Excellent post. Like most, I try to limit testing and to look at the needs/problems of the individual patient in the context of overall expert recommendations and evidence (though I suppose every doctor believes they do the same).
Usually the biggest complication is not the medical complication (hopefully my conversation in the office mentions what might worsen or what symptoms to worry about), but other doctors.
The number of times I lose a patient due to another MD proudly announcing that their last doctor (me) was either an idiot or fool who clearly failed to see the correct diagnosis or could have prevented the new problem...
I remember a talk I had from a malpractice lawyer who laughed saying the greatest enemy of a doctor (and the biggest help to him) is other doctors.
I so appreciate both of you! I am definitely a "constrained" thinker, which is throwing my senior nursing students for a loop! Several things: 1. I am generally opposed to population-level guidelines because it states that everyone needs the same thing and prevents treating/educating the person right in front of you. 2. People get sick. It is hubris to think that we can prevent all illness. Also, I think that the systems of the body are damaged when we "prevent" too many regular illnesses, which may be a factor in the increase in chronic illness. 3. I think "disease" is way more nuanced than Exposure to A always = outcome B. This is a very mechanistic view of humans and we are not machines.
I wish more doctors could see constrained care as people age. I know a 94 year old that had a bone density test. Can you explain that? Why would we even prescribe bone medicine in this age group? Little late for that? Plus what effect of those medicines is really positive? Maybe someone should have thought about gut health decades ago so that they could better absorb the food they were eating so their bones wouldn't be so bad now? Or check their hormone levels to see if there is/was an imbalance? And in this same patient, her PCP never tested her hearing and she has almost complete hearing loss? Can you explain that? Or when they took a chunk of her skin off for cancer, didn't get clear margins and then want to go back in! I just don't get it. I want to bang my head against a wall and scream I can't take it anymore. I feel like the only sensible medicine I know lives in this blog. And one last thing...what about those covid vaccines? Could someone please stop the industry and all the tentacles pushing that line of BS. Talk about a system too big to fail.
These are wonderful posts, both of you. I love reading thoughtful takes on real life experiences. Humans are born, live a life, get sick and injured from time to time, may stay sick for a long time or not, and die. We all want to live happy, healthy lives, but none does that perfectly, and some are very unfortunate and suffer a lot. A good, intelligent, experienced caregiver who simply wishes to make life better, if possible, is a gift to their patients. I am most definitely a constrained thinker - at 75 I take no medications outside of the very rare ibuprofen, train in aikido several times a week, walk about 2.5 miles a day, enjoy visiting my nurse practitioner about once a year, and mostly refuse all tests and recommended treatments except for PT when needed. I will die, and if it’s before I become extremely frail I will be happy. Preventing disease is not interesting to me, except in the case of vaccines that make sense to me. I do try to prevent falls, and have adjusted my activities as I notice increasing difficulty with balance and strength on very rocky paths alone in remote areas. If I acquire a “preventable” disease and die I hope my NP will not feel any chagrin at all. He’s been good to me and taken me seriously. That’s mostly what I want from him. I’m grateful for my robust good health, which is simply the lucky outcome of good genes, and an innate delight in movement. It certainly isn’t a result of trying to prevent disease!
I would frame it a little differently. There are those who think a primary goal is to prevent disease as well as diagnose and treat it. At the other end of the spectrum are those who are skeptical about practically all of the preventive medicine nostrums. And, of course, there are gradations in between. I wouldn't put you or Adam at either extreme but definitely more to the skeptical end. The phrase I would use is healthy skepticism and/or realism. That, after all, is why you both contribute to Sensible Medicine---much to the benefit of your devoted readers.
John: Great Piece and such an interesting discussion
I am also a constrained thinker and life is indeed a continuous trade off struggle.
Smoking, for example, increases immediate pleasure but has an incremental effect on the probability of dying sometime in the future. Do you care about it?
The main issue I see is the effect of time: either you focus on the short or the long term. How do you as a patient and Doctor, respectively, value each one This also depends on a life expectancy estimation, which itself depends on patients values, whom must be aware of these trade offs.
I also agree with Dr R's comments: "Not complaining doesn’t mean they are healthy"
I also loved Vad's comment: "But we must acknowledge the tyranny of the available option. Once a preventative treatment exists, the ethical and psychological pressure on doctors and patients to use it becomes immense, regardless of trial evidence." I would add this applies not only to preventative treatment but also to hyped new treatments based on short term data.
And scientific evidence is more and more difficult to interpret as the devil is in the details often hidden in the appendix section, or methodological flaws not easily detected by the "normally busy" epidemiology untrained physician. Thanks John for your efforts helping us decrypting the evidence.
Humility to accept the limitations of trials with their lack of external validity, (random allocation which is great but hides the random selection which is a myth), the methodological twists like changing the composition, the timeline or the definitions of end points and so on.
And finally how Guidelines Task force writers and Scientific Societies are often the ones benefitting, even if indirectly, from upgrading their recommendations to support the new "evidence based" unconstrained practice.
Unfortunatley Karl Popper's teachings accepting that scientific knowledge is never absolutely certain and is always open to revision is far from applied in Medicine
The key to interpreting "scientific" studies is to determine who is sponsoring them or who is benefiting from them. There are 100 ways to distort, misinterpret and design studies for a favorable outcome, while ignoring the truth. Medicine in the USA is controlled by Big Pharma. Follow the money.
After 27 years of nursing, I learned two things: one is that “shit happens,“ and when I read it in your piece, I laughed out loud. The second is that most people are doing the best they can.
I agree with most of your comments but we often compare the risk of so called “adverse effects or events” with the outcome we are trying to prevent - but not all effects or events are equal. I would take a higher risk of a possible non life threatening event to prevent a less frequent significant one like stroke for example
I once was advocating for a friend who had been prescribed some medication who was supposed to help her manage her psychosis. he drug delivered side effects but no benefits. Some forward thinking resident said "let's try waning her off the med." We met again a few weeks later and the resident tells me that all the staff has noticed that the patient is not only not doing worse without the medication but is way more engaged and alert, so she is going to keep the patient off the drug. Then she says one of the best lines I ever heard from a doctor:
Great point. Psychotropic drugs, in general, are far more detrimental to a clear, peaceful mind than 20 other natural interventions. Too many doctors believe Big Pharma's narratives about imbalances of chemicals and the benefits or altering serotonin etc. Is our goal to make the patient a zombie, or to address the root cause of their depression and anxiety?
I remember shocking someone who was adamant that she will need antidepressants for life because "my brain does not produce enough serotonin" when I replied "And why does your brain not produce enough serotonin? Maybe that can be fixed?"
She didn't even tell me hat it was supposedly genetic.
Such a nice piece!
Excellent post. Like most, I try to limit testing and to look at the needs/problems of the individual patient in the context of overall expert recommendations and evidence (though I suppose every doctor believes they do the same).
Usually the biggest complication is not the medical complication (hopefully my conversation in the office mentions what might worsen or what symptoms to worry about), but other doctors.
The number of times I lose a patient due to another MD proudly announcing that their last doctor (me) was either an idiot or fool who clearly failed to see the correct diagnosis or could have prevented the new problem...
I remember a talk I had from a malpractice lawyer who laughed saying the greatest enemy of a doctor (and the biggest help to him) is other doctors.
I so appreciate both of you! I am definitely a "constrained" thinker, which is throwing my senior nursing students for a loop! Several things: 1. I am generally opposed to population-level guidelines because it states that everyone needs the same thing and prevents treating/educating the person right in front of you. 2. People get sick. It is hubris to think that we can prevent all illness. Also, I think that the systems of the body are damaged when we "prevent" too many regular illnesses, which may be a factor in the increase in chronic illness. 3. I think "disease" is way more nuanced than Exposure to A always = outcome B. This is a very mechanistic view of humans and we are not machines.
Again, thank you both for all you do!
One of the best: Kudos to our Authors : some thoughtful responses as well. Great stuff.
Wonderful post, we need to see the two face of the coin !
Just an illustration : in anesthesiology in my area, we have evolved toward much less preop exams and surgery goes smoothly.
Don't need to struggle anymore with false thrombine time etc.
Superb articulation.
I think too many attorneys and the judgement of our colleagues have skewed our metrics towards over screening and over treating.
Honoring patient values and giving our best to those who ask for our help are excellent principles to practice by.
Thanks for writing this.
I wish more doctors could see constrained care as people age. I know a 94 year old that had a bone density test. Can you explain that? Why would we even prescribe bone medicine in this age group? Little late for that? Plus what effect of those medicines is really positive? Maybe someone should have thought about gut health decades ago so that they could better absorb the food they were eating so their bones wouldn't be so bad now? Or check their hormone levels to see if there is/was an imbalance? And in this same patient, her PCP never tested her hearing and she has almost complete hearing loss? Can you explain that? Or when they took a chunk of her skin off for cancer, didn't get clear margins and then want to go back in! I just don't get it. I want to bang my head against a wall and scream I can't take it anymore. I feel like the only sensible medicine I know lives in this blog. And one last thing...what about those covid vaccines? Could someone please stop the industry and all the tentacles pushing that line of BS. Talk about a system too big to fail.
These are wonderful posts, both of you. I love reading thoughtful takes on real life experiences. Humans are born, live a life, get sick and injured from time to time, may stay sick for a long time or not, and die. We all want to live happy, healthy lives, but none does that perfectly, and some are very unfortunate and suffer a lot. A good, intelligent, experienced caregiver who simply wishes to make life better, if possible, is a gift to their patients. I am most definitely a constrained thinker - at 75 I take no medications outside of the very rare ibuprofen, train in aikido several times a week, walk about 2.5 miles a day, enjoy visiting my nurse practitioner about once a year, and mostly refuse all tests and recommended treatments except for PT when needed. I will die, and if it’s before I become extremely frail I will be happy. Preventing disease is not interesting to me, except in the case of vaccines that make sense to me. I do try to prevent falls, and have adjusted my activities as I notice increasing difficulty with balance and strength on very rocky paths alone in remote areas. If I acquire a “preventable” disease and die I hope my NP will not feel any chagrin at all. He’s been good to me and taken me seriously. That’s mostly what I want from him. I’m grateful for my robust good health, which is simply the lucky outcome of good genes, and an innate delight in movement. It certainly isn’t a result of trying to prevent disease!
First, do no harm sounds like a good thing to practice.
I would frame it a little differently. There are those who think a primary goal is to prevent disease as well as diagnose and treat it. At the other end of the spectrum are those who are skeptical about practically all of the preventive medicine nostrums. And, of course, there are gradations in between. I wouldn't put you or Adam at either extreme but definitely more to the skeptical end. The phrase I would use is healthy skepticism and/or realism. That, after all, is why you both contribute to Sensible Medicine---much to the benefit of your devoted readers.
🥰
John: Great Piece and such an interesting discussion
I am also a constrained thinker and life is indeed a continuous trade off struggle.
Smoking, for example, increases immediate pleasure but has an incremental effect on the probability of dying sometime in the future. Do you care about it?
The main issue I see is the effect of time: either you focus on the short or the long term. How do you as a patient and Doctor, respectively, value each one This also depends on a life expectancy estimation, which itself depends on patients values, whom must be aware of these trade offs.
I also agree with Dr R's comments: "Not complaining doesn’t mean they are healthy"
I also loved Vad's comment: "But we must acknowledge the tyranny of the available option. Once a preventative treatment exists, the ethical and psychological pressure on doctors and patients to use it becomes immense, regardless of trial evidence." I would add this applies not only to preventative treatment but also to hyped new treatments based on short term data.
And scientific evidence is more and more difficult to interpret as the devil is in the details often hidden in the appendix section, or methodological flaws not easily detected by the "normally busy" epidemiology untrained physician. Thanks John for your efforts helping us decrypting the evidence.
Humility to accept the limitations of trials with their lack of external validity, (random allocation which is great but hides the random selection which is a myth), the methodological twists like changing the composition, the timeline or the definitions of end points and so on.
And finally how Guidelines Task force writers and Scientific Societies are often the ones benefitting, even if indirectly, from upgrading their recommendations to support the new "evidence based" unconstrained practice.
Unfortunatley Karl Popper's teachings accepting that scientific knowledge is never absolutely certain and is always open to revision is far from applied in Medicine
The key to interpreting "scientific" studies is to determine who is sponsoring them or who is benefiting from them. There are 100 ways to distort, misinterpret and design studies for a favorable outcome, while ignoring the truth. Medicine in the USA is controlled by Big Pharma. Follow the money.
What a great piece. Thanks John.
After 27 years of nursing, I learned two things: one is that “shit happens,“ and when I read it in your piece, I laughed out loud. The second is that most people are doing the best they can.
I agree with most of your comments but we often compare the risk of so called “adverse effects or events” with the outcome we are trying to prevent - but not all effects or events are equal. I would take a higher risk of a possible non life threatening event to prevent a less frequent significant one like stroke for example
I once was advocating for a friend who had been prescribed some medication who was supposed to help her manage her psychosis. he drug delivered side effects but no benefits. Some forward thinking resident said "let's try waning her off the med." We met again a few weeks later and the resident tells me that all the staff has noticed that the patient is not only not doing worse without the medication but is way more engaged and alert, so she is going to keep the patient off the drug. Then she says one of the best lines I ever heard from a doctor:
Who am I treating? Myself for the patient?
Great point. Psychotropic drugs, in general, are far more detrimental to a clear, peaceful mind than 20 other natural interventions. Too many doctors believe Big Pharma's narratives about imbalances of chemicals and the benefits or altering serotonin etc. Is our goal to make the patient a zombie, or to address the root cause of their depression and anxiety?
I remember shocking someone who was adamant that she will need antidepressants for life because "my brain does not produce enough serotonin" when I replied "And why does your brain not produce enough serotonin? Maybe that can be fixed?"
She didn't even tell me hat it was supposedly genetic.