Regarding not prescribing Paxlovid that is the right decision in 2024. Paxlovid has been disproven in the only study done since Omicron and primum non nocere still trumps faith based medicine. My brother recently fainted from Shy-Drager from Parkinson's. He got carted to the hospital and labeled Covid and aspiration pneumonia. What he had was a cold from his Covid. Proof. They discharged him in 3 days but after 3 days of bedrest and no therapy he was so deconditioned he couldn't go home. So they put him back a couple more days by 2 more days of bed rest because the rehab facility doesn't do therapy on weekends. He would have been better off at home continuing his daily exercises. His wife picks him up regularly and he doesn't have 5 days of forced bed rest. Last time I looked the only medical indication for bed rest was threatened ab.
Here is my counterfactual: An elderly (85 years old) physician patient who was in the early stages of dementia developed low grade breast cancer, diagnosed after she insisted on getting a screening mammogram. She wanted maximal treatment including a double mastectomy (declined by the operating surgeon) and chemotherapy. An oncologist warned that chemotherapy in this setting is often poorly tolerated and could accelerate cognitive decline. The patient insisted on getting chemotherapy. The chemo was poorly tolerated, and her dementia did exponentially worsen. Her remaining life was characterized by very difficult to manage dementia characterized by verbally abusive, violent behaviors-completely uncharacteristic of her pre-dementia self. I felt that she would have been much better off without the chemo. Perhaps your patient did well because he did not get aggressive cancer care.
I'm disappointed in the way you practice medicine. 'Insisted' a patient have a colonoscopy? Refused care if she didn't? At the very least, you didn't take the time to find out if she was risk tolerant, risk averse, wanted intensive medical intervention or minimal medical involvement... It sounds like you implemented your one size fits all management plan on her, screw her values, choice and autonomy. Empowering someone to manage their health the way they want to manage it (my goal) is clearly not your intent; your patient's role is to facilitate you managing her health the way you want to manage it. At least that's how it reads. I'm disappointed in a preceptor.
in March 2021, my 57 year old husband (non smoker) was diagnosed with squamous cell carcinoma of the tongue. It had not spread to lymph nodes and the standard of care for the size of the tumor was a hemi-glossectomy. The full surgical biopsy showed clear borders, but a chance error in the report wording caused the radiation oncologist to look at the samples and he found what the pathologist did not...3 stray cells that caused him to recommend radiation, which was the next treatment in the standard of care.
I wish to God we had not done that. He still would have died of this aggressive cancer, but not the horrific way that 7 weeks of daily radiation to the neck caused. Infection and sepsis and necrosis of his neck that literally ate down to his carotid artery. Sure, I don't know the counterfactuals, but I can tell you that this was a very gruesome and painful death. The "cure" was definitely worse than the disease.
The docs I worry about are the ones who aren’t concerned about the counterfactuals.
It’s amazing how many people think they got everything about COVID right. They’re just on a hot streak. Look how amazing they are. And if you don’t consider the (unknowable) counterfactuals, it becomes much easier to continue living under the impression that you are infallible.
I think “the great assumption that medicine has all the cures” (and it doesn’t, for those that are confused)
Should be just below the name of the MD on the door of the practice? Or should it just say “we do the best we can with the knowledge we have and our personal skill set, good luck 🙏🏻)🤷🏼♀️😉
Hell would freeze over before I'd do chemo. Nor will I ever have a colonoscopy again. They are coming at us in so many directions they'll get us one way or another and I'm not wasting THOUSANDS of dollars, time, and energy on medical care. ESPECIALLY for cancer when I 100% believe they have a cure and don't believe AT ALL chemotherapy or radiation works! It's about as piss ignorant as getting a mammogram if you suspect cancer! Does getting a 100 x-rays at one time sound wise to point at cancer. Now I'm not a rocket scientist, but I'm going to say no! You can get a much healthier scan called a thermogram, but then if dr suspects cancer all a cancer dr is going to do is follow crooked CDC's protocol of you MUST then get a mammogram! No thanks! I've watched what people go through after chemo and radiation and THAT'S NOT LIVING! Then they ALWAYS say they got it and it didn't spread, but lo and behold...🥴 Sure some get lucky or probably most likely didn't actually have cancer. It sounds like he doesn't regret his situation so you don't either. Sounds like he was just happy to see you! Can't wish for more than that! At least you care. After the scamdemic many are so desensitized you wonder how they are even human anymore! You wonder, well I certainly do, how they sleep at night! I used to think being an ENT or ER Trauma nurse/dr had to be the hardest jobs ever! How could they not take what they see home...to their nightmares?! But it seems as though thousands of drs and nurses have litterally murdered people with protocols they knew weren't working and went on as nothing ever happened. "Just doing my job!" Sad and scary! So as for me again hell will freeze over before I kill off the rest of what cancer doesn't with chemo or radiation while big harma lines their pockets to then line demon-rats pockets. My oldest son is 37. When he was 17 he came bebopping through the house to grab a snack from the kitchen. I had a friend over and we were discussing about a friend who had cancer. He said hi them stopped in his tracks, "Are y'all talking about cancer?!" I explained. He then said something I'll never EVER forget, "Mom you know they have a cure right?! But do you believe they'll let a MULTI-BILLION operation go?! There's WAY too much money to be made between insurance and donations to give that up! There's no money in cured people!" Today I believe that still, but also now know THEY are causing cancer!!! Between bpa in plastics, pesticides, all the RIDICULOUS amounts of preservatives in EVERYTHING, chemtrails, etc and the list goes on and on! If that's not PURE evil I don't know what is!!! Earth is not our HOME anyway! Thanks to the evil doers (especially last 4 years) who didn't heed God's warning...the root of ALL evil is the LOVE/LUST of money...it's not worth going through the horrors of chemo/radiation to remain here. I can ONLY imagine what now to November will bring! ESPECIALLY since the majority believes we can vote ourselves out of this! 🙄🥴 God help us through until we die or You return! 🙏
Adam, your essay is poignant because you genuinely care about those under your care. But doctors are not God. They do the best they can with the information available to them. Second-guessing yourself and “what-iffing” yourself to death is counterproductive and damaging. If you did the best you could with the information at hand, then let it go. No one can see the future. Jesus had it right when He said, “Don’t worry about tomorrow. Today has enough worry of its own.”
"Any difficult decision I make with a patient is more art (or maybe a gamble) than science."
Thanks for admitting this. I wish more doctors did. If they did, there'd be less "which one of us has the medical degree?" responses to people who do research on their own conditions and understand that everyone's disease presents differently.
Sounds as if a new theory about cancer etiology offers more hope for patients (MTOC: metabolic theory of cancer). That is, if the medical establishment and Big Pharma allow it to evolve.
I can’t imagine the internal fortitude it would take to be a trauma surgeon who experiences this every call night.
I once ran a code in which it was clear PEA arrest from massive PE (pt had just transferred for limb threatening DVT). I begged the pharmacist to let me push tPA. Because he had fallen in the shower and on AC, our esteemed CCA code doc arrived and said no. With POCUS, watching that massive RV go lifeless is a visual torment on repeat.
Counterfactuals suck! We all have our private graveyards, helps to share. Great read.
Uncertainty is a constant fact of life in every medical decision but here are my answers to the questions posed in the three examples:
1. For the woman with cardiovascular disease: Had I not treated her, would she have had a cardiovascular complication? Probably, but the risk is essentially the same with or without statins. I was somewhat surprised with the statement that "withholding the drug could be considered malpractice".
2. For the Covid case: Would he have done just as badly had I started Paxlovid? Yes. No reliable evidence that Paxlovid works. Some would say he would have been better off without taking the four vaccinations.
3. For the woman with colon cancer: Would she have lived if she had heeded her previous doctor's advice to have a colonoscopy at 50? Probably not. Perhaps the tumor might be missed or just not visible at the earlier stage and then she would probably wait until 55 to have another exam. Also likely that the liver was already seeded with mets at that time. Would the end of her life have been better if I had not "insisted" on a colonoscopy? Impossible to say with any degree of confidence. It depends on the patient's particular nature and preferences as well as the degree of her tolerance to the side effects of the therapy.
When a whippersnapper (probably a nephew or my son) first suggested to me "what about the counterfactual", I instinctively blurted out: the waveform has collapsed there are no counterfactuals!
Regarding not prescribing Paxlovid that is the right decision in 2024. Paxlovid has been disproven in the only study done since Omicron and primum non nocere still trumps faith based medicine. My brother recently fainted from Shy-Drager from Parkinson's. He got carted to the hospital and labeled Covid and aspiration pneumonia. What he had was a cold from his Covid. Proof. They discharged him in 3 days but after 3 days of bedrest and no therapy he was so deconditioned he couldn't go home. So they put him back a couple more days by 2 more days of bed rest because the rehab facility doesn't do therapy on weekends. He would have been better off at home continuing his daily exercises. His wife picks him up regularly and he doesn't have 5 days of forced bed rest. Last time I looked the only medical indication for bed rest was threatened ab.
Here is my counterfactual: An elderly (85 years old) physician patient who was in the early stages of dementia developed low grade breast cancer, diagnosed after she insisted on getting a screening mammogram. She wanted maximal treatment including a double mastectomy (declined by the operating surgeon) and chemotherapy. An oncologist warned that chemotherapy in this setting is often poorly tolerated and could accelerate cognitive decline. The patient insisted on getting chemotherapy. The chemo was poorly tolerated, and her dementia did exponentially worsen. Her remaining life was characterized by very difficult to manage dementia characterized by verbally abusive, violent behaviors-completely uncharacteristic of her pre-dementia self. I felt that she would have been much better off without the chemo. Perhaps your patient did well because he did not get aggressive cancer care.
My Prof of medicine..
The retrospectoscope is a singularly useless diagnostic instrument...
He was right.
Useless diagnostically but maybe useful educationally?
I'm disappointed in the way you practice medicine. 'Insisted' a patient have a colonoscopy? Refused care if she didn't? At the very least, you didn't take the time to find out if she was risk tolerant, risk averse, wanted intensive medical intervention or minimal medical involvement... It sounds like you implemented your one size fits all management plan on her, screw her values, choice and autonomy. Empowering someone to manage their health the way they want to manage it (my goal) is clearly not your intent; your patient's role is to facilitate you managing her health the way you want to manage it. At least that's how it reads. I'm disappointed in a preceptor.
in March 2021, my 57 year old husband (non smoker) was diagnosed with squamous cell carcinoma of the tongue. It had not spread to lymph nodes and the standard of care for the size of the tumor was a hemi-glossectomy. The full surgical biopsy showed clear borders, but a chance error in the report wording caused the radiation oncologist to look at the samples and he found what the pathologist did not...3 stray cells that caused him to recommend radiation, which was the next treatment in the standard of care.
I wish to God we had not done that. He still would have died of this aggressive cancer, but not the horrific way that 7 weeks of daily radiation to the neck caused. Infection and sepsis and necrosis of his neck that literally ate down to his carotid artery. Sure, I don't know the counterfactuals, but I can tell you that this was a very gruesome and painful death. The "cure" was definitely worse than the disease.
The docs I worry about are the ones who aren’t concerned about the counterfactuals.
It’s amazing how many people think they got everything about COVID right. They’re just on a hot streak. Look how amazing they are. And if you don’t consider the (unknowable) counterfactuals, it becomes much easier to continue living under the impression that you are infallible.
I think “the great assumption that medicine has all the cures” (and it doesn’t, for those that are confused)
Should be just below the name of the MD on the door of the practice? Or should it just say “we do the best we can with the knowledge we have and our personal skill set, good luck 🙏🏻)🤷🏼♀️😉
Hell would freeze over before I'd do chemo. Nor will I ever have a colonoscopy again. They are coming at us in so many directions they'll get us one way or another and I'm not wasting THOUSANDS of dollars, time, and energy on medical care. ESPECIALLY for cancer when I 100% believe they have a cure and don't believe AT ALL chemotherapy or radiation works! It's about as piss ignorant as getting a mammogram if you suspect cancer! Does getting a 100 x-rays at one time sound wise to point at cancer. Now I'm not a rocket scientist, but I'm going to say no! You can get a much healthier scan called a thermogram, but then if dr suspects cancer all a cancer dr is going to do is follow crooked CDC's protocol of you MUST then get a mammogram! No thanks! I've watched what people go through after chemo and radiation and THAT'S NOT LIVING! Then they ALWAYS say they got it and it didn't spread, but lo and behold...🥴 Sure some get lucky or probably most likely didn't actually have cancer. It sounds like he doesn't regret his situation so you don't either. Sounds like he was just happy to see you! Can't wish for more than that! At least you care. After the scamdemic many are so desensitized you wonder how they are even human anymore! You wonder, well I certainly do, how they sleep at night! I used to think being an ENT or ER Trauma nurse/dr had to be the hardest jobs ever! How could they not take what they see home...to their nightmares?! But it seems as though thousands of drs and nurses have litterally murdered people with protocols they knew weren't working and went on as nothing ever happened. "Just doing my job!" Sad and scary! So as for me again hell will freeze over before I kill off the rest of what cancer doesn't with chemo or radiation while big harma lines their pockets to then line demon-rats pockets. My oldest son is 37. When he was 17 he came bebopping through the house to grab a snack from the kitchen. I had a friend over and we were discussing about a friend who had cancer. He said hi them stopped in his tracks, "Are y'all talking about cancer?!" I explained. He then said something I'll never EVER forget, "Mom you know they have a cure right?! But do you believe they'll let a MULTI-BILLION operation go?! There's WAY too much money to be made between insurance and donations to give that up! There's no money in cured people!" Today I believe that still, but also now know THEY are causing cancer!!! Between bpa in plastics, pesticides, all the RIDICULOUS amounts of preservatives in EVERYTHING, chemtrails, etc and the list goes on and on! If that's not PURE evil I don't know what is!!! Earth is not our HOME anyway! Thanks to the evil doers (especially last 4 years) who didn't heed God's warning...the root of ALL evil is the LOVE/LUST of money...it's not worth going through the horrors of chemo/radiation to remain here. I can ONLY imagine what now to November will bring! ESPECIALLY since the majority believes we can vote ourselves out of this! 🙄🥴 God help us through until we die or You return! 🙏
Adam, your essay is poignant because you genuinely care about those under your care. But doctors are not God. They do the best they can with the information available to them. Second-guessing yourself and “what-iffing” yourself to death is counterproductive and damaging. If you did the best you could with the information at hand, then let it go. No one can see the future. Jesus had it right when He said, “Don’t worry about tomorrow. Today has enough worry of its own.”
True that! Sometimes life just bites.
"Any difficult decision I make with a patient is more art (or maybe a gamble) than science."
Thanks for admitting this. I wish more doctors did. If they did, there'd be less "which one of us has the medical degree?" responses to people who do research on their own conditions and understand that everyone's disease presents differently.
Sounds as if a new theory about cancer etiology offers more hope for patients (MTOC: metabolic theory of cancer). That is, if the medical establishment and Big Pharma allow it to evolve.
So much of the outcome, if not all, is in God’s hands.
I can’t imagine the internal fortitude it would take to be a trauma surgeon who experiences this every call night.
I once ran a code in which it was clear PEA arrest from massive PE (pt had just transferred for limb threatening DVT). I begged the pharmacist to let me push tPA. Because he had fallen in the shower and on AC, our esteemed CCA code doc arrived and said no. With POCUS, watching that massive RV go lifeless is a visual torment on repeat.
Counterfactuals suck! We all have our private graveyards, helps to share. Great read.
The ability to weigh these scenarios with kindness and tolerance towards uncertainty seems to me one of the hallmarks of a mature caring physician.
I’ll tried not to read “mature” as “elderly”. 😉
😂
I think maturity means humility and wisdom.
Uncertainty is a constant fact of life in every medical decision but here are my answers to the questions posed in the three examples:
1. For the woman with cardiovascular disease: Had I not treated her, would she have had a cardiovascular complication? Probably, but the risk is essentially the same with or without statins. I was somewhat surprised with the statement that "withholding the drug could be considered malpractice".
2. For the Covid case: Would he have done just as badly had I started Paxlovid? Yes. No reliable evidence that Paxlovid works. Some would say he would have been better off without taking the four vaccinations.
3. For the woman with colon cancer: Would she have lived if she had heeded her previous doctor's advice to have a colonoscopy at 50? Probably not. Perhaps the tumor might be missed or just not visible at the earlier stage and then she would probably wait until 55 to have another exam. Also likely that the liver was already seeded with mets at that time. Would the end of her life have been better if I had not "insisted" on a colonoscopy? Impossible to say with any degree of confidence. It depends on the patient's particular nature and preferences as well as the degree of her tolerance to the side effects of the therapy.
Thank you for your thoughtful reflection.
When a whippersnapper (probably a nephew or my son) first suggested to me "what about the counterfactual", I instinctively blurted out: the waveform has collapsed there are no counterfactuals!
As good a response as any.😂