Why have I been committed to medical education? Some of the reasons are admirable but not terribly novel. Others are a bit hard to admit, but just as true.
Your course sounds incredibly rewarding for you and your students. Another possible selfish interpretation: Teaching them to fish will mean that they are better able to look after you when you need it!
Could you please share your syllabus or a link to the course description?
I still remember at a conference about how pharmaceutical industry payments create bias in prescribing. I spoke up about critical thinking as a solution, and the response that I got was that this sort of bias was unlikely to be affected by a person's intelligence or critical thinking skills; people find ways to rationalize what's in their own interest, I was told.
I do of course enjoy teaching critical thinking. It was one of the first classes I took as an undergrad. But that counterpoint sticks in my mind.
I do hope you filmed this series of lectures and will make it available to the general public at some point as an online course...if you need help doing so (and potentially monetizing it), reach out...
Love this piece. Definitely left me wanting to debate the case above. As a nephrologist, I could make a full time job of stopping medications that are causing more harm than good for individual patients, clinical trials be damned. The flozins have certainly been a good fit in this regard.
I had a similar experience, though not near the depth, at the end of my Nursing career. For years a physician colleague and I had worked with providers and nurses on refining our resuscitation efforts. We had a measure of success: our survival rates dramatically improved, and our staff were much more positive about resuscitation and being members of the team. We were able to introduce our methods to other acute care facilities, presented at state and national symposiums, and published our work.
I stayed quite hands-on with our process; I did mock codes throughout facilities, on all shifts, gave individual instruction, taught classes of Critical Care students and Residents, created and initiated Resident hands-on training, adult and pediatric.
I was involved in training my replacement. I admit to angst about finding someone with *my* level of commitment. Would they keep up the standards? Follow through with issues? Unrealistic expectations, of course. I finally just turned it all over and retired, hoping our process was hardwired enough to stay maintained.
I had to be content with knowing we had done our best to strive for excellence, and hope that the lessons learned would have lasting impressions on our colleagues.
Keep teaching the course! Your experience is priceless. Coach it with a younger colleague who’s like minded and let them do the heavy lifting.
As an aside, I’m not so sure about the “flozins.” They are basically osmotic diuretics and I think the real study is them versus an extra 20 or 40 of Lasix. They don’t add a minute to your life. Time will tell.
Dr. Cifu, I'm sorry that you are drawn to stop teaching. The further apart generations become, as in the older we get the younger students get. The ceaseless flow of new, young, untainted minds looking forward to a life in medicine deserve absorbing the words and stories you have to share. When you stop sharing them no one else will be benefiting from them. It all ends there.
Hey Adam, appreciate your reflections today and always. I'm a fledgling PGY-3 and only discovered EBM in the past few years. You and the Sensible Med crowd have provided me with new excitement in pursuing medicine - an excitement that is stronger now than when I graduated med school. Feel like I've finally found my people here. Thanks for taking learners under your wing and for fostering a community focused on crucially important topics. Happy Friday.
Dr Cifu - this is Matt Phillips - I am a cardiologist . I have a friend who has multiple family members ( he named about 5) with pancreatic ca. he went to Hopkins I think for some genetic studies. I read your article a few weeks ago . Is there a resource , site or physician that you might suggest he seek counsel from. He is a retired engineer ( I met them at the HAM radio club-my new and only post retirement hobby -that is another story worthy of discussion -physician retirement -not for the weak ) - and otherwise very healthy . Any guidance appreciated . I am on Doximity and I am subscribed so my contact is somewhere in your system thx
I was retired after a car accident coming home from outreach clinic. Having been a physician leader of a large group and busy in the national Society. It was difficult to overnight going to the guy standing in line in Walgreens waiting for medicines. I became very depressed. I think all physicians need disability insurance outside of their employers because that's another story . Everyone needs high dollar uninsured motorist coverage because 1/3 people at least in Texas have no car insurance. And then, especially for physicians, it would be very helpful if they had an outside interest. My grandkids saved me. I started to go to their games and activities. I missed most of my children's
Finally, recently, I got a Ham radio license. It's an interesting hobby science based, but no one dies at least not if you can help it and not get electrocuted. There are tests and you meet a lot of interesting people. KJ5EBB
I am not a medical student, but I am interested in teaching myself how to interpret and analyze these studies. Would you say that JAMA guide is self-sufficient (albeit presumaby difficult), or were there other protocols you incorporated that you've found to be important whilst teaching your students?
I always love your reflections. And the fact that you are a minimalist is the reason I admire you the most! Doing only what’s needed and allowing the patient to do his/her part is such an important part of medicine. I remember my medical director telling a patient once that he could get him off 5-7 medicines he was on if he’d limit caffeine, stop smoking, eat 4 fresh servings of fruits and vegetables a day, and exercise. The fella looked at Doc and said, “I like my cheeseburgers…”
People are so apt to “blame pharma” for their role, but we Americans tend to set that up outta sheer laziness. I digress…thanks again for allowing us to reflect on your reflections!
No wonder he is doing less well. When do you get to the point that enough drugs are enough? You just keep adding more and more as the patient gets sicker and sicker. You never in a million years try to understand what the real problems and causes are. The worse situation I can think of is to die under the yoke of big pharma drugs.
As I wrote to Luc, it is critical to be skeptical but also important to recognize what the advances in medicine have brought. In the patient described, all of these meds have a very robust, clinical trial, evidence base showing that they improve health and life expectancy in the situation described. This evidence also includes combinations of medications, though certainly not every combination.
I most likely would have loved your class, and certainly would have loved to have taught something similar. An academic career was my plan but not my reality. Now living a ‘retired life’ I do enjoy reading your essays…!
Just one question.. did anyone ever ask the contraindications of taking ALL these meds at the same time? Probably not cause there is NO evidence base on that is there, Doc?
"He currently takes rivaroxaban, atorvastatin, metformin, losartan, and spironolactone. He is seeing his general internist who suggests initiating therapy with empagliflozin."
As I wrote this, I knew at least one person would ask this question. In the patient described, all of these meds have a very robust, clinical trial, evidence base. This evidence also includes combinations of medications, though certainly not every combination. If the patient was me, I’d want to be on the 5 meds described (assuming I tolerated them well).
Yes it does. Because that should be your first "go to" and not how many meds you can get a patient on to FIX the symptoms of their problems. Sadly (nothing personal) but Doctors these days have just become drug pushers. I've seen it over and over being a third party in the room. It's sad.
Your course sounds incredibly rewarding for you and your students. Another possible selfish interpretation: Teaching them to fish will mean that they are better able to look after you when you need it!
Could you please share your syllabus or a link to the course description?
I still remember at a conference about how pharmaceutical industry payments create bias in prescribing. I spoke up about critical thinking as a solution, and the response that I got was that this sort of bias was unlikely to be affected by a person's intelligence or critical thinking skills; people find ways to rationalize what's in their own interest, I was told.
I do of course enjoy teaching critical thinking. It was one of the first classes I took as an undergrad. But that counterpoint sticks in my mind.
I do hope you filmed this series of lectures and will make it available to the general public at some point as an online course...if you need help doing so (and potentially monetizing it), reach out...
Looking forward to the syllabus!
Love this piece. Definitely left me wanting to debate the case above. As a nephrologist, I could make a full time job of stopping medications that are causing more harm than good for individual patients, clinical trials be damned. The flozins have certainly been a good fit in this regard.
I had a similar experience, though not near the depth, at the end of my Nursing career. For years a physician colleague and I had worked with providers and nurses on refining our resuscitation efforts. We had a measure of success: our survival rates dramatically improved, and our staff were much more positive about resuscitation and being members of the team. We were able to introduce our methods to other acute care facilities, presented at state and national symposiums, and published our work.
I stayed quite hands-on with our process; I did mock codes throughout facilities, on all shifts, gave individual instruction, taught classes of Critical Care students and Residents, created and initiated Resident hands-on training, adult and pediatric.
I was involved in training my replacement. I admit to angst about finding someone with *my* level of commitment. Would they keep up the standards? Follow through with issues? Unrealistic expectations, of course. I finally just turned it all over and retired, hoping our process was hardwired enough to stay maintained.
I had to be content with knowing we had done our best to strive for excellence, and hope that the lessons learned would have lasting impressions on our colleagues.
Dr. Cifu,
Keep teaching the course! Your experience is priceless. Coach it with a younger colleague who’s like minded and let them do the heavy lifting.
As an aside, I’m not so sure about the “flozins.” They are basically osmotic diuretics and I think the real study is them versus an extra 20 or 40 of Lasix. They don’t add a minute to your life. Time will tell.
I always enjoy reading your articles.
That was out take on the flozins for this indication in the class.
Dr. Cifu, I'm sorry that you are drawn to stop teaching. The further apart generations become, as in the older we get the younger students get. The ceaseless flow of new, young, untainted minds looking forward to a life in medicine deserve absorbing the words and stories you have to share. When you stop sharing them no one else will be benefiting from them. It all ends there.
That Friday 4:40 case needed to add "he has recently developed microcytic anemia..."
LOL.
Hey Adam, appreciate your reflections today and always. I'm a fledgling PGY-3 and only discovered EBM in the past few years. You and the Sensible Med crowd have provided me with new excitement in pursuing medicine - an excitement that is stronger now than when I graduated med school. Feel like I've finally found my people here. Thanks for taking learners under your wing and for fostering a community focused on crucially important topics. Happy Friday.
You just pretty much made my week. Thanks.
Dr Cifu - this is Matt Phillips - I am a cardiologist . I have a friend who has multiple family members ( he named about 5) with pancreatic ca. he went to Hopkins I think for some genetic studies. I read your article a few weeks ago . Is there a resource , site or physician that you might suggest he seek counsel from. He is a retired engineer ( I met them at the HAM radio club-my new and only post retirement hobby -that is another story worthy of discussion -physician retirement -not for the weak ) - and otherwise very healthy . Any guidance appreciated . I am on Doximity and I am subscribed so my contact is somewhere in your system thx
I'm so sorry. Not much specific to recommend. I do know that JH has a very good genetics group.
(Also, totally into the HAM radio reference!)
Thanks
I was retired after a car accident coming home from outreach clinic. Having been a physician leader of a large group and busy in the national Society. It was difficult to overnight going to the guy standing in line in Walgreens waiting for medicines. I became very depressed. I think all physicians need disability insurance outside of their employers because that's another story . Everyone needs high dollar uninsured motorist coverage because 1/3 people at least in Texas have no car insurance. And then, especially for physicians, it would be very helpful if they had an outside interest. My grandkids saved me. I started to go to their games and activities. I missed most of my children's
Finally, recently, I got a Ham radio license. It's an interesting hobby science based, but no one dies at least not if you can help it and not get electrocuted. There are tests and you meet a lot of interesting people. KJ5EBB
I am not a medical student, but I am interested in teaching myself how to interpret and analyze these studies. Would you say that JAMA guide is self-sufficient (albeit presumaby difficult), or were there other protocols you incorporated that you've found to be important whilst teaching your students?
Users' guide and the book is a great place to start.
I always love your reflections. And the fact that you are a minimalist is the reason I admire you the most! Doing only what’s needed and allowing the patient to do his/her part is such an important part of medicine. I remember my medical director telling a patient once that he could get him off 5-7 medicines he was on if he’d limit caffeine, stop smoking, eat 4 fresh servings of fruits and vegetables a day, and exercise. The fella looked at Doc and said, “I like my cheeseburgers…”
People are so apt to “blame pharma” for their role, but we Americans tend to set that up outta sheer laziness. I digress…thanks again for allowing us to reflect on your reflections!
Glad to have you back...
No wonder he is doing less well. When do you get to the point that enough drugs are enough? You just keep adding more and more as the patient gets sicker and sicker. You never in a million years try to understand what the real problems and causes are. The worse situation I can think of is to die under the yoke of big pharma drugs.
As I wrote to Luc, it is critical to be skeptical but also important to recognize what the advances in medicine have brought. In the patient described, all of these meds have a very robust, clinical trial, evidence base showing that they improve health and life expectancy in the situation described. This evidence also includes combinations of medications, though certainly not every combination.
I most likely would have loved your class, and certainly would have loved to have taught something similar. An academic career was my plan but not my reality. Now living a ‘retired life’ I do enjoy reading your essays…!
SUNY-Syracuse HSC ‘92
Thanks so much.
Just one question.. did anyone ever ask the contraindications of taking ALL these meds at the same time? Probably not cause there is NO evidence base on that is there, Doc?
"He currently takes rivaroxaban, atorvastatin, metformin, losartan, and spironolactone. He is seeing his general internist who suggests initiating therapy with empagliflozin."
As I wrote this, I knew at least one person would ask this question. In the patient described, all of these meds have a very robust, clinical trial, evidence base. This evidence also includes combinations of medications, though certainly not every combination. If the patient was me, I’d want to be on the 5 meds described (assuming I tolerated them well).
And what lifestyle changes did you recommend for this patient? What diet changes?
Does it matter?
Yes it does. Because that should be your first "go to" and not how many meds you can get a patient on to FIX the symptoms of their problems. Sadly (nothing personal) but Doctors these days have just become drug pushers. I've seen it over and over being a third party in the room. It's sad.
If he was a real patient, I’d say that they all had been recommended years before and he was unable to adopt any of the changes.
Unable or unwilling?