT. This was not fun as at that time we didn’t have a clue about transmission and we went full on “hazmat” going into houses: gown, shoe covers, N95 w/ cloth cover, face shield, hair net (or as I called it the Lunch Lady Hat) and of course gloves. Not so comfortable in Georgia during the heat of summer. Here’s some bullet points of thing I noticed, all anecdotal, that I would like any one to comment on.
Prolonged hospital stays after coming off vent. Patients Stays up to 7-8 weeks as they were still testing positive for Covid on PCR. Were they still with virus or was the PCR test problematic?
Post vent Covid patients demonstrating upper extremity weakness like a neurapraxia . Was it from the virus or was it position related from the frequent proning while on vent?
Again post vent Covid patients, would subjectively report “feeling better” when the patient was finally strong enough to get outside in the sun or even on the porch in the shade. One patient’s daughter even made the comment how her mother hated to go outside but now wanted to go out and sit every day. Was it the whole Vitamin D thing? Was it a cabin fever thing after being locked up in a hospital for several weeks? I found some YouTube videos about Light as Medicine “ I found interesting.
The variability of COVID’s effect on individuals in the home. Husband and wife would both get the virus, one would go on vent and the other have a few days in hospital and come home usually to be the caregiver of their spouse.
Note: The patient population demographics varied from low to high socioeconomics, age 50’s to 70’s, mostly African-American, low to high comorbidities. So a mixed bag of people.
I am not a hairdresser on the side trying to push this as observational study results. The podcast just sparked my memory about other things I observed that never really got explained to me and was hoping to get some input. Were these regional things to my area or did other people see them too?
Again not specifically Long Covid but maybe related? Anyway thank you Sensible Medicine for another interesting and enjoyable podcast.
Good conversation on the fellowship. I think a major problem is the dumbing down of the American higher education system. When I went to school it only took 4 years to be ready to be a CPA. Now it takes 5 and the kids don't learn anything major in accounting until the 5th year. They just changed Physical Therapy so you need to have a doctorate.
Definitely agree about the dumbing down of education. I don't know what Dr. Prasad's experience of getting an MPH was, but mine has been mostly a review of statistics and methodology that I learned as a college sophomore 15 years ago. And I don't think having a virtual year (or more) of college helped.
I remember the change over from Bachelorette to Doctorate for PT. Our Department Head gave us a talk about it saying that as the field has progressed the education level has gotten more rigorous and assessed to be worthy of a Doctorate Level. That was in 1997. I think some of this push was for PT’s to get Direct Access to treat patients without a referral from an MD. A Doctor of PT maybe does get more differential diagnosis than I got in PT school along with some other specialty classes here and there. But I’m not sure over all it has pushed the profession toward Independence from a referral system. It definitely hasn’t made reimbursement any better for PT services. I know for sure that new grads from PT school are definitely saddled with more debt than I was.
Same with audiology!
In regards to the vascular surgery intergrated program it is a 5 year program that has been around since 2008. There were 4 spots pgy 1 in 2008 and now close to 90. The breakdown is about 50/50 male female. It had been a very popular option over the years. Interestingly there are many job posting will specifically ask for traditionally 5+2 trained applicants.
I also like to hear the audio podcast sometimes because I do not have the ability to read something during my workouts which involve moving around too much. I like the definition of suffering – suffering is pain(emotional, psychological, physical)and resistance to pain. I recommend MBSR for all.
I LOVE listening to these podcasts.
I know others have said they don't have the time, but I find the time for the things that I want to read or listen to.
I love the back & forth commentary & the 'down to earth' thoughts!
Yes. I read much faster than I listen. Nobody has a waking hour to spare (especially for a possibly mythical ailment like long Covid).
Want to change my mind about long Covid? Let’s have transcripts! Thanks.
Transcript is up.
Post virus issues don't exist?
Oh. Okay.
I guess the shingles/chicken pox connection doesn't exist either?
Hey …I love you guys Dr Prasad… I totally agree with your “view” of long Covid. I wish we better understood the true pathophysiology of this “condition “ and could offer a therapeutic.
I know you guys don’t do this stuff, but I’m pretty surprised that more people don’t seek acupuncture for treatment of long Covid. The reason I think this is that acupuncture seems to regulate systems, and so much long Covid seems systemic. I’m not any sort of healthcare practitioner, so maybe I’m just pulling this out of my ass, but that’s just my feeling, as a former acupuncture patient.
I had Covid last year, and actually having suffered insomnia, it seemed to help me sleep better! I slept so much better while I had COVID and actually had an improvement in my health as a result (even though initially, I was exhausted with Covid). Where is the research on any positive effects from it? Now, I'm probably an outlier, and I was NOT expecting any benefit from Covid, but for sure, 3 months on, on a subjective level, I feel better than before.
Regarding long COVID, please look at the website www.incelldx.com, which is the website for Bruce Patterson, MD's laboratory where they perform diagnostic studies on long COVID patients and find biochemical markers that do not show up on routine laboratory testing. You would also gain a great deal of knowledge on long COVID from the MDs on the website FLCCC.net and PeterMcCulloughmd@substack.com.
Thank you!
How do you explain a healthy 55y/o female, non-smoker, rare alcohol, BMI 23, no co-morbidities, who used to train/compete in long distance triathlon....now, can barely run, and experiences dyspnea on a daily basis after Covid infection??? I was dismissed by a pulmonologist who said he had nothing to offer me, misdiagnosed by an internist who said I had lymphoma, and now spend my time researching long Covid protocols that recommend supplements and H1/H2 blockers and cholesterol lowering drugs such as Fenofibrate. Do Not say long covid doesn’t exist. Even if there is research that does not support any treatment protocols at least try something based on knowledge that we already have. Some of these suggestions are over the counter and easily obtained. What really stings as much as not feeling well is the hurt one feels as a medical professional, who is being blown off by another medical professional. Medical practice can be myopic, often non compassionate and downright frustrating! We are so in trouble moving forward!
As a fellow person with subjective illness not well understood by the medical profession, I think one has to consider this question. Acknowledging that both of these are problems, which do you think is a bigger problem:
1. Overdiagnosis and overtreatment of patients whose complaints are not, in the pertinent sense, a "real" physiologic illness (and are instead psychosomatic, social contagion, or otherwise idiopathic).
2. Underdiagnosis and undertreatment of patients whose complaints are real, but are not well understood by modern science or are simply missed by clinicians who are ignorant, rushed, or uncaring.
I think both are problems. I think I'm in the second category as a patient myself. I also think that on a national level, the first problem is an order of magnitude or more greater than the second. I acknowledge this as a perpetual challenge in my practice. It's just a classic sensitivity/specificity problem. How do you make sure you are treating people's illness without falling into the trap of medicalization of nonmedical problems?
Do you disagree?
You post two great problems. I have had time to consider both on my journey to wellness. In my mind it depends on the path taken to get to the point where you either have resolution or complete frustration because answers are not forthcoming. Sometimes being listened to, and acknowledged are a great start. Practitioners need to acknowledge the path a patient has taken and take the time to understand what they are explaining, not all patients can be black boxed either. I personally wanted more answers to understand what was happening, and was often told finding the answer to a problem was not necessarily the purpose. To answer your question it really depends on the patient. I believe I am also In category 2. Medical practitioners are capable of trying medication‘s off label. Provided the patient is aware of the side effects. A mutual decision between the patient and practitioner should be a green light in the process of treatment. Telling a patient you don’t understand something and allowing them to walk away without trying something thing is in my mind negligence. They also need to realize that not every patient is seeking a medication to treat their issue that often there are alternatives that can be explored. To do nothing is under treatment, and to not seek the answers to a problem because of time constraints or ignorance is inexcusable.
Thanks for responding to my post. I have often been frustrated by medicine and science, and acknowledge that we are smart, but just not smart enough. If anything, the Covid pandemic has heightened the imperfections in our medical system, and has shown us that we do not know how to respond very well to that which we do not understand. The biggest frustration I have looking forward is when I look behind us and I see very little effort going into understanding Covid especially when there are companies out there making billions of dollars on pushing harmful vaccines. I wish to be clear I am not anti-vaccination but I have seen far too much evidence to know the harms are vastly under reported, and the recommendations are no longer based on the scientific method.
What I experienced in medical education was certainly a strong drive away from listening to the patient, and a paradigm driven around pattern recognition (i.e. stereotyping). I don't think it's wrong per se to try to look for common patterns, but for patients whose complaints are poorly understood (particularly likely with an emerging illness), it's clear that this can result in a dehumanizing experience and ineffective care.
But what I also see is a society where 13-14% of people in the U.S. are taking SSRIs (and trending up, from the best figures I could fine). I see hospital beds filled with people who shouldn't be there. I see kids being pushed into surgeries and medications for things like obesity and gender dysphoria. I see too much medicine and not enough benefit. And I don't particularly disagree with any of your points about COVID highlighting problems in the system or vaccines being rushed.
It's just inherently very difficult to go against the grain, to be a minority. If you're a patient with long COVID or chronic Lyme or whatever else, I think part of the deal is accepting that you are going into a healthcare system that is not built for you, because you are not average. Separately, it may be that our system needs to be built more around chronic illness and prevention, which is why I'm training in the public health space.
Great discussion John. As an anesthesia provider we must consider the patients entire health history. If we need an answer or additional work up, we get it. One particular medical provider I was working with actually told me my profession has spoiled me because I am able to get answers quickly. That person is no longer providing any care for me despite the fact that there is truth in what this person said, but it was said in the wrong context. Moving forward I am getting back to normal, but there are some issues unresolved partially because we just don’t have answers yet I believe some of our CT scans are in capable of determining tissue damage at the microvascular level and there is more information forthcoming that micro vascular clotting in the endothelium is responsible for some of the long haul Covid symptoms. So for now I will keep listening to podcasts, reading, literature, and having discussions with intelligent beings like yourself. I wish you well on your personal health journey and please feel free to reach out with updates, and or any new knowledge you can bring to this discussion.
As a professional transcriptionist, I have to say that AI transcriptions suck.
I agree with Dr K. 5 minutes vs 1 hour is a no-brainer. Please consider request. Thank you
Transcript is up.
Gentlepeople, I will continue to post these comments. We would all love to know what came out of this conversation -- I expect the content is marvelous. But I do not have an hour. Some of us are hard of hearing. And many of us are visual/reading learners. An hour long podcast can typically be read in under five minutes when transcribed. Autotranscribers are cheap/free and excellent (not perfect, but certainly good enough). You would reach far more people if you posted a transcription for these podcasts or videos when you posted the audio. Most sites are now doing this...the numbers are compelling for increased engagement. Many thanks.
Transcript is up.
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