Along with your substack, I have become very interested in The Forgotten Side of Medicine and that physician's dive into simpler remedies for all manner of ills. Of particular interest is the use of DMSO for everything from sore muscles to tinnitus to auto-immune issues including arthritis. (My household now uses it regularly for sore muscles and I have managed to dim my tinnitus with sporadic use.) Have you ever suggested a patient use DMSO, or would you suggest its use perhaps in adjunct with an existing remedy? If not, why?
Also, with otherwise good cholesterol numbers and great health but a wildly high LP(a) (300+), is a statin really needed even though it cannot specifically lower LP(a)?
I was wondering if you have any thoughts about the use of psilocybin for mental health issues or even for personal growth. If
you don’t have an opinion on that, then I’d love to know your thoughts on continuing screening mammography past the age of 70 in average risk women. I’ve seen women having them well into their 80’s!
After listening to and learning from This Week in Cardiology and How Not to Get Fooled, I would like to know why many of the most prestigious medical journals publish so many severely flawed studies. Are the reviewers junior faculty with little knowledge of study design (I was, frequently being told by my mentor to review a manuscript)? Do the journal editors feel compelled to publish a recognized senior author to prevent a competitor from publishing the seemingly breakthrough study first? Many thanks!
My left wing friends often cite how people they know who are doctors or work in medicine often complain of how idiotic patients are and how they lack common sense and don't listen to their advice. When I attempt to tell them that doctors also don't tend to listen to genuine concerns from patients I get brushed off. And then when shows like The Pitt win Emmys and all the left wing people watch this caricature of patients pour through the door, what are some ways I can convince them that they shouldn't just blindly trust anecdotal evidence and dramatic television shows when people show concerns about some medical treatments? I'm not a trump or RFK supporter, not anti-vax and not against western medicine generally, but I do have what I consider to be very reasonable skepticism in the way certain medications and vaccines are blatantly and broadly prescribed without any attempt to cater to individual circumstances, and when it comes to certain things like nutrition and exercise (both of which doctors don't have any education in as far as I understand it) I'm told to "listen to the science"
What is your opinion of the recent news regarding graduate nurse programs, PT, OT, etc facing federal loan limits being proposed by the DOE? As a RN with an ADN I think this is ok, especially if it lowers tuition and debt levels. A MSN or NP should not cost $100,000+. I never took this news as an affront to nurses or a belittling of my profession, but I've argued with many on social media that are insulted. It's been a rough week on my feed to say the least. Happy Thanksgiving!
Please discuss the lack of transparency patients encounter when there are shortages of their medications. In the past week, I have encountered three patients with different prescriptions who were told by pharmacists that their doctors would need to order a substitute medication because of supply shortages. Then, after detailing the reason why a substitute would not be acceptable, the pharmacists unexpectedly found a supply, after all.
There is a lot of noise in the alternative medicine world about DMSO for inflammation, cancer , stroke. Is any of it real. Similarly there are a lot of folks getting red light and methylene blue. These all seem to go back to two jargon mitochondrial dysfunction and zeta potential. Any thing you can tell me would be helpful.
Thank you for your contributions to "sensible" medicine! Much needed!
I know it has been discussed before, but there are so many articles now and some of it is confusing. I'd love to hear your take on the current utilization and best practices regarding coronary artery calcium (CAC) scoring in low risk asymptomatic individuals without established ASCVD. Would you even obtain a CAC in those individuals? What if they come to you with a scan and a number, how do you address the hidden concern that they may be at increased risk of MI?
Continue the fight for sensibility in our medical practice!
I have very much enjoyed this Substack and have learned a lot from you all. I am a primary care internist in the mid-west and would love to hear your take on GDMT for systolic heart failure. Our organization has selected this as a "quality" measure for the upcoming year, as a way of possibly reducing hospital admissions; this will be loosely tied to our salaries. I have several problems with this:
1. Each of the individual medication classes (ACE/ARB/ANRi, BB, spironolactone, SGLT-2 inhibitors) have been shown in varying degrees through RCT's to lower mortality and hospitalization, but never when combined all together. In the real, practical world I have found compliance with this cocktail to be problematic, due to hypotension, cost, renal dysfunction, etc.
2. The entire concept of GDMT is a "guideline", not based on clinical trials asking the question of whether or not this combination of medications is effective in morbidity/mortality reduction.
3. I took the time (because I am crazy) to look up the various committee members who published the guideline, through the Medicare Sunshine Act. A substantial number have received significant amounts of money from industry.
Thank you for the opportunity to pose specific questions. I have some questions concerning the relationship between atrial fibrillation and stroke. What are the numbers and how are they derived? Is there a difference between persistent vs. intermittent atrial fib? What is the evidence that emboli arise from the left atrium? How were embolic vs. hemorrhagic strokes diagnosed prior to the availability of CT and MRI? Couldn't emboli come from unstable plaques in the carotids by the same pathophysiologic process that occurs in the coronary circulation? I guess you could do an entire episode on this topic. Perhaps a few references to seminal studies would suffice. My training in Internal Medicine and Cardiology was over 50 years ago, and I frequently had the impression that some of these factors were adopted based on theories that made sense but lacked solid evidence.
Along with your substack, I have become very interested in The Forgotten Side of Medicine and that physician's dive into simpler remedies for all manner of ills. Of particular interest is the use of DMSO for everything from sore muscles to tinnitus to auto-immune issues including arthritis. (My household now uses it regularly for sore muscles and I have managed to dim my tinnitus with sporadic use.) Have you ever suggested a patient use DMSO, or would you suggest its use perhaps in adjunct with an existing remedy? If not, why?
Also, with otherwise good cholesterol numbers and great health but a wildly high LP(a) (300+), is a statin really needed even though it cannot specifically lower LP(a)?
I was wondering if you have any thoughts about the use of psilocybin for mental health issues or even for personal growth. If
you don’t have an opinion on that, then I’d love to know your thoughts on continuing screening mammography past the age of 70 in average risk women. I’ve seen women having them well into their 80’s!
After listening to and learning from This Week in Cardiology and How Not to Get Fooled, I would like to know why many of the most prestigious medical journals publish so many severely flawed studies. Are the reviewers junior faculty with little knowledge of study design (I was, frequently being told by my mentor to review a manuscript)? Do the journal editors feel compelled to publish a recognized senior author to prevent a competitor from publishing the seemingly breakthrough study first? Many thanks!
My left wing friends often cite how people they know who are doctors or work in medicine often complain of how idiotic patients are and how they lack common sense and don't listen to their advice. When I attempt to tell them that doctors also don't tend to listen to genuine concerns from patients I get brushed off. And then when shows like The Pitt win Emmys and all the left wing people watch this caricature of patients pour through the door, what are some ways I can convince them that they shouldn't just blindly trust anecdotal evidence and dramatic television shows when people show concerns about some medical treatments? I'm not a trump or RFK supporter, not anti-vax and not against western medicine generally, but I do have what I consider to be very reasonable skepticism in the way certain medications and vaccines are blatantly and broadly prescribed without any attempt to cater to individual circumstances, and when it comes to certain things like nutrition and exercise (both of which doctors don't have any education in as far as I understand it) I'm told to "listen to the science"
Should I stay on my blood thinner (Eliquis) or get a Watchman?
Is my blood thinner extra protection against an MI or stroke?
Thanks!
Should we be avoiding wearing polyester fabrics because of endocrine disruption? Is food-grade silicone actually safe? (That is, safer than plastic?)
What is your opinion of the recent news regarding graduate nurse programs, PT, OT, etc facing federal loan limits being proposed by the DOE? As a RN with an ADN I think this is ok, especially if it lowers tuition and debt levels. A MSN or NP should not cost $100,000+. I never took this news as an affront to nurses or a belittling of my profession, but I've argued with many on social media that are insulted. It's been a rough week on my feed to say the least. Happy Thanksgiving!
If you guys were omnipotent, omniscient, and essentially Gods, how would you address the current debacle that is medical research?
Ben Hourani MD, MBA
Please discuss the lack of transparency patients encounter when there are shortages of their medications. In the past week, I have encountered three patients with different prescriptions who were told by pharmacists that their doctors would need to order a substitute medication because of supply shortages. Then, after detailing the reason why a substitute would not be acceptable, the pharmacists unexpectedly found a supply, after all.
There is a lot of noise in the alternative medicine world about DMSO for inflammation, cancer , stroke. Is any of it real. Similarly there are a lot of folks getting red light and methylene blue. These all seem to go back to two jargon mitochondrial dysfunction and zeta potential. Any thing you can tell me would be helpful.
Thank you for your contributions to "sensible" medicine! Much needed!
I know it has been discussed before, but there are so many articles now and some of it is confusing. I'd love to hear your take on the current utilization and best practices regarding coronary artery calcium (CAC) scoring in low risk asymptomatic individuals without established ASCVD. Would you even obtain a CAC in those individuals? What if they come to you with a scan and a number, how do you address the hidden concern that they may be at increased risk of MI?
Continue the fight for sensibility in our medical practice!
I have very much enjoyed this Substack and have learned a lot from you all. I am a primary care internist in the mid-west and would love to hear your take on GDMT for systolic heart failure. Our organization has selected this as a "quality" measure for the upcoming year, as a way of possibly reducing hospital admissions; this will be loosely tied to our salaries. I have several problems with this:
1. Each of the individual medication classes (ACE/ARB/ANRi, BB, spironolactone, SGLT-2 inhibitors) have been shown in varying degrees through RCT's to lower mortality and hospitalization, but never when combined all together. In the real, practical world I have found compliance with this cocktail to be problematic, due to hypotension, cost, renal dysfunction, etc.
2. The entire concept of GDMT is a "guideline", not based on clinical trials asking the question of whether or not this combination of medications is effective in morbidity/mortality reduction.
3. I took the time (because I am crazy) to look up the various committee members who published the guideline, through the Medicare Sunshine Act. A substantial number have received significant amounts of money from industry.
Thank you.
Thank you for the opportunity to pose specific questions. I have some questions concerning the relationship between atrial fibrillation and stroke. What are the numbers and how are they derived? Is there a difference between persistent vs. intermittent atrial fib? What is the evidence that emboli arise from the left atrium? How were embolic vs. hemorrhagic strokes diagnosed prior to the availability of CT and MRI? Couldn't emboli come from unstable plaques in the carotids by the same pathophysiologic process that occurs in the coronary circulation? I guess you could do an entire episode on this topic. Perhaps a few references to seminal studies would suffice. My training in Internal Medicine and Cardiology was over 50 years ago, and I frequently had the impression that some of these factors were adopted based on theories that made sense but lacked solid evidence.
Hello, your thoughts please on CCTA vs angiograms.
Thank you!
Do you all think most public health level interventions should require a “real world” study before being implemented?
Love the Fortnight series: esp. reviews of “older” studies that form bases for established current practice. Maybe change to “weekly “?