I so enjoy your musings and this substack. As a medical professional, I enjoy hearing how you care for your patients. It's reaffirming in this not so healthy medical care system (my view which is based on my own experiences 😉).
May 6, 2023·edited May 6, 2023Liked by Adam Cifu, MD
As an IM doctor who also tends to minimalism and conservatism, I recognize my acts and reflections so much in your reflection. "Am I being careless and nihilistic?" » I wonder sometimes. Mostly when I see most of my colleagues tending towards maximalism. "Am I so wrong in this? Hopefully, I'm not alone."
And while there is an over-riding personality, it is still more nuanced than that, isn't it. How we approach a 93-year old with a new Ca prostate diagnosis will be different from a 45-years old with newly diagnosed Ca prostate. Even a maximalist will balk at treating the 93-years old, while even a minimalist will likely throw everything available at the 45-years old.
We also change with age. The younger you are, the more aggressive you tend to be. It is only after you have seen a large number of patients and tracked outcomes that you tend to mellow with time. So a maximalist at the age of 40 can become a minimalist at the age of 65. Some of the best surgeons are those whose fingers may not still be as nimble as they were at age 35 or 40, but who take far better decisions on when not to operate, etc at age 60 or 65...are are probably better surgeons with better outcomes.
‘Gross’ is another word commonly used in the clinic setting. Every so often, I still slip up and say it to a patient. As in “well, isn’t it great that your face isn’t grossly swollen anymore?” Doesn’t come across quite as the complement I intend :)
I would be that (probably atypical) physician whose orientation is in the direction of therapeutic nihilism. Don't get me wrong, if someone's bleeding out from a gunshot wound, they probably need trauma surgery, but I don't have that high an opinion of medicine overall.
One of the more impactful educational experiences I had pre- med school was a public health researcher who tracked improvements in lifespan over the past century or so and attributed most of the change to improvements in sanitation and a few medical advances like vaccines and antibiotics, which does not paint a rosy picture of the rest of medicine. I don't know whether he was right, but it was certainly an interesting framing. I've also heard several interesting presentations from very impressive speakers on topics like the failure of targeted drug design, the lack of clinically meaningful benefits from a lot of oncology (a favorite Vinay Prasad topic), and the pervasive influence of for-profit corporations on medical decisions.
I was also a chronic pain patient who witnessed the medical meltdown now known as the opioid crisis, which does not exactly inspire confidence in the effectiveness of medicine to treat chronic illness.
And I was involved in integrative medicine research in various ways, and while I'm not a "woo" person, I see some compelling critiques of medicine from the outside looking in. "Headaches are not caused by Tylenol deficiency" one alternative medicine proponent told me. "I've never written a prescription for a patient that I wouldn't take myself" said an herbalist. These people make some valid points.
And a lot of other countries (including Australia where I studied) emphasize public health at the expense of medicine. The idea that you can eat a shit diet and sit around smoking, drinking, and watching youtube videos all day and then take a statin, metformin, and an ACE inhibitor to fix all your problems does not make a ton of sense, but that is how a lot of people view American medicine.
So here I am practicing, trying to find a way to make a difference and make the system better, but I see an abundance of reasons to think that a lot of common medical practices probably aren't that beneficial.
Always fascinating to hear you thinking through these issues. I think medical conservatism as you put it forward is pretty solid. It's been one of the major problems I've had over the past few years. I would say the opposite is medical hypochondria. The belief that more equals better regardless of outcomes.
Interesting post. My personal set-point has always been “just because we can, doesn’t mean we should”. I have no idea how that came to be. But it certainly fits my overall personality.
And as I work in a single payer system, and overall costs and expenditures can be more closely accounted for and attributed, I do know that my “adjusted cost base” has always been below median for my specialty, among my cohorts. This no doubt is a reflection of my practice philosophy. The aspect which is unknown, but would interest me greatly to find out, is my clinical outcomes relative to my cohort.
Also, interesting point about how one defines “aggressive”. I practiced by “courage” and “ischemia” trial standards, long before those trials came out. It could be argued that being so passive about revasc for stable cad was “aggressive” at the time. But I will say those results were, if not vindication, at least comforting affirmation at the time.
Because I really did enjoy this blog, I’m a bit embarrassed to admit: The first thing I thought of, when I saw the word “kwashiorkor” was “Prime Medical”:
Prime is the hospital chain that was caught diagnosing Kwashiorkor in large numbers of California Medicare beneficiaries. Were these folks sick? Sure. Did they have malnutrition? Some of them, of some type, probably. But all were adults, and most were overweight. It was Upcoding, of course—Prime was chasing the payment boost awarded by Medicare for certain severe diagnoses. They were playing a similar game with “septicemia.”
What scares me as a patient is that more and more clinicians don’t seem to be free to make their own decisions—conservative, aggressive or otherwise. At Prime Medical, doctors were handed a “goal” of admitting 50% of the Medicare patients who wandered into their ER. Sure, Prime was/is an outlier, but it’s a growing problem. (I’m skeptical of statins for female people with no heart disease, but I’ve had two docs tell me they “have to” prescribe me one. Both with downcast eyes, looking like schoolkids outside the principal’s office. Smart, highly educated, experienced people.)
So I wonder: How widespread is this? How many of the doctors you know still feel like their judgment and set-point are even relevant?
I think you’re right. But on the other hand, both these docs are over fifty and never went to the medical schools of today. (Some of the young ones would not even be embarrassed by the situation!) I suspect the real source of the pressure was either their employers, or the insurance companies. Or maybe their employers acting to placate the insurance companies.
At a conference on health-care reform a few years back, several patient-activists complained about overprescribing of anti-depressants. Two doctors stood up to say they agreed, but had no choice—they were “forced” to prescribe them. I got to chat with one, who explained that the Source of the Force was insurers.
Thank you, Adam. What do we do when some of our colleagues are minimalists and patients die as a result. I spent my career in pediatric pulmonology. I took care of lots of critically ill children and worked closely with pediatric critical care docs, many of whom chose a pessimistic and minimalist approach to patients in their care. Time and time again, I had parents tell me after their children recovered from a critical illness that my cautious optimism with encouragement of hope was both rare and helpful to them. I really think that there needs to be more open discussion of "clinical set points" and the impact that these individually inherited or chosen approaches actually cost lives. Nurses used to be routinely taught as well about patient health belief systems and how they impacted their adherence. Physicians were not and, I assume, still are not. The delay of so many of our citizens to access the healthcare system during the pandemic when early diagnosis and early treatment might have saved so many. Interestingly, Fauci never spoke of these critical elements of effective health care!
I never thought of having a clinical set point. And that the clinical set point is somewhat of an inherent characteristic of the physician, made from experiences and personality.
Admittedly, and at the risk of embarrassing myself, there are many times where I felt my clinical setpoint was superior to the practice patterns I observed around me. I assumed that there must be a right way to do things, the right way to consider harms and benefits, the right moment an intervention should be offered, and otherwise deferred.
I also appreciate and agree with meeting the patients where they are at. Some patients may want more aggressive interventions. Part of the physician's role is to decide where to draw the line, for which I'm sure every physician has different thresholds.
Appreciate you pointing out the two general “types”. It helps to know onwa tendencies and at times I will share my “bias” with a patient and offer to refer them to someone who may go about it differently than I would. As I get older I have become much more comfortable with this and noticing when my ego wants to be in play.
I loved this essay. Especially as I sit here charting on a bedbound LTC resident w h/o TBI, significant delusions, labile mood and sometimes agitation, which causes significant distress to himself and staff. Outpatient neuro wanted his Seroquel GDR’d d/t possible minor EPS but afterward his behaviors worsened considerably. No change to minor tremor. So I returned the seroquel to previous dose and behavior is back at baseline. Didn’t want to but felt was appropriate.
Your essay made me wear my ‘big girl pants’ more readily today. Thank you and I’ll look forward to your next work!
"I couldn’t help but think about children who would go blind unless their mother fed them rice fortified with vitamin A". You're hinting here that the biggest impact clinicians may have will be researching and advocating for health promoting policies in their clinics and societies, rather than practice style. I'm thinking of getting lead out of gasoline, indoor tobacco bans, promoting low-cost exercise opportunities, and the emerging data to support sugar taxes https://www.thelancet.com/pdfs/journals/landia/PIIS2213-8587(17)30070-0.pdf The latest advances in lung cancer or diabetes therapy are important, but after-the-fact!
I so enjoy your musings and this substack. As a medical professional, I enjoy hearing how you care for your patients. It's reaffirming in this not so healthy medical care system (my view which is based on my own experiences 😉).
As an IM doctor who also tends to minimalism and conservatism, I recognize my acts and reflections so much in your reflection. "Am I being careless and nihilistic?" » I wonder sometimes. Mostly when I see most of my colleagues tending towards maximalism. "Am I so wrong in this? Hopefully, I'm not alone."
Fortunately, I'm not alone.
Thanks Bernardo.
Adam
And while there is an over-riding personality, it is still more nuanced than that, isn't it. How we approach a 93-year old with a new Ca prostate diagnosis will be different from a 45-years old with newly diagnosed Ca prostate. Even a maximalist will balk at treating the 93-years old, while even a minimalist will likely throw everything available at the 45-years old.
We also change with age. The younger you are, the more aggressive you tend to be. It is only after you have seen a large number of patients and tracked outcomes that you tend to mellow with time. So a maximalist at the age of 40 can become a minimalist at the age of 65. Some of the best surgeons are those whose fingers may not still be as nimble as they were at age 35 or 40, but who take far better decisions on when not to operate, etc at age 60 or 65...are are probably better surgeons with better outcomes.
So so true. Great point. Thanks Bhavin. Adam
‘Gross’ is another word commonly used in the clinic setting. Every so often, I still slip up and say it to a patient. As in “well, isn’t it great that your face isn’t grossly swollen anymore?” Doesn’t come across quite as the complement I intend :)
I would be that (probably atypical) physician whose orientation is in the direction of therapeutic nihilism. Don't get me wrong, if someone's bleeding out from a gunshot wound, they probably need trauma surgery, but I don't have that high an opinion of medicine overall.
One of the more impactful educational experiences I had pre- med school was a public health researcher who tracked improvements in lifespan over the past century or so and attributed most of the change to improvements in sanitation and a few medical advances like vaccines and antibiotics, which does not paint a rosy picture of the rest of medicine. I don't know whether he was right, but it was certainly an interesting framing. I've also heard several interesting presentations from very impressive speakers on topics like the failure of targeted drug design, the lack of clinically meaningful benefits from a lot of oncology (a favorite Vinay Prasad topic), and the pervasive influence of for-profit corporations on medical decisions.
I was also a chronic pain patient who witnessed the medical meltdown now known as the opioid crisis, which does not exactly inspire confidence in the effectiveness of medicine to treat chronic illness.
And I was involved in integrative medicine research in various ways, and while I'm not a "woo" person, I see some compelling critiques of medicine from the outside looking in. "Headaches are not caused by Tylenol deficiency" one alternative medicine proponent told me. "I've never written a prescription for a patient that I wouldn't take myself" said an herbalist. These people make some valid points.
And a lot of other countries (including Australia where I studied) emphasize public health at the expense of medicine. The idea that you can eat a shit diet and sit around smoking, drinking, and watching youtube videos all day and then take a statin, metformin, and an ACE inhibitor to fix all your problems does not make a ton of sense, but that is how a lot of people view American medicine.
So here I am practicing, trying to find a way to make a difference and make the system better, but I see an abundance of reasons to think that a lot of common medical practices probably aren't that beneficial.
Loved this reflection on clinical setpoint!
Thanks so much Bella.
Adam
Always fascinating to hear you thinking through these issues. I think medical conservatism as you put it forward is pretty solid. It's been one of the major problems I've had over the past few years. I would say the opposite is medical hypochondria. The belief that more equals better regardless of outcomes.
Thanks Andrew.
Interesting post. My personal set-point has always been “just because we can, doesn’t mean we should”. I have no idea how that came to be. But it certainly fits my overall personality.
And as I work in a single payer system, and overall costs and expenditures can be more closely accounted for and attributed, I do know that my “adjusted cost base” has always been below median for my specialty, among my cohorts. This no doubt is a reflection of my practice philosophy. The aspect which is unknown, but would interest me greatly to find out, is my clinical outcomes relative to my cohort.
Also, interesting point about how one defines “aggressive”. I practiced by “courage” and “ischemia” trial standards, long before those trials came out. It could be argued that being so passive about revasc for stable cad was “aggressive” at the time. But I will say those results were, if not vindication, at least comforting affirmation at the time.
I like to defining a set point as “just because we can, doesn’t mean we should”.
And this applies to many things in life! I could poke that sleeping bear....
you had me at two months of diarrhea. _JC
didnt know you check these! i wouldnt have also tweeted it at you. well. it all draws more ppl in. =) _JC
Tee hee.
Thanks
Because I really did enjoy this blog, I’m a bit embarrassed to admit: The first thing I thought of, when I saw the word “kwashiorkor” was “Prime Medical”:
https://revealnews.org/article/hospital-chain-already-under-scrutiny-reports-high-malnutrition-rates/
Prime is the hospital chain that was caught diagnosing Kwashiorkor in large numbers of California Medicare beneficiaries. Were these folks sick? Sure. Did they have malnutrition? Some of them, of some type, probably. But all were adults, and most were overweight. It was Upcoding, of course—Prime was chasing the payment boost awarded by Medicare for certain severe diagnoses. They were playing a similar game with “septicemia.”
What scares me as a patient is that more and more clinicians don’t seem to be free to make their own decisions—conservative, aggressive or otherwise. At Prime Medical, doctors were handed a “goal” of admitting 50% of the Medicare patients who wandered into their ER. Sure, Prime was/is an outlier, but it’s a growing problem. (I’m skeptical of statins for female people with no heart disease, but I’ve had two docs tell me they “have to” prescribe me one. Both with downcast eyes, looking like schoolkids outside the principal’s office. Smart, highly educated, experienced people.)
So I wonder: How widespread is this? How many of the doctors you know still feel like their judgment and set-point are even relevant?
I didn’t know the Prime story. Depressing.
I'd probably prescribe a statin for you with enthusiasm!
But, you're right: Medical schools of today select for obedience, not the autonomy needed to determine one's own "set point."
I think you’re right. But on the other hand, both these docs are over fifty and never went to the medical schools of today. (Some of the young ones would not even be embarrassed by the situation!) I suspect the real source of the pressure was either their employers, or the insurance companies. Or maybe their employers acting to placate the insurance companies.
At a conference on health-care reform a few years back, several patient-activists complained about overprescribing of anti-depressants. Two doctors stood up to say they agreed, but had no choice—they were “forced” to prescribe them. I got to chat with one, who explained that the Source of the Force was insurers.
Thank you, Adam. What do we do when some of our colleagues are minimalists and patients die as a result. I spent my career in pediatric pulmonology. I took care of lots of critically ill children and worked closely with pediatric critical care docs, many of whom chose a pessimistic and minimalist approach to patients in their care. Time and time again, I had parents tell me after their children recovered from a critical illness that my cautious optimism with encouragement of hope was both rare and helpful to them. I really think that there needs to be more open discussion of "clinical set points" and the impact that these individually inherited or chosen approaches actually cost lives. Nurses used to be routinely taught as well about patient health belief systems and how they impacted their adherence. Physicians were not and, I assume, still are not. The delay of so many of our citizens to access the healthcare system during the pandemic when early diagnosis and early treatment might have saved so many. Interestingly, Fauci never spoke of these critical elements of effective health care!
I never thought of having a clinical set point. And that the clinical set point is somewhat of an inherent characteristic of the physician, made from experiences and personality.
Admittedly, and at the risk of embarrassing myself, there are many times where I felt my clinical setpoint was superior to the practice patterns I observed around me. I assumed that there must be a right way to do things, the right way to consider harms and benefits, the right moment an intervention should be offered, and otherwise deferred.
I also appreciate and agree with meeting the patients where they are at. Some patients may want more aggressive interventions. Part of the physician's role is to decide where to draw the line, for which I'm sure every physician has different thresholds.
Appreciate you pointing out the two general “types”. It helps to know onwa tendencies and at times I will share my “bias” with a patient and offer to refer them to someone who may go about it differently than I would. As I get older I have become much more comfortable with this and noticing when my ego wants to be in play.
All I can say is "Thank You". Oh, also have a great weekend.
Same to you...
I loved this essay. Especially as I sit here charting on a bedbound LTC resident w h/o TBI, significant delusions, labile mood and sometimes agitation, which causes significant distress to himself and staff. Outpatient neuro wanted his Seroquel GDR’d d/t possible minor EPS but afterward his behaviors worsened considerably. No change to minor tremor. So I returned the seroquel to previous dose and behavior is back at baseline. Didn’t want to but felt was appropriate.
Your essay made me wear my ‘big girl pants’ more readily today. Thank you and I’ll look forward to your next work!
"I couldn’t help but think about children who would go blind unless their mother fed them rice fortified with vitamin A". You're hinting here that the biggest impact clinicians may have will be researching and advocating for health promoting policies in their clinics and societies, rather than practice style. I'm thinking of getting lead out of gasoline, indoor tobacco bans, promoting low-cost exercise opportunities, and the emerging data to support sugar taxes https://www.thelancet.com/pdfs/journals/landia/PIIS2213-8587(17)30070-0.pdf The latest advances in lung cancer or diabetes therapy are important, but after-the-fact!
Thanks Andy.