That 2x2 table is only a portion of how good decisions are made. A patient may desire a therapy (e.g., dialysis) because, well, that's what you do when your kidneys fail. A physician may recommend a therapy (e.g., dialysis) because, well, that's what you do when someone's kidneys fail. But both have totally overlooked whether those preferences link up with any meaningful goal for the patient.
Very often in my palliative care practice people tell me, "Of course I want to live!" Yes, and with what trade-offs are you willing to pursue that goal? You allude to it a bit in that conversation about the statin being well-tolerated. If it weren't well-tolerated, presumably that would be a more involved conversation. That conversation would be a negotiation of the trade-offs in pursuit of a particular value or goal. But when you substitute a preference for a value, chaos ensues. People start ordering medical care piecemeal, instead of as a care plan in pursuit of a goal.
When you said you heard it many times in the office, you mean they were changing codes strictly for financial reasons and not patient benefit? Sounds like you worked for crooks willing to lose their license. There are a few bad apples in every profession but I don't believe most doctors are bad apples, and/or stupid enough to risk losing their license. Anyway, as for my husband, yes, he's tried all your suggestions, even though there is no RCT to support any of them, he figured there was no harm. All were totally ineffective. They do not lower Il-17, and I doubt there is a "natural" treatment that does, but if you find one, let me know. If we go to a cash system, my husband will be back to suffering and dysfunction, as treatment would be totally unaffordable. But if you want, go off insurance and just pay cash. But please don't declare bankruptcy if you end up needing mega-bucks treatment (even a car accident victim can end up owing hundreds of thousands), because then everybody else will have to pay for your treatment.
Nice lead-in to a discussion of shared decisions. Thank you. I’m in the category where I have to doctor-shop. With my clinical and didactic background, I have to find a doc who won’t become paternalistic and drop into Cell A every time. With my current PCP, if I’m going to ask him for a change of therapy I come in with citations and references. And the fact that he listens to some of the same podcasts that I follow helps: I can reference a specific podcast (he’s started writing those down) and he can check my interpretation. In general terms, we reach consensus, and most of my requests, even those I’m pretty solid on, can be swayed if he’s uncomfortable with the change. About the only place we’ve disagreed significantly is that he wants me on a statin, and I’m intolerant, something he’s finally accepted and noted on the chart. He still wants me on a PCSK9-i, but can’t justify it in terms of my lipid profile. I know he gets pinged by the QA folks for that shortcoming on his part on a quarterly basis, but there’s no reason for me to be miserable and unable to keep up with my normal exercise regimen due to myalgia and brain-fog.
Umm so talking ALL these meds together cause what kind of interactions/side effects?
"metoprolol, chlorthalidone, potassium chloride, isosorbide mononitrate, metformin, atorvastatin, and aspirin."
Sorry but you probably have NO idea. Probably individually but not all together cause let me guess there has never been any research on any one that takes them all together!
And telling any patients
"Me: They are generally very well-tolerated medications, and given your cardiovascular risk, the benefits greatly outweigh the harms."
Do you outline the side effects or interactions? Is it up to YOU to decide how this specific patient will "TOLERATE" them or not.
So you offer NO other remedies but pharmaceuticals? Really? Are you serious?
Actually, not a good point at all. Clearly, the person does not know the first thing about any of the medications he lists. He seems to follow this substack merely to heckle, not contribute.
Great piece, thank you. I see so many instances of cell C (dr recommends, pt declines) where the doctor soils the relationship because they dont understand how to graciously handle this. It makes for such a bad experience, as i have seen both as physician and when i am the patient. Maybe its easier for me as a surgeon, since not wanting surgery is very “relatable”. Not as easy if they are declining something easy and proven (taking aspirin when you have coronary disease).
Thank you again for your simple eloquent expression/sharing. The writers here in this substack and commenters help take away a little of the disenfranchisement with this profession- you help stave off the burnout!!! Now, i am off to answer some email and electronic messages...!
I think that direct-to-consumer marketing is largely responsible for cell B. The U.S.A. and New Zealand are the only countries that permit it, as far as I know.
Diabetes, CVD, cancer...the list of common chronic diseases that appear to be directly affected by VK goes on and on. Probably obesity, too.
Docs don't know.
No patentable drugs, no medical societies stand to benefit...plus we're stuck in stupid.
We've messed up fats, and VK is a fat soluble vitamin that we've thought was sufficient if coagulation was ok. Nope.
Those so-called dietary trans fats? It's bc we messed up VK1 to create what is often called dihydrophiloquinone (dK1). It doesn't act the right way; the bonds of fats are not what is pertinent. Hence, all that saturated/trans/mono saturated talk is BS. But that's what we looked at; that's what the literature discusses. We forgot fat soluble vitamins. Especially VK.
Been reading and enjoying since you launched Adam, but "Like most complex phenomena, this can be reduced to a 2X2 table" convinced me to upgrade to paid :)
I can cite my personal experiences with endocrinologists and their "lovely" recommendations and expertise as examples of how very misguided/ignorant most of you medical experts can be.
I am hypothyroid: diagnosed TSH in mid 80s and symptoms like inability to control body temperature, depression, brain fog.
Following guidelines, levothyroxine monotherapy was begun and my TSH was followed until it was in the so-called normal range. Only my symptoms weren't helped. I followed drug regimen and eventually went to about 5 docs/endos, all looking at these test results and no one remotely capable of listening to me. "Symptoms of hypothyroidism can be from many things, and your tests show that your thyroid is being correctly treated."
Eventually, I fell asleep driving on the interstate one afternoon and decided to try once again with yet another (dumbass) endocrinologist.
She added T3 to my T4 monotherapy and by the end of the second day, a huge cloud lifted! Much like when the Wizard of Oz goes to color from B&W. BUT...since she, along with the vast majority of idiot endos, had cut my T4 to add T3, as per their idiotic understanding of thyroid function, I began to decline again. This remarkable improvement began to decline in a few days.
As per those guidelines, she wanted to wait and then monitor TSH after 5 weeks.
I left her and went back to my family doctor and got a Rx for Armour thyroid. I have taken this for decades and I flourish.
So...dear uninformed doctor:
Do you know what causes cardiovascular disease? Why statins are misguided?
It's this: calcium dysregulation.
Matrix gla protein, the most potent anti-calcification agent known, keeps inappropriate calcium from depositing in arteries. You know...CAC. The REAL thing; not cholesterol, but calcium dysregulation causes events.
A zero CAC translates to a 15 year warranty from death by all causes. Statins actually INCREASE CAC, especially lipophilic ones.
And dear endogenously made T3 is essential to create matrix gla protein. THAT is where we've screwed up.
Turns out, TSH sucks as a determinate of thyroid function and T3 is not consistently made in all tissues. Serum T3 is not accurate for all tissue levels. Endocrinology, much like cardiology, is pretty full of it.
The recommended switch from desiccated thyroid was in the 70s and lies/obfuscation by pharma has led us - much like statins - horribly astray.
Are you aware that ALL the stuff you've been fed about statins cites relative risk and not absolute risk, dear doc? Those drugs reduce risk of an event by less than one percent for primary prevention and may increase life by about 4 days. (Feel free to reach me for citations)
Secondary prevention isn't much better.
And so-called side effects? (Bwahaha, side effects when they really should be called harms)
Now... after pouring over the literature for 20+ years, I have learned how very, very misguided modern medicine really is
Go look. Learn about statistical manipulation.
And learn about vitamin K2. It's powerful, misunderstood and has gone missing in diet bc we're absolutely stupid. MK-4, made endogenously, is messed up by statins. That's only one harm from statins. But our lousy foods, our lousy toxins also cause diseases, so we have lousy controls to compare to treatment arms....when we're actually trying to understand statins effects in RCTs, the holy drug class with many harms, few benefits and by monitoring/chasing all the wrong things.
Modern medicine is stuck in stupid.
The problems and diseases are very real, but the treatment ideas are abysmal.
Your comments remind me of the story of H. Pylori (yes, I intended the rhyme).
Like almost any comment or feedback, you give me food for thought, reflection, further studey and assimilation.
I have a daughter struggling with hypothyroid whom needed T3 to get any relief & she still struggles. And I am reminded of my mother in law. When I first met her during my courtship with my wife of 43 years, she consulted me, a newly minted pharmacist, about nutritional supplements. After a 25 minute consult at the breakfast table on a Sunday morning, I had redirected the conversation: As MD to check your throid." A cardiac med she had been on for ~35 years, a beta locker added a year prior and diazepam added 3 months prior were ultimately discontinued when her hyperthyroidism was diagnosed and treated.
The point I was making with the H. Pylori is that we have a lot to learn. The science is not settled. The MD who discovered H. Pylori in the 1980s met almost perfect resistance until researchers were able to confirm his discovery. And then we have all the other factors involved. Especially so today with the internet and social medias. I have a lifetime of stories.
The best I can tell you is, the best doctors are constantly reviewing and learning and willing to consult others, listen to patients, and try to see more than what is just "known".
Using pharma is not a negative thing at all as is minimizing or reducing poly pharma when appropriate. Or even just reducing dose age based on patient factors like age or drug or lifestyle interaction. Risk reward is a real issue with drugs, as well as non pharma approaches.
Regardless, we have come a long way. While I wouldn't necessarily say 'modern' medicine is simply "barbaric", as the fictional Dr McCoy said in that Star Trek movie, it definitely has a long way to go and we have a lot to learn. So, be frustrated. Be angry, even. Strive to learn, find that answer, and to share. Just remember. Even the best are human. As I told my mother in law some years into our relationship started when she said "You know. Doctors can't make mistakes.": "They are human first, doctors second, as we all are."
Not sure all the doctors (and remember the surgeons on here just cut so what do they advise when you see them.. um cutting LOL) on here wanna hear from patients. I think we see from the same perspective.
Dec 1, 2023·edited Dec 1, 2023Liked by Adam Cifu, MD
I am sorry for whatever happened to you, Micki. But, it seems to me that your comment is not contributing here. Rather, you are taking out your resentment on everyone and denigrating all doctors which categorically cannot be justified. Dr. Cifu, if you follow him, has taken great pains to share his experiences concerning what he’s learned while practicing medicine, and like a good science practitioner, he’s been humble and appropriately rather self-deprecating.
He didn't recommend anything but pharma. What has he learned about diet, lifestyle, I don't see any of that.
Didn't see this in the article. Note it says risks, benefits AND alternatives. Yes, a short article but there were no alternatives.
"Informed consent is the process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention. "
Yes I have actually. I'm an interpreter so I have seen there work over the last 25 years not only in my own family but also as a third party observer with no interest in the outcome so, yeah, I'd say I have... have you? And no I don't stalk them I ask questions which, if you have noticed, they never respond to!!
Watch the documentary "medicating Normal" and see about how the "game" rule are set up for a certain division of medicine. LMK what you think.
It's interesting that asking questions (about informed consent and lifestyle and diet) would be impugning your integrity. There is nothing nefarious about my questions. It's a question that as I said never gets answered. Why is that? Do you think that YOU are all knowing and patients shouldn't have the gall to question you because of your education and practice?
When my 91 year old mother went to a Cardiologist and he wanted to put her on a med (where she was supposed to be observed in the hospital for a few days but that was never mentioned) for her heart and I asked "what are the side effects" he said "there are none". I said "so this medication has no side effects". He said "if I told my patients the side effects they would never take the medications I suggest".
I went through an expensive waste of time and effort when my primary doc noted I have a small goiter and somewhat elevated TSH. I ended up getting nuclear imaging and a needle biopsy at an ENT. No malignancy.
But the whole flap was worth it because the ENT, who is a good doctor, told me afterward that some people have elevated TSH and it doesn't mean they have a thyroid problem. It's just where their set-point resides. (And I can't tolerate levothyroxine in any form, anyway)
So the whole episode was stupid. My primary doc was fairly young, and she was trying to do the right thing. But this taught me it's best to at least get a second opinion. Or maybe stay away from doctors if you're not aware of any problem.
And statins! You're right.. The absolute risk reduction is pretty low. At least here Dr Cifu says he'd prescribe a low dose which may have antiinflammatory benefit without the dementia, muscle pain, rhabdo risk. He listens to the patient. But I have friends stuck on 40 -50mg/day of atorvastatin by overloaded VA docs and they're not enjoying the ride.
My mention of vitamin K2 is bc my 20+ years of searching the literature led me there. PubMed search VK2, matrix gla protein, osteocalcin, UBIAD1. That last one is the enzyme that turns VK3 (created in small intestine from all forms of dietary VK by cleaving and then packaged in chylomicrons to go all over) where this enzyme creates MK-4. UBIAD1 controls cellular calcium and cholesterol. MK-4 is an endogenously made hormone that bunds SXR and affects the expression of many genes.
VK2 is huge player in diabetes, cancer, inflammation and more.
It sounds like you are trained in motivational interviewing. Your patients are lucky! You must take a lot of time with each patient, and I'm curious if you ever get in trouble for that. It seems like most visits are expected to be 15 minutes or less these days! If you have a fair number of patients like PP (older with multiple chronic conditions), it must take a lot of time because you also have to discuss the potential adverse events due to polypharmacy in older people (link #1). Maybe you can write an article on deprescribing and how those decisions are made. Also, you're right about the NNT having a cringe factor, and I prefer the ARR for reasons discussed in link #2. But I'd still love to have you as my PCP. I promise not to fall into Boxes B or C too often! :)
Just anecdotal, but removing drugs -especially in elderly - has made our neighbor, who's dying from cancer, feel sooo much better. He's actually able to do more now. Quality of life went way up!
Polypharmacy is dangerous and ubiquitous.
Pharma is happy, docs are expected to hand out scripts, and we're just fat and not-so-happy.
Read my links. Look further. Show me I'm misguided. You, doc, show me. Only you'll find that there's a better way than a lot of these ill-considered drugs.
Etiology of common chronic diseases is mostly misunderstood.
Hi Micki. I didn't see any links. I'm not sure if your "You, doc, show me" is directed at me or at Dr. Cifu. Since your comment was a reply to my comment, I'll respond the best that I can, given that I'm not a physician. I agree that polypharmacy can be dangerous and is fairly common in older people with multiple chronic conditions. That's why I posted the link about it, along with a suggestion that Dr. Cifu write an article on how deprescribing decisions are made. Sometimes the decision to deprescribe is easy, such as the neighbor you describe. He's dying, so the risk of harm from deprescribing is not a consideration. But other times, it's not so easy, and the patient and doctor together need to make a decision based on evidence and patient preference, and it sounds like this is exactly what Dr. Cifu does. Sometimes patients do not want to go off their meds, so one cannot put it all on doctors, although it is their responsibility to explain the most likely risk/benefit ratio in light of many, many patient-specific factors, which can change with age. As for "etiology of common chronic diseases is mostly understood," I think that depends on how you define "understood." We know a lot about the risk factors for CVD, and docs understand etiology more than even a decade ago, but I think it's naive to think they know all that there is to know. Same for various forms of dementia and cancer. Inflammaging seems to be the key to most chronic diseases of aging, but there is still much to learn about this process. As for "we're just fat and not-so-happy," I'm not sure what you're suggesting....just blame the overweight patient and tell them to lose weight? I think doctors who treat patients like PP do their best to inform them of eating healthy and exercising, but as they say, you can lead a horse to water..... Why are people so resistant? Because ultra-processed food (UPF) is addictive to many (link #2), and most people need help overcoming addiction. But with UPF addiction, research is in its infancy, so little is known about the most valid methods of Dx and Rx. And no, I'm not a shill for Big Pharma. I don't like a lot of what they do, and the FDA is in need of serious reform. But I also wouldn't want to live in a world without drugs or vaccines. I wish there were a way to fund drug research other than primarily through Big Pharma, but that type of research is tremendously expensive, so that's not practical. We need to find more ways to draw an inpenetrable wall between the researchers and the companies that fund them. Maybe a system like how the banks fund the FDIC, where the money all goes into a single pot. OK, that's just the first thought of my brainstorming and still needs refining! :) In the mean time, I'll rely on the good docs at Sensible Medicine and thennt.com to help me sift through risk/benefit ratios.
When a cardiologist recommended a drug to my, at the time, 91 year old mother and I was there and asked "What side effects does it have". He said.. are you ready? READY? "NONE" Yep that's what he said. I was shocked but not nearly so as when his next line was after I inquired again "If I tell my patients all the side effects they won't take the medication"
I am glad Dr. Cifu sits and talks to his patients but again he offered (in this writing) no alternatives other than pharmacological ones. Maybe he offers other things but if it was a routine practice I doubt he would not include it in his writing.
Perhaps he and Mandola will team up and discuss their experiences with recommending non-pharmacological interventions to their cardiac patients. One also has to examine why insurance doesn’t cover such interventions, or even the time needed to go over them with patients. 15 minute intervals seem pretty standard for most types of appointments and that’s not the doctor’s fault. To really help patients with lifestyle interventions requires far more time than that.
I was aware in the past that if a doctor changed a medication for a patient they were reimbursed more (by Medicare) but I am not sure that is still the case
If you're implying it's common for doctors to change a medication for Medicare patients to increase reimbursement rather than because it was clinically indicated, that's a damning claim, and IMHO opinion, should only be made if you can prove it with credible evidence, which you failed to provide. Doctors have to know not only medicine, but billing practices or they risk losing money, and it's just crazy (see Medicare billing below, and that's just one of many they deal with). As for your comment below, I know why people don't trust Pharma. As I first stated, there's a lot they do that I don't like, and both drug research funding and the FDA need to be reformed. But it's not an easy problem to solve, given that such research is tremendously expensive, unless you want your taxes to increase proportionately so the government can fund it. I haven't heard any solutions from you, unless you're suggesting we should just eliminate medications. In that case, my husband would be in much pain and unable to function. He has psoriatic arthritis (PsA) through no fault of his own (autoimmune diseases run in his family), and he exercises more than anybody I know and eats healthy. But his inflammation was sky high, which is bad for the entire body, not just joints, and he experienced pain and loss of function. Since starting a biologic (a monoclonal antibody), his inflammation is in the normal range, his pain is gone, his grip strength is back to normal, and he's no longer experiencing joint degeneration. There are may other diseases besides PsA for which medication is the only efficacious intervention. So speak for yourself; as I said before, I wouldn't want to live in a world with no medications. There may come a day when you will be unable to survive and/or function without medication but you can always refuse to take it because you don't trust Pharma.
Working at a Brown U Teaching hospital during this Bendectin period, we were witness to the tragedy of this series of events, being the impact on pregnant women. In my experience, it wasn't until the approval of Zofran that things really began to ease for them. My recollection was all my associates recognized the problems and failures leading up to the withdrawal of Bendectin. I see the same pattern potentially emerging regarding the CRC issue. Control for (unknowable) confounding factors, indeed.
This is worth a quote:
"There are at least 14 cohort and 18 case–control epidemiologic investigations on Bendectin and pregnancy outcome in addition to one, by the NIH, in which the occurrence of congenital malformations was prospectively studied in 31 564 newborns. The results of the NIH study, like those of others, found that the odds ratio for any of 58 major categories of malformation and Bendectin exposure was 1.0 – exactly that which is expected by chance alone. Of those categories with trends or suggestive positive associations, the magnitude of those associations was as great as that from vomiting during pregnancy without Bendectin use as with Bendectin use. There was no increase in malformation rate after exposure to Bendectin in utero than would otherwise be expected by chance; there are no objective data to conclude that exposure to Bendectin in animals or humans has any adverse effects on embryonic or fetal development at the doses used by these 30 million women.
As of 1987, at least 300 lawsuits had been filed alleging that Bendectin caused congenital malformations. The drug was dropped from commerce not because of lack of efficacy, or because it caused toxicity or because there was no market for the drug, but because of the excessive cost incurred by the manufacturer in defending the drug in litigation."
And I suggest this is more of the same about to kick up some dust. Correlations do not equate to causation. Even when reportely "after controlling for potential confounding factors" (as if that is even a certain possibility):
Study the Bendectin fiasco and learn why lawsuits can cause problems and lead to poor results. It is late. I don't have time to find links or get into it just now. Maybe I can remember and do so later this week.
Thank you. That means something coming from you. As a shrink and mediator, I'm working on a piece about how to bring about world peace. It might take awhile! 😳
I mainly worked in schools (a little bit in private practice), and we had our own system based on the Individuals with Disabilities Education Act (IDEA). But I can't tell you how often I said, "I wish we didn't have to diagnose people." Since you accessed my LinkedIn account, you can verify how I feel about Dx by reading my series, "Can you change somebody?" But diagnoses are mandated for insurance reimbursement and also IDEA services. The DSM is moving towards a dimensional rather than categorical system (link below), which is a step in the right direction, but they have a ways to go. When I used to protest labeling people, my grad school advisor would say, "Labels are just words, and we do need words to describe, so what else do you suggest?" I get the argument, and I think much of the negative results of labeling are due to our society's prejudice against mental illness, and until that changes, we can change the words but they will continue to take on negative connotations. My solution was to just identify "strengths and needs" and work on those, but my professor might be right and it wouldn't really help until society changes. The IDEA system in particular is very flawed and leaves out a lot of kids needing help. But to help them all, well, you know, that would be TOO expensive and Congress doesn't provide enough funding as it is. So what is your solution? I'm all ears.
To avoid the dread of ‘Cell B’ it’s common (and perhaps wise) to not bring up measures that are considered futile (eg LVAD in multiorgan failure from end stage cirrhosis in a patient who is not a transplant candidate).
This finger on the scale of SDM is more palatable the more that one’s shared values, goals, and understanding is calibrated. Always a risk of mistrust in assuming a patient hasn’t considered what escalation of care might look like though.
My biggest fear (using your lane analogy) is not when a patient is demanding a treatment that wouldn’t benefit them but rather when I don’t fully understand the reason behind it. Those rare occasions when motives are less than forthcoming feel more like lane switching across the median into oncoming traffic and the search for mutual understanding can be painful, particularly if there’s a sense of urgency (eg refusing palliation of pain to ‘go down fighting’)
That 2x2 table is only a portion of how good decisions are made. A patient may desire a therapy (e.g., dialysis) because, well, that's what you do when your kidneys fail. A physician may recommend a therapy (e.g., dialysis) because, well, that's what you do when someone's kidneys fail. But both have totally overlooked whether those preferences link up with any meaningful goal for the patient.
Very often in my palliative care practice people tell me, "Of course I want to live!" Yes, and with what trade-offs are you willing to pursue that goal? You allude to it a bit in that conversation about the statin being well-tolerated. If it weren't well-tolerated, presumably that would be a more involved conversation. That conversation would be a negotiation of the trade-offs in pursuit of a particular value or goal. But when you substitute a preference for a value, chaos ensues. People start ordering medical care piecemeal, instead of as a care plan in pursuit of a goal.
When you said you heard it many times in the office, you mean they were changing codes strictly for financial reasons and not patient benefit? Sounds like you worked for crooks willing to lose their license. There are a few bad apples in every profession but I don't believe most doctors are bad apples, and/or stupid enough to risk losing their license. Anyway, as for my husband, yes, he's tried all your suggestions, even though there is no RCT to support any of them, he figured there was no harm. All were totally ineffective. They do not lower Il-17, and I doubt there is a "natural" treatment that does, but if you find one, let me know. If we go to a cash system, my husband will be back to suffering and dysfunction, as treatment would be totally unaffordable. But if you want, go off insurance and just pay cash. But please don't declare bankruptcy if you end up needing mega-bucks treatment (even a car accident victim can end up owing hundreds of thousands), because then everybody else will have to pay for your treatment.
Nice lead-in to a discussion of shared decisions. Thank you. I’m in the category where I have to doctor-shop. With my clinical and didactic background, I have to find a doc who won’t become paternalistic and drop into Cell A every time. With my current PCP, if I’m going to ask him for a change of therapy I come in with citations and references. And the fact that he listens to some of the same podcasts that I follow helps: I can reference a specific podcast (he’s started writing those down) and he can check my interpretation. In general terms, we reach consensus, and most of my requests, even those I’m pretty solid on, can be swayed if he’s uncomfortable with the change. About the only place we’ve disagreed significantly is that he wants me on a statin, and I’m intolerant, something he’s finally accepted and noted on the chart. He still wants me on a PCSK9-i, but can’t justify it in terms of my lipid profile. I know he gets pinged by the QA folks for that shortcoming on his part on a quarterly basis, but there’s no reason for me to be miserable and unable to keep up with my normal exercise regimen due to myalgia and brain-fog.
Anyway, thanks for a good discussion.
Umm so talking ALL these meds together cause what kind of interactions/side effects?
"metoprolol, chlorthalidone, potassium chloride, isosorbide mononitrate, metformin, atorvastatin, and aspirin."
Sorry but you probably have NO idea. Probably individually but not all together cause let me guess there has never been any research on any one that takes them all together!
And telling any patients
"Me: They are generally very well-tolerated medications, and given your cardiovascular risk, the benefits greatly outweigh the harms."
Do you outline the side effects or interactions? Is it up to YOU to decide how this specific patient will "TOLERATE" them or not.
So you offer NO other remedies but pharmaceuticals? Really? Are you serious?
I'll leave you with this
https://www.bmj.com/content/349/bmj.g5385/rr/764093
Good point
Actually, not a good point at all. Clearly, the person does not know the first thing about any of the medications he lists. He seems to follow this substack merely to heckle, not contribute.
The 2x2 chart that defines my day-in-day-out as a primary internist. Thanks for fleshing this out, Adam.
Great piece, thank you. I see so many instances of cell C (dr recommends, pt declines) where the doctor soils the relationship because they dont understand how to graciously handle this. It makes for such a bad experience, as i have seen both as physician and when i am the patient. Maybe its easier for me as a surgeon, since not wanting surgery is very “relatable”. Not as easy if they are declining something easy and proven (taking aspirin when you have coronary disease).
Thank you again for your simple eloquent expression/sharing. The writers here in this substack and commenters help take away a little of the disenfranchisement with this profession- you help stave off the burnout!!! Now, i am off to answer some email and electronic messages...!
I think that direct-to-consumer marketing is largely responsible for cell B. The U.S.A. and New Zealand are the only countries that permit it, as far as I know.
Excellent Adam! 👏 So much human drama packed in that 2x2 chart!
Diabetes, CVD, cancer...the list of common chronic diseases that appear to be directly affected by VK goes on and on. Probably obesity, too.
Docs don't know.
No patentable drugs, no medical societies stand to benefit...plus we're stuck in stupid.
We've messed up fats, and VK is a fat soluble vitamin that we've thought was sufficient if coagulation was ok. Nope.
Those so-called dietary trans fats? It's bc we messed up VK1 to create what is often called dihydrophiloquinone (dK1). It doesn't act the right way; the bonds of fats are not what is pertinent. Hence, all that saturated/trans/mono saturated talk is BS. But that's what we looked at; that's what the literature discusses. We forgot fat soluble vitamins. Especially VK.
https://pubmed.ncbi.nlm.nih.gov/37552330/#:~:text=Conclusion%3A%20Vitamin%20K4%20supplementation%20for,decrease%20in%20antidiabetic%20medication%20doses.
https://pubmed.ncbi.nlm.nih.gov/37171959/
Add these to your list of fun articles.
And search more... it's amazing and unknown by most.
Been reading and enjoying since you launched Adam, but "Like most complex phenomena, this can be reduced to a 2X2 table" convinced me to upgrade to paid :)
I too had a nice chuckle at that.
If I knew that's all it would have taken... :-)
Thanks.
I can cite my personal experiences with endocrinologists and their "lovely" recommendations and expertise as examples of how very misguided/ignorant most of you medical experts can be.
I am hypothyroid: diagnosed TSH in mid 80s and symptoms like inability to control body temperature, depression, brain fog.
Following guidelines, levothyroxine monotherapy was begun and my TSH was followed until it was in the so-called normal range. Only my symptoms weren't helped. I followed drug regimen and eventually went to about 5 docs/endos, all looking at these test results and no one remotely capable of listening to me. "Symptoms of hypothyroidism can be from many things, and your tests show that your thyroid is being correctly treated."
Eventually, I fell asleep driving on the interstate one afternoon and decided to try once again with yet another (dumbass) endocrinologist.
She added T3 to my T4 monotherapy and by the end of the second day, a huge cloud lifted! Much like when the Wizard of Oz goes to color from B&W. BUT...since she, along with the vast majority of idiot endos, had cut my T4 to add T3, as per their idiotic understanding of thyroid function, I began to decline again. This remarkable improvement began to decline in a few days.
As per those guidelines, she wanted to wait and then monitor TSH after 5 weeks.
I left her and went back to my family doctor and got a Rx for Armour thyroid. I have taken this for decades and I flourish.
So...dear uninformed doctor:
Do you know what causes cardiovascular disease? Why statins are misguided?
It's this: calcium dysregulation.
Matrix gla protein, the most potent anti-calcification agent known, keeps inappropriate calcium from depositing in arteries. You know...CAC. The REAL thing; not cholesterol, but calcium dysregulation causes events.
A zero CAC translates to a 15 year warranty from death by all causes. Statins actually INCREASE CAC, especially lipophilic ones.
And dear endogenously made T3 is essential to create matrix gla protein. THAT is where we've screwed up.
Turns out, TSH sucks as a determinate of thyroid function and T3 is not consistently made in all tissues. Serum T3 is not accurate for all tissue levels. Endocrinology, much like cardiology, is pretty full of it.
The recommended switch from desiccated thyroid was in the 70s and lies/obfuscation by pharma has led us - much like statins - horribly astray.
Are you aware that ALL the stuff you've been fed about statins cites relative risk and not absolute risk, dear doc? Those drugs reduce risk of an event by less than one percent for primary prevention and may increase life by about 4 days. (Feel free to reach me for citations)
Secondary prevention isn't much better.
And so-called side effects? (Bwahaha, side effects when they really should be called harms)
Now... after pouring over the literature for 20+ years, I have learned how very, very misguided modern medicine really is
Go look. Learn about statistical manipulation.
And learn about vitamin K2. It's powerful, misunderstood and has gone missing in diet bc we're absolutely stupid. MK-4, made endogenously, is messed up by statins. That's only one harm from statins. But our lousy foods, our lousy toxins also cause diseases, so we have lousy controls to compare to treatment arms....when we're actually trying to understand statins effects in RCTs, the holy drug class with many harms, few benefits and by monitoring/chasing all the wrong things.
Modern medicine is stuck in stupid.
The problems and diseases are very real, but the treatment ideas are abysmal.
https://www.cureus.com/articles/141648-historical-review-of-the-use-of-relative-risk-statistics-in-the-portrayal-of-the-purported-hazards-of-high-ldl-cholesterol-and-the-benefits-of-lipid-lowering-therapy#!/
Your comments remind me of the story of H. Pylori (yes, I intended the rhyme).
Like almost any comment or feedback, you give me food for thought, reflection, further studey and assimilation.
I have a daughter struggling with hypothyroid whom needed T3 to get any relief & she still struggles. And I am reminded of my mother in law. When I first met her during my courtship with my wife of 43 years, she consulted me, a newly minted pharmacist, about nutritional supplements. After a 25 minute consult at the breakfast table on a Sunday morning, I had redirected the conversation: As MD to check your throid." A cardiac med she had been on for ~35 years, a beta locker added a year prior and diazepam added 3 months prior were ultimately discontinued when her hyperthyroidism was diagnosed and treated.
The point I was making with the H. Pylori is that we have a lot to learn. The science is not settled. The MD who discovered H. Pylori in the 1980s met almost perfect resistance until researchers were able to confirm his discovery. And then we have all the other factors involved. Especially so today with the internet and social medias. I have a lifetime of stories.
The best I can tell you is, the best doctors are constantly reviewing and learning and willing to consult others, listen to patients, and try to see more than what is just "known".
Using pharma is not a negative thing at all as is minimizing or reducing poly pharma when appropriate. Or even just reducing dose age based on patient factors like age or drug or lifestyle interaction. Risk reward is a real issue with drugs, as well as non pharma approaches.
Regardless, we have come a long way. While I wouldn't necessarily say 'modern' medicine is simply "barbaric", as the fictional Dr McCoy said in that Star Trek movie, it definitely has a long way to go and we have a lot to learn. So, be frustrated. Be angry, even. Strive to learn, find that answer, and to share. Just remember. Even the best are human. As I told my mother in law some years into our relationship started when she said "You know. Doctors can't make mistakes.": "They are human first, doctors second, as we all are."
Not sure all the doctors (and remember the surgeons on here just cut so what do they advise when you see them.. um cutting LOL) on here wanna hear from patients. I think we see from the same perspective.
I am sorry for whatever happened to you, Micki. But, it seems to me that your comment is not contributing here. Rather, you are taking out your resentment on everyone and denigrating all doctors which categorically cannot be justified. Dr. Cifu, if you follow him, has taken great pains to share his experiences concerning what he’s learned while practicing medicine, and like a good science practitioner, he’s been humble and appropriately rather self-deprecating.
He didn't recommend anything but pharma. What has he learned about diet, lifestyle, I don't see any of that.
Didn't see this in the article. Note it says risks, benefits AND alternatives. Yes, a short article but there were no alternatives.
"Informed consent is the process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention. "
Yes I have actually. I'm an interpreter so I have seen there work over the last 25 years not only in my own family but also as a third party observer with no interest in the outcome so, yeah, I'd say I have... have you? And no I don't stalk them I ask questions which, if you have noticed, they never respond to!!
Watch the documentary "medicating Normal" and see about how the "game" rule are set up for a certain division of medicine. LMK what you think.
Wait is this you???
Just someone who really wants to see integrity in journalism and open, free public discourse.
What do you think "free public discourse is"?
It's interesting that asking questions (about informed consent and lifestyle and diet) would be impugning your integrity. There is nothing nefarious about my questions. It's a question that as I said never gets answered. Why is that? Do you think that YOU are all knowing and patients shouldn't have the gall to question you because of your education and practice?
When my 91 year old mother went to a Cardiologist and he wanted to put her on a med (where she was supposed to be observed in the hospital for a few days but that was never mentioned) for her heart and I asked "what are the side effects" he said "there are none". I said "so this medication has no side effects". He said "if I told my patients the side effects they would never take the medications I suggest".
Is that you too?
🙏
Ditto 🙏🏻, Doctor. I look forward to every article you post.
I went through an expensive waste of time and effort when my primary doc noted I have a small goiter and somewhat elevated TSH. I ended up getting nuclear imaging and a needle biopsy at an ENT. No malignancy.
But the whole flap was worth it because the ENT, who is a good doctor, told me afterward that some people have elevated TSH and it doesn't mean they have a thyroid problem. It's just where their set-point resides. (And I can't tolerate levothyroxine in any form, anyway)
So the whole episode was stupid. My primary doc was fairly young, and she was trying to do the right thing. But this taught me it's best to at least get a second opinion. Or maybe stay away from doctors if you're not aware of any problem.
And statins! You're right.. The absolute risk reduction is pretty low. At least here Dr Cifu says he'd prescribe a low dose which may have antiinflammatory benefit without the dementia, muscle pain, rhabdo risk. He listens to the patient. But I have friends stuck on 40 -50mg/day of atorvastatin by overloaded VA docs and they're not enjoying the ride.
Nice story!
Glad you emerged relatively unscathed.
My mention of vitamin K2 is bc my 20+ years of searching the literature led me there. PubMed search VK2, matrix gla protein, osteocalcin, UBIAD1. That last one is the enzyme that turns VK3 (created in small intestine from all forms of dietary VK by cleaving and then packaged in chylomicrons to go all over) where this enzyme creates MK-4. UBIAD1 controls cellular calcium and cholesterol. MK-4 is an endogenously made hormone that bunds SXR and affects the expression of many genes.
VK2 is huge player in diabetes, cancer, inflammation and more.
Look at this:
https://pubmed.ncbi.nlm.nih.gov/30051950/
Recently, new larger vitamin K-dependent proteins were found in the ER of pancreatic beta cells and they directly affect calcium behavior.
The implications are mind-blowing.
20 years. Good effort!
And consider the changes in knowledge and technology during that time.
It sounds like you are trained in motivational interviewing. Your patients are lucky! You must take a lot of time with each patient, and I'm curious if you ever get in trouble for that. It seems like most visits are expected to be 15 minutes or less these days! If you have a fair number of patients like PP (older with multiple chronic conditions), it must take a lot of time because you also have to discuss the potential adverse events due to polypharmacy in older people (link #1). Maybe you can write an article on deprescribing and how those decisions are made. Also, you're right about the NNT having a cringe factor, and I prefer the ARR for reasons discussed in link #2. But I'd still love to have you as my PCP. I promise not to fall into Boxes B or C too often! :)
https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-021-02183-0
https://discourse.datamethods.org/t/problems-with-nnt/195/4
Just anecdotal, but removing drugs -especially in elderly - has made our neighbor, who's dying from cancer, feel sooo much better. He's actually able to do more now. Quality of life went way up!
Polypharmacy is dangerous and ubiquitous.
Pharma is happy, docs are expected to hand out scripts, and we're just fat and not-so-happy.
Read my links. Look further. Show me I'm misguided. You, doc, show me. Only you'll find that there's a better way than a lot of these ill-considered drugs.
Etiology of common chronic diseases is mostly misunderstood.
Hi Micki. I didn't see any links. I'm not sure if your "You, doc, show me" is directed at me or at Dr. Cifu. Since your comment was a reply to my comment, I'll respond the best that I can, given that I'm not a physician. I agree that polypharmacy can be dangerous and is fairly common in older people with multiple chronic conditions. That's why I posted the link about it, along with a suggestion that Dr. Cifu write an article on how deprescribing decisions are made. Sometimes the decision to deprescribe is easy, such as the neighbor you describe. He's dying, so the risk of harm from deprescribing is not a consideration. But other times, it's not so easy, and the patient and doctor together need to make a decision based on evidence and patient preference, and it sounds like this is exactly what Dr. Cifu does. Sometimes patients do not want to go off their meds, so one cannot put it all on doctors, although it is their responsibility to explain the most likely risk/benefit ratio in light of many, many patient-specific factors, which can change with age. As for "etiology of common chronic diseases is mostly understood," I think that depends on how you define "understood." We know a lot about the risk factors for CVD, and docs understand etiology more than even a decade ago, but I think it's naive to think they know all that there is to know. Same for various forms of dementia and cancer. Inflammaging seems to be the key to most chronic diseases of aging, but there is still much to learn about this process. As for "we're just fat and not-so-happy," I'm not sure what you're suggesting....just blame the overweight patient and tell them to lose weight? I think doctors who treat patients like PP do their best to inform them of eating healthy and exercising, but as they say, you can lead a horse to water..... Why are people so resistant? Because ultra-processed food (UPF) is addictive to many (link #2), and most people need help overcoming addiction. But with UPF addiction, research is in its infancy, so little is known about the most valid methods of Dx and Rx. And no, I'm not a shill for Big Pharma. I don't like a lot of what they do, and the FDA is in need of serious reform. But I also wouldn't want to live in a world without drugs or vaccines. I wish there were a way to fund drug research other than primarily through Big Pharma, but that type of research is tremendously expensive, so that's not practical. We need to find more ways to draw an inpenetrable wall between the researchers and the companies that fund them. Maybe a system like how the banks fund the FDIC, where the money all goes into a single pot. OK, that's just the first thought of my brainstorming and still needs refining! :) In the mean time, I'll rely on the good docs at Sensible Medicine and thennt.com to help me sift through risk/benefit ratios.
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2810482
https://www.bmj.com/content/383/bmj-2023-075354
AND those I linked are ONLY the five largest.
When a cardiologist recommended a drug to my, at the time, 91 year old mother and I was there and asked "What side effects does it have". He said.. are you ready? READY? "NONE" Yep that's what he said. I was shocked but not nearly so as when his next line was after I inquired again "If I tell my patients all the side effects they won't take the medication"
I am glad Dr. Cifu sits and talks to his patients but again he offered (in this writing) no alternatives other than pharmacological ones. Maybe he offers other things but if it was a routine practice I doubt he would not include it in his writing.
Perhaps he and Mandola will team up and discuss their experiences with recommending non-pharmacological interventions to their cardiac patients. One also has to examine why insurance doesn’t cover such interventions, or even the time needed to go over them with patients. 15 minute intervals seem pretty standard for most types of appointments and that’s not the doctor’s fault. To really help patients with lifestyle interventions requires far more time than that.
I was aware in the past that if a doctor changed a medication for a patient they were reimbursed more (by Medicare) but I am not sure that is still the case
We won't even talk about this article.
https://jamanetwork.com/journals/jama/fullarticle/192577
If you're implying it's common for doctors to change a medication for Medicare patients to increase reimbursement rather than because it was clinically indicated, that's a damning claim, and IMHO opinion, should only be made if you can prove it with credible evidence, which you failed to provide. Doctors have to know not only medicine, but billing practices or they risk losing money, and it's just crazy (see Medicare billing below, and that's just one of many they deal with). As for your comment below, I know why people don't trust Pharma. As I first stated, there's a lot they do that I don't like, and both drug research funding and the FDA need to be reformed. But it's not an easy problem to solve, given that such research is tremendously expensive, unless you want your taxes to increase proportionately so the government can fund it. I haven't heard any solutions from you, unless you're suggesting we should just eliminate medications. In that case, my husband would be in much pain and unable to function. He has psoriatic arthritis (PsA) through no fault of his own (autoimmune diseases run in his family), and he exercises more than anybody I know and eats healthy. But his inflammation was sky high, which is bad for the entire body, not just joints, and he experienced pain and loss of function. Since starting a biologic (a monoclonal antibody), his inflammation is in the normal range, his pain is gone, his grip strength is back to normal, and he's no longer experiencing joint degeneration. There are may other diseases besides PsA for which medication is the only efficacious intervention. So speak for yourself; as I said before, I wouldn't want to live in a world with no medications. There may come a day when you will be unable to survive and/or function without medication but you can always refuse to take it because you don't trust Pharma.
https://www.cms.gov/files/document/chapter1generalcorrectcodingpoliciesfinal11.pdf
These are why people don't trust Pharma
https://www.enjuris.com/blog/resources/largest-pharmaceutical-settlements-lawsuits/
https://www.justice.gov/opa/pr/drug-maker-forest-pleads-guilty-pay-more-313-million-resolve-criminal-charges-and-false
Working at a Brown U Teaching hospital during this Bendectin period, we were witness to the tragedy of this series of events, being the impact on pregnant women. In my experience, it wasn't until the approval of Zofran that things really began to ease for them. My recollection was all my associates recognized the problems and failures leading up to the withdrawal of Bendectin. I see the same pattern potentially emerging regarding the CRC issue. Control for (unknowable) confounding factors, indeed.
This is worth a quote:
"There are at least 14 cohort and 18 case–control epidemiologic investigations on Bendectin and pregnancy outcome in addition to one, by the NIH, in which the occurrence of congenital malformations was prospectively studied in 31 564 newborns. The results of the NIH study, like those of others, found that the odds ratio for any of 58 major categories of malformation and Bendectin exposure was 1.0 – exactly that which is expected by chance alone. Of those categories with trends or suggestive positive associations, the magnitude of those associations was as great as that from vomiting during pregnancy without Bendectin use as with Bendectin use. There was no increase in malformation rate after exposure to Bendectin in utero than would otherwise be expected by chance; there are no objective data to conclude that exposure to Bendectin in animals or humans has any adverse effects on embryonic or fetal development at the doses used by these 30 million women.
As of 1987, at least 300 lawsuits had been filed alleging that Bendectin caused congenital malformations. The drug was dropped from commerce not because of lack of efficacy, or because it caused toxicity or because there was no market for the drug, but because of the excessive cost incurred by the manufacturer in defending the drug in litigation."
Try the following for some interesting reading:
https://www.sciencedirect.com/topics/medicine-and-dentistry/bendectin
And I suggest this is more of the same about to kick up some dust. Correlations do not equate to causation. Even when reportely "after controlling for potential confounding factors" (as if that is even a certain possibility):
https://www.medscape.com/viewarticle/989787
Study the Bendectin fiasco and learn why lawsuits can cause problems and lead to poor results. It is late. I don't have time to find links or get into it just now. Maybe I can remember and do so later this week.
Wow, thanks. Really well said. You need to submit something!
It was a good day when I discovered thennt.
Adam
Thank you. That means something coming from you. As a shrink and mediator, I'm working on a piece about how to bring about world peace. It might take awhile! 😳
OH you are retired psychologist? Wanna talk about the DSM ?? How about watching a documentary called
Here's a link. Let me know what you think about the process.
https://youtu.be/-Nd40Uy6tbQ?feature=shared
I mainly worked in schools (a little bit in private practice), and we had our own system based on the Individuals with Disabilities Education Act (IDEA). But I can't tell you how often I said, "I wish we didn't have to diagnose people." Since you accessed my LinkedIn account, you can verify how I feel about Dx by reading my series, "Can you change somebody?" But diagnoses are mandated for insurance reimbursement and also IDEA services. The DSM is moving towards a dimensional rather than categorical system (link below), which is a step in the right direction, but they have a ways to go. When I used to protest labeling people, my grad school advisor would say, "Labels are just words, and we do need words to describe, so what else do you suggest?" I get the argument, and I think much of the negative results of labeling are due to our society's prejudice against mental illness, and until that changes, we can change the words but they will continue to take on negative connotations. My solution was to just identify "strengths and needs" and work on those, but my professor might be right and it wouldn't really help until society changes. The IDEA system in particular is very flawed and leaves out a lot of kids needing help. But to help them all, well, you know, that would be TOO expensive and Congress doesn't provide enough funding as it is. So what is your solution? I'm all ears.
https://journals.sagepub.com/doi/full/10.1177/1529100617727267
I’m willing to wait!
To avoid the dread of ‘Cell B’ it’s common (and perhaps wise) to not bring up measures that are considered futile (eg LVAD in multiorgan failure from end stage cirrhosis in a patient who is not a transplant candidate).
This finger on the scale of SDM is more palatable the more that one’s shared values, goals, and understanding is calibrated. Always a risk of mistrust in assuming a patient hasn’t considered what escalation of care might look like though.
My biggest fear (using your lane analogy) is not when a patient is demanding a treatment that wouldn’t benefit them but rather when I don’t fully understand the reason behind it. Those rare occasions when motives are less than forthcoming feel more like lane switching across the median into oncoming traffic and the search for mutual understanding can be painful, particularly if there’s a sense of urgency (eg refusing palliation of pain to ‘go down fighting’)
What...only 7 drugs? No wonder she is still having problems.