Dr Prasad my favorite clinician and writer forgot or maybe he is too young? Maybe I am too old. I was taught this in 1978 as a 3rd med student when "The House of God" was published with the rules of medicine which HAVE NEVER BEEN IMPROVED in almost 50 years
"If you don't take a temperature you can't find a fever".
If you are non medical or are medical and do not know read the book. Here is the list
The Rules
GOMERS don't die.
GOMERS go to ground.
At a cardiac arrest, the first procedure is to take your own pulse.
The patient is the one with the disease.
Placement comes first.
There is no body cavity that cannot be reached with a #14G needle and a good strong arm.
Age + BUN = Lasix dose.
They can always hurt you more.
The only good admission is a dead admission.
If you don't take a temperature, you can't find a fever.
Show me a BMS (Best Medical Student, a student at The Best Medical School) who only triples my work and I will kiss his feet.
If the radiology resident and the medical student both see a lesion on the chest x-ray, there can be no lesion there.
The delivery of good medical care is to do as much nothing as possible.
Wow. Spot on. Love this substack. I agree with Hodges, being a good doctor is formost being a friend and advocate of your patients. I'm going out to my garage to smoke a cigarette and change the oil on my car. RB / Cardiologist
As a primary internist, the best and (in my opinion) most important part of my job is knowing my patient. The "doctoring" part is easy. The challenge is knowing the patient well enough to speak his language, bring to light what I know to be his values, and making the decision with him AND for him. I have to do both at the same time...with him and for him. He bears responsibility in the decision, but ultimately he looks to me to tell him the best course of action. I'm a "garage" doc...100%.
This is a case of psychological immune system at work. Replace oncologist with "goalie" and this description of how we "ward off psychological threats" as physicians is eerily similar.
"On penalty kicks, goalies should wait to jump until the ball is kicked. But doing so is rare: most goalies guess which way the ball will be kicked and jump before the kick. Nevertheless, Bayesians have a response to this apparently sub-optimal behavior. They argue that it is actually optimal once you understand what goalies are actually maximizing, which is not just goals allowed but instead regret Goalies are calculating not only the goals they will allow, but also their reaction to the outcome. Bar-Eli et al. reason that the goalies will regret not jumping early more than jumping early. Since they are trying to optimize both the goals stopped and their future regret, they will tend to jump early even if that is a worse strategy for stopping goals.
Mandelbaum, E. Troubles with Bayesianism: An introduction to the psychological immune system. Mind Lang. 2019; 34: 141– 157. https://doi.org/10.1111/mila.12205
This is great. You’re the kind of Doctor I want. Right now, I’m supposed to be imposing a torture routine on my cat and I don’t want to do it. It hasn’t been working anyway. Yes, let her die. Quality over quantity.
Insightful presentation, as usual. Like you, I am conservative and refuse embarking on interventions of dubious merit. -Especially if data is ambiguous or indicates harm to all-cause mortality. However, as you've described, there is a strong bias toward "doing something - anything!", rather than observation. This is generally true in many/most medical professionals and definitely in the culture at large.
You have described here a good ethical approach: keep up with the literature, and then hold a non-hurried counseling session with the patient, as the situation demands.
Blame also falls on the shoulders of the "Quality" industry. Measures do not take into account patient preferences as far as I have seen. So a screening test not done means your score falls. And that means less compensation etc etc etc
One of the reasons I left academic medicine was the immense pressure to "score" high on the percent of patients screened for cancer diagnoses, regardless of whether or not the screenings were wanted or even appropriate. Perverse incentives everywhere.
The other day an older, thin, man told my husband and I he was a diabetes medication because his A1C was high. Blood sugar was fine. He had no symptoms. The first medication he was put on gave him bad side effects so he stopped taking it. He lowered his A1C with diet and exercise alone after but the dr still had him on another medication because it was still high.
When he left I told my husband what you’ve said over and over that you can’t make a well person more well. If someone has no symptoms but a recommended screening schedule says do this or blood work shows that, what benefit is there for treatment.
I think the same goes in the opposite case as well. If a patient comes in with symptoms and tests are normal the doc is done.
My MIL is overweight and has issues with her blood sugar on and off. She’s also on a statin for high cholesterol. Her heart is fine. The statin is doing nothing to prevent heart disease/attacks so she’s just giving herself side effects. One of which, for women, is an increased chance of diabetes.
Pharma, and whatever industry pushes cancer screening for low risk people of a certain age, need to be checked big time. It increases everyone’s costs (no matter who is writing the checks).
Yet another example of “just because you can, doesn’t mean you should”.
Guideline writers who overstep the bounds of current knowledge, and pretend to know something that they don’t, seems to be a fairly ubiquitous problem these days.
I see this all too often. A well intentioned clinician trying to talk someone who has never wanted medical intervention into some screening test. The EHR is screaming at the medical team to do something! All those unmet quality measures! Can’t you just talk the patient into one or two of them? Sometimes I think patients acquiesce to make the team feel better - and to avoid being labeled difficult. It’s unpopular to say no to everything a doctor offers you. Most doctors aren’t taught how to ask about cancer screening in a way that actually discloses the risks. I would LOVE if sensible medicine would come up with some scripts for true honest conversations for “shared decision making” for colonoscopy, mammogram, psa and lung cancer screening. As a primary care provider, if I don’t offer screening and that patient gets cancer, the family often blames primary care and looks for the discussion in the chart where I have recommended screening. So many societal pressures for primary care to convince patients to screen- even if we are presented with a patient who has never had any interest in medical intervention.
And the ever-present “gaps in care”. So many gaps and unchecked boxes...followed by “friendly reminders” from the Practice Manager which hint at, but never come out and state explicitly that the real reason that these boxes and gaps must be addressed and completed (in the manner that HMS prefers) all comes down to reimbursement and Press-Ganey scores. The patient’s wishes be damned.
Agreed! So, if you think about it, it is the drive to quantify “value” of care delivered by counting USPSTF a and b’s over a population that has led us here. Again, ignoring the complexities of the individual patient and not understanding that the value of health care to a particular patient often takes a human interaction to clarify.
Exactly. It’s frustrating, tiresome, and pointless to spend 90% of your day mindlessly “meeting milestones” (80% of women > 50 have their annual mamma? No? Why not, Doc?), leaving precious little time to actually find out what the patient needs/wants and then doing that.
In a perfect world, many of us would kick this system to the curb and start over with simple fee-for-service (complete with discounted fees/free care for those with limited means), house calls, and even bartering. Kinda like concierge medicine for the average American. Something I will be undertaking in the next several months, I hope. If enough “providers” told Corporate Medicine that we’re tired of playing by their rules and walked out, maybe things would change. Maybe.
This brings to mind a conversation I once had with my primary care physician. My LDL levels were peaking, and she had just prescribed me a statin. I was curious and concerned, so I asked her about the overall impact of the statin on all-cause mortality, specifically for individuals like me with no history of MI. Her response was as chilly as the sterile examination room - a blunt, 'Are you interested in treatment or not?' That encounter marked our last meeting.
Doctors are human beings, too--I hope she learned something there. My LDL recently shot up (age 69). My internist consulted with a cardiologist who recommended a statin. We decided to wait 6 months and retest. Similar blood numbers. I am grateful that he then sent me for a cardiac calcium test (easy; non invasive). My score: zero.
Thank you for offering your insights. As a lay person, I understand my question might have inadvertently bruised the ego of a seasoned MD with over 30 years of experience and a top-rated private practice in my county. After all, I'm merely a small entry in her EHR. I strongly advocate for informed consent and shared decision-making, as opposed to a more paternalistic approach to medical practice.
Switching gears slightly, if a CAC score returns positive and if I'm put on statin therapy, are you aware of any robust RCT that support a reduction in overall mortality for primary prevention patients? I feel it's important to educate myself on this topic before potentially ruffling the feathers of a seasoned cardiologist.
Lay person here, too. I'm as clueless as the 74-year-old smoker as to what the evidence-of-the-day demonstrates. I've been taking AREDS-2 supplements for years hoping to forestall macular degeneration (which runs in our family) only to be told that new studies don't support what looked like very robust evidence in its favor. Find a cardiologist whose feathers don't ruffle!
Between Dr. Prasad and Dr. K they have defined what I believe to be what medicine should be, should have been and should be in the future.
I have been preaching this for decades. I practice it myself. I treat my patients with this.
No, I do not even know 1/1000th of what a doctor knows, but I can speak with some degree of knowledge about diseases, trajectory, symptoms, and where the journey will end. I take this knowledge and I place it on the table for my patients and their families. It's like the map on the inside door of your hotel room. "In case of fire" "Here you are" "follow the red line to the nearest exit"
Here is the disease you have. Here are the co-morbidities you also have. I'll show you the paths that are available to you and the pros and cons of each path. There is no right or wrong answer. You can't choose a path to please me or anyone else. This is your journey. At your starting point here, what are your goals, what would you like to do most? Now walk down each path and think about it. Come back to the next path. Etc.
If they need more information that I can give I do. If I can't I will consult with our doctor and let him explain the answer to their questions in more detail .
When will Sensible Medicine take over the Senseless Medical Providers?
Dr Prasad my favorite clinician and writer forgot or maybe he is too young? Maybe I am too old. I was taught this in 1978 as a 3rd med student when "The House of God" was published with the rules of medicine which HAVE NEVER BEEN IMPROVED in almost 50 years
"If you don't take a temperature you can't find a fever".
If you are non medical or are medical and do not know read the book. Here is the list
The Rules
GOMERS don't die.
GOMERS go to ground.
At a cardiac arrest, the first procedure is to take your own pulse.
The patient is the one with the disease.
Placement comes first.
There is no body cavity that cannot be reached with a #14G needle and a good strong arm.
Age + BUN = Lasix dose.
They can always hurt you more.
The only good admission is a dead admission.
If you don't take a temperature, you can't find a fever.
Show me a BMS (Best Medical Student, a student at The Best Medical School) who only triples my work and I will kiss his feet.
If the radiology resident and the medical student both see a lesion on the chest x-ray, there can be no lesion there.
The delivery of good medical care is to do as much nothing as possible.
Bravo. NO, double bravo.
Wow. Spot on. Love this substack. I agree with Hodges, being a good doctor is formost being a friend and advocate of your patients. I'm going out to my garage to smoke a cigarette and change the oil on my car. RB / Cardiologist
As a primary internist, the best and (in my opinion) most important part of my job is knowing my patient. The "doctoring" part is easy. The challenge is knowing the patient well enough to speak his language, bring to light what I know to be his values, and making the decision with him AND for him. I have to do both at the same time...with him and for him. He bears responsibility in the decision, but ultimately he looks to me to tell him the best course of action. I'm a "garage" doc...100%.
This is a case of psychological immune system at work. Replace oncologist with "goalie" and this description of how we "ward off psychological threats" as physicians is eerily similar.
"On penalty kicks, goalies should wait to jump until the ball is kicked. But doing so is rare: most goalies guess which way the ball will be kicked and jump before the kick. Nevertheless, Bayesians have a response to this apparently sub-optimal behavior. They argue that it is actually optimal once you understand what goalies are actually maximizing, which is not just goals allowed but instead regret Goalies are calculating not only the goals they will allow, but also their reaction to the outcome. Bar-Eli et al. reason that the goalies will regret not jumping early more than jumping early. Since they are trying to optimize both the goals stopped and their future regret, they will tend to jump early even if that is a worse strategy for stopping goals.
Mandelbaum, E. Troubles with Bayesianism: An introduction to the psychological immune system. Mind Lang. 2019; 34: 141– 157. https://doi.org/10.1111/mila.12205
Oh worth really pondering! What criteria would you use to determine which screening test you would do ?
There's an old saying in Korea: Not knowing is the medicine. Seems to be the case here.
This is great. You’re the kind of Doctor I want. Right now, I’m supposed to be imposing a torture routine on my cat and I don’t want to do it. It hasn’t been working anyway. Yes, let her die. Quality over quantity.
For some reason, we humans aren’t as kind to each other as we are to our animals... I totally agree with you.
Vinay,
Insightful presentation, as usual. Like you, I am conservative and refuse embarking on interventions of dubious merit. -Especially if data is ambiguous or indicates harm to all-cause mortality. However, as you've described, there is a strong bias toward "doing something - anything!", rather than observation. This is generally true in many/most medical professionals and definitely in the culture at large.
You have described here a good ethical approach: keep up with the literature, and then hold a non-hurried counseling session with the patient, as the situation demands.
Blame also falls on the shoulders of the "Quality" industry. Measures do not take into account patient preferences as far as I have seen. So a screening test not done means your score falls. And that means less compensation etc etc etc
One of the reasons I left academic medicine was the immense pressure to "score" high on the percent of patients screened for cancer diagnoses, regardless of whether or not the screenings were wanted or even appropriate. Perverse incentives everywhere.
The other day an older, thin, man told my husband and I he was a diabetes medication because his A1C was high. Blood sugar was fine. He had no symptoms. The first medication he was put on gave him bad side effects so he stopped taking it. He lowered his A1C with diet and exercise alone after but the dr still had him on another medication because it was still high.
When he left I told my husband what you’ve said over and over that you can’t make a well person more well. If someone has no symptoms but a recommended screening schedule says do this or blood work shows that, what benefit is there for treatment.
I think the same goes in the opposite case as well. If a patient comes in with symptoms and tests are normal the doc is done.
My MIL is overweight and has issues with her blood sugar on and off. She’s also on a statin for high cholesterol. Her heart is fine. The statin is doing nothing to prevent heart disease/attacks so she’s just giving herself side effects. One of which, for women, is an increased chance of diabetes.
Pharma, and whatever industry pushes cancer screening for low risk people of a certain age, need to be checked big time. It increases everyone’s costs (no matter who is writing the checks).
Yet another example of “just because you can, doesn’t mean you should”.
Guideline writers who overstep the bounds of current knowledge, and pretend to know something that they don’t, seems to be a fairly ubiquitous problem these days.
So wise, so important - thank you!
I see this all too often. A well intentioned clinician trying to talk someone who has never wanted medical intervention into some screening test. The EHR is screaming at the medical team to do something! All those unmet quality measures! Can’t you just talk the patient into one or two of them? Sometimes I think patients acquiesce to make the team feel better - and to avoid being labeled difficult. It’s unpopular to say no to everything a doctor offers you. Most doctors aren’t taught how to ask about cancer screening in a way that actually discloses the risks. I would LOVE if sensible medicine would come up with some scripts for true honest conversations for “shared decision making” for colonoscopy, mammogram, psa and lung cancer screening. As a primary care provider, if I don’t offer screening and that patient gets cancer, the family often blames primary care and looks for the discussion in the chart where I have recommended screening. So many societal pressures for primary care to convince patients to screen- even if we are presented with a patient who has never had any interest in medical intervention.
I always used to say that the mouse clicks have taken over common sense in medicine. Not that common sense is very common, but you feel me!
And the ever-present “gaps in care”. So many gaps and unchecked boxes...followed by “friendly reminders” from the Practice Manager which hint at, but never come out and state explicitly that the real reason that these boxes and gaps must be addressed and completed (in the manner that HMS prefers) all comes down to reimbursement and Press-Ganey scores. The patient’s wishes be damned.
Agreed! So, if you think about it, it is the drive to quantify “value” of care delivered by counting USPSTF a and b’s over a population that has led us here. Again, ignoring the complexities of the individual patient and not understanding that the value of health care to a particular patient often takes a human interaction to clarify.
Exactly. It’s frustrating, tiresome, and pointless to spend 90% of your day mindlessly “meeting milestones” (80% of women > 50 have their annual mamma? No? Why not, Doc?), leaving precious little time to actually find out what the patient needs/wants and then doing that.
In a perfect world, many of us would kick this system to the curb and start over with simple fee-for-service (complete with discounted fees/free care for those with limited means), house calls, and even bartering. Kinda like concierge medicine for the average American. Something I will be undertaking in the next several months, I hope. If enough “providers” told Corporate Medicine that we’re tired of playing by their rules and walked out, maybe things would change. Maybe.
This brings to mind a conversation I once had with my primary care physician. My LDL levels were peaking, and she had just prescribed me a statin. I was curious and concerned, so I asked her about the overall impact of the statin on all-cause mortality, specifically for individuals like me with no history of MI. Her response was as chilly as the sterile examination room - a blunt, 'Are you interested in treatment or not?' That encounter marked our last meeting.
Doctors are human beings, too--I hope she learned something there. My LDL recently shot up (age 69). My internist consulted with a cardiologist who recommended a statin. We decided to wait 6 months and retest. Similar blood numbers. I am grateful that he then sent me for a cardiac calcium test (easy; non invasive). My score: zero.
Thank you for offering your insights. As a lay person, I understand my question might have inadvertently bruised the ego of a seasoned MD with over 30 years of experience and a top-rated private practice in my county. After all, I'm merely a small entry in her EHR. I strongly advocate for informed consent and shared decision-making, as opposed to a more paternalistic approach to medical practice.
Switching gears slightly, if a CAC score returns positive and if I'm put on statin therapy, are you aware of any robust RCT that support a reduction in overall mortality for primary prevention patients? I feel it's important to educate myself on this topic before potentially ruffling the feathers of a seasoned cardiologist.
Lay person here, too. I'm as clueless as the 74-year-old smoker as to what the evidence-of-the-day demonstrates. I've been taking AREDS-2 supplements for years hoping to forestall macular degeneration (which runs in our family) only to be told that new studies don't support what looked like very robust evidence in its favor. Find a cardiologist whose feathers don't ruffle!
Between Dr. Prasad and Dr. K they have defined what I believe to be what medicine should be, should have been and should be in the future.
I have been preaching this for decades. I practice it myself. I treat my patients with this.
No, I do not even know 1/1000th of what a doctor knows, but I can speak with some degree of knowledge about diseases, trajectory, symptoms, and where the journey will end. I take this knowledge and I place it on the table for my patients and their families. It's like the map on the inside door of your hotel room. "In case of fire" "Here you are" "follow the red line to the nearest exit"
Here is the disease you have. Here are the co-morbidities you also have. I'll show you the paths that are available to you and the pros and cons of each path. There is no right or wrong answer. You can't choose a path to please me or anyone else. This is your journey. At your starting point here, what are your goals, what would you like to do most? Now walk down each path and think about it. Come back to the next path. Etc.
If they need more information that I can give I do. If I can't I will consult with our doctor and let him explain the answer to their questions in more detail .
When will Sensible Medicine take over the Senseless Medical Providers?