There is now some important, off-topic breaking news. Someone has done some excellent analysis of UK normalized all-cause mortality data for all age groups over time, comparing the vaxxed with the unvaxxed. Simpson's Paradox is ruled out.
Is there realistically any hope for a turn-around? I read these (excellent) entries about conformity actually experienced by individuals in the trenches, about the 500+ studies retracted by Hindawi, studies that can't be replicated, overt or subtle bias by researchers and journals, studies designed to fail, study results misinterpreted and misreported, problems in medical education, animosity against those not walking in lock-step, and the exclusion of diet and nutrition and complementary practices, and I wonder, where is truth? How can I possibly know what or whom to believe?
There's the problem - in this environmenet, what is "due dilligence"? For years I've done a lot of medical research and read a lot of studies, but...are they accurate? bogus? biased? compromised? poorly designed? paid for by pharma? How much stock can I put in them? I read broadly and look for concurrence of thought. That helps somewhat. I've also developed sources I trust, but they don't always deal with subjects I'm researching or I need further input. Reading Sensible Medicine posts has only increased my jaundiced view of the current medical/pharma/government establishment. Thank you for responding; I appreciate your involvement in commenting. I will continue to work on developing better "due diligence."
If there's controversy, I look at data and methods carefully. I have worked quite a lot on this and it's a skill that can be developed.
So there's no controversy about when max viral load occurs in cases of mild covid, so I didn't need to look at the data for that, although I did to some degree.
Someone--Dr. Paul Marik in an interview--brought up the fact that major medical journals are curating the science so that research either isn't published or is relegated to science journal backwaters.
What impact does this have on continuing medical education? I have seen instances where major scientific/philosophy breakthroughs have been reported in low-influence journals, so these journals shouldn't be ignored, but how often does the average physician read these journals? And doesn't the backwater reasearch have to appear in a news item in a professional weekly before it gets much notice?
It seems that science reporters may be important for something after all in terms of informing physicians.
I think the point on conformity is one that should be screamed from the roof tops. The hierarchy in academic medicine is not only real, but dangerous. At my school we are actively reminded by administrators and course directors to never correct an intern in front of an upper level or an upper level in front of an attending. A caveat is always given for patient safety, but it isn’t always a matter of safety. Often times it could be what is best for the patient or is there an alternative medicine, etc. I have been shut down for asking questions or making suggestions because of my location on the hierarchy even though some of these suggestions have been legitimate.
An additional point on conformity is that because of the hierarchy you can defer decision making to the next level up until one day you are the attending. If there are strong educators and leaders this can be done well, where the learner has increasing responsibility until they are ready to take over, but it also allows weak learners to pass through relatively unscathed because someone else is always watching their mistakes.
Feedback in academic medicine also makes it difficult for real assessment of learning as many give good evals hoping for good evals. Alternatively some people will give a standard set of evals no matter how well the learner excels. Only if they struggle greatly might actionable feedback be given.
Thanks for the observations. The effort to improve education is worth doing. I am curious about medical education in foreign countries. We now have a large percent of practicing doctors with degrees from elsewhere. Those treating my conditions have seemed quite adequate. I understand that the US has issues producing enough doctors because of school admission limitations, difficulties with residencies and general high costs. We always have a perpetual shortage of trained staff. In a really free marketplace such shortages would build more capacity, yet we still are constrained.
Fair point. By neurodivergent we meant it literally, as in people who think differently than others- e.g., more obsessive or less agreeable.
For some non patient-facing roles like pathologists or radiologists, these qualities may actually be assets. For physician-scientists pursuing unusual hypotheses, what we currently select for (conformity, agreeableness) could even be detrimental to scientific discovery.
NYT ran interesting piece on NYU firing a professor for students complaining about Organic Chemistry, Gift Link below for those without subscription.
If I understand VP correctly in the first piece, he argues gatekeeping medical school behind courses like the notoriously brutal Organic Chemistry is unnecessary / inefficient. I might agree too, though I also see value in a brutally hard course - even if it winds up being irrelevant in your career - to test whether you can absorb and understand a very difficult subject.
Since liability insurance ensures that the vast majority of doctors follow together as a herd, insurance is a bigger factor than med ed in restricting variation. Isn't getting doctors to think and practice outside the box in beneficial directions one aim of this med ed series? Perhaps some attention should be paid to insurance and legal issues in medicine.
Yes, insurance companies definitely make physician practice more uniform. Even outside of the realm of liability, what these companies will pay for can determine medical treatment. It could be argued that this even constitutes the practice of medicine—deciding what treatments patients can get and in what order. Doctors then are expected to conform to these demands or face prior auth hell. We actually discuss this in our episode with Christy Chapin: https://externalmedicinepodcast.com/christy-chapin/
I'm more interested in the liability angle, where the FDA gets to practice meta-medicine and tell doctors what they may and may not prescribe (with the implication that if doctors don't toe the line, they face potential liability lawsuits). If consumer health insurance companies won't pay for a treatment, that doesn't prevent someone else from paying, so CHIC isn't practicing meta-medicine. However, since CMS sets insurance standards, it could be argued that CMS is practicing de facto meta-medicine.
Consider the FDA warning that hydroxychloroquine was potentially dangerous to treat covid. With billions of doses prescribed, there were tens of reports of adverse events in the FDA reporting system. Contrast with hundreds of millions of vaccine doses given, with tens of thousands of VAERS reports of deaths and hundreds of thousands of reports of adverse events.
The FDA gets to pick and choose who wins and doctors have to toe the line or be punished.
Now California has passed a law that the medical board (chaired by a lawyer) gets to punish doctors for mis-speaking with no accountability. No way that could go wrong.
But why did the FDA, with no real science of real-world harm from HCQ--only theoretical harm, make its decision to publish an advisory against using HCQ to treat covid?
And why did physician influencers, especially cardiologists, speak out about the dangers to the heart from HCQ? Do they have any experience prescribing HCQ to their patients? Did the cardiologist influencers have a conflict of interest?
Why weren't rheumatologists consulted about HCQ and real world adverse effects by the FDA?
Nothing about all of this made any sense to me, except a potential conflict of interest of cardiologist influencers.
I also noticed that the professional medical societies should have noticed these things that I noticed and questioned the FDA advisory. But crickets....
So, in medical school, perhaps it's important to teach students to follow the $$$ and beware of pharma geeks bearing gifts. ;)
And it's also important for doctors to be able to voice their medical opinions freely, without fear of coercion. This means that there must be a society dedicated to freedom of speech for all health professionals. Which would not be the co-opted AMA.
Both are great points. It's definitely important to consider what drives uniformity and sets the standard of care. If uniformity in practice is created by non-conflicted consensus on a good evidence base (with all the complexity that those last three words entail) then is such uniformity a bad thing? If uniformity is driven more by reimbursements, conflicted expert opinion or simply practice inertia then it is at risk of preventing innovative challenges and seeding the view that a practice must be alright as everyone is doing it.
Secondly, when trying to push for unified practices for the right reasons, we should we wary of not making it excessively difficult to deviate when appropriate (insurance reimbursement doesn't help - though my knowledge of this area from the UK is more limited). Equally, too much freedom on behalf of clinicians to practice how they wish comes with real risks particularly when you sprinkle in some financial conflict of interest and a reluctance to change practice in the face of new evidence.
Good points- Uniformity of practice is not always a bad thing. I’d prefer my surgeon to use standardized scrubbing and aseptic technique thank you very much, and many times standardization can lead to superior outcomes.
The operative point though is who has that decision-making authority, and where on the margins is there room for innovation. In short, there are few circumstances in which an insurance administrator is best positioned to decide how a physician should practice. And if we want to have any progress in medicine at all, there must necessarily be good faith experimentation at the margins.
I think that the questioning of accepted wisdom should be encouraged. For example, are we really sure that staff wearing medical masks in the OR really reduce surgical wound infections? Or is there another purpose to masking which might be better accomplished by some other method?
But liability insurance subtly reaches down into medical education and practice, doesn't it? And the FDA and HHS get to decide which practices are protected and which aren't, right?
I am not sure you can teach empathy, although it can be cultivated. What most people don’t realize is that most US medical students are “taught” empathy. Most, if not all, medical students in the US have undergone some form of an Objective Structured Clinical Exam (OSCE). These are are standardized scenarios with a standardized patient that are often 15-20 minute long encounters where you are graded on a checklist. One checklist item is empathy where you get points for canned lines such as “I am sorry you feel this way” or “that sounds difficult”. Family Medicine residencies use something called Balint Group to also try and encourage empathy by working through the doctor patient relationship. So many doctors have had some form of empathy training, but still struggle. It is possible (and highly likely in my opinion) that the training is subpar, but I also believe it is not something you can teach well. Our admission system selects for high achieving students straight out of college and it is often times hard for them to relate to patients with diverse experiences when their entire life experience is medical education.
I agree on both accounts. I was not attempting to solve anything, merely pointing out the challenges the system has created and how the current system is not designed to teach or cultivate empathy (which I also agree is a form of teaching) in a meaningful way, as someone who has been through it. The admissions process is also not designed to teach humanity, I am pointing out that life challenges are one way to naturally teach (and cultivate) empathy and the admissions process makes it harder for “non traditional” students to be accepted. One solution, then, would be to change admissions in a way that encourages students with life experiences to apply and decreases roadblocks to admissions. Not only would they potentially have had more experiences to cultivate this empathy, but could also share their experiences with classmates who may not have had them.
A lot of people share your sentiment, but not me. If given the choice, I'd choose skills over empathy. Nice to have both but that's a very rare find in doctors, especially those who don't have a lot of face time with patients, such as surgeons.
Both can be had Diana. Empathy goes hand in hand with skill. Both are learned. And since surgeons don't have a lot of face time with patients, the more reason to have empathy. I know many doctors that have both and this includes surgeons.
Empathy + skill is the gold standard, no argument there! It can sometimes be like searching for a unicorn looking for a doc with both. I worked in a surgical ICU for nine years, and I can tell you niceness of the surgeon had zero relationship to patient outcome. Often the real b@srards were technically excellent. I counsel friends and family to choose a technically outstanding surgeon and make sure your friends and family are there for hand-holding if the surgeon isn't very personable.
There is now some important, off-topic breaking news. Someone has done some excellent analysis of UK normalized all-cause mortality data for all age groups over time, comparing the vaxxed with the unvaxxed. Simpson's Paradox is ruled out.
https://expose-news.com/2022/10/09/gov-confirms-covid-vaccination-increases-risk-death/
Is there realistically any hope for a turn-around? I read these (excellent) entries about conformity actually experienced by individuals in the trenches, about the 500+ studies retracted by Hindawi, studies that can't be replicated, overt or subtle bias by researchers and journals, studies designed to fail, study results misinterpreted and misreported, problems in medical education, animosity against those not walking in lock-step, and the exclusion of diet and nutrition and complementary practices, and I wonder, where is truth? How can I possibly know what or whom to believe?
Believe yourself and your own due diligence, especially about any controversial topic.
There's the problem - in this environmenet, what is "due dilligence"? For years I've done a lot of medical research and read a lot of studies, but...are they accurate? bogus? biased? compromised? poorly designed? paid for by pharma? How much stock can I put in them? I read broadly and look for concurrence of thought. That helps somewhat. I've also developed sources I trust, but they don't always deal with subjects I'm researching or I need further input. Reading Sensible Medicine posts has only increased my jaundiced view of the current medical/pharma/government establishment. Thank you for responding; I appreciate your involvement in commenting. I will continue to work on developing better "due diligence."
If there's controversy, I look at data and methods carefully. I have worked quite a lot on this and it's a skill that can be developed.
So there's no controversy about when max viral load occurs in cases of mild covid, so I didn't need to look at the data for that, although I did to some degree.
Someone--Dr. Paul Marik in an interview--brought up the fact that major medical journals are curating the science so that research either isn't published or is relegated to science journal backwaters.
What impact does this have on continuing medical education? I have seen instances where major scientific/philosophy breakthroughs have been reported in low-influence journals, so these journals shouldn't be ignored, but how often does the average physician read these journals? And doesn't the backwater reasearch have to appear in a news item in a professional weekly before it gets much notice?
It seems that science reporters may be important for something after all in terms of informing physicians.
I think the point on conformity is one that should be screamed from the roof tops. The hierarchy in academic medicine is not only real, but dangerous. At my school we are actively reminded by administrators and course directors to never correct an intern in front of an upper level or an upper level in front of an attending. A caveat is always given for patient safety, but it isn’t always a matter of safety. Often times it could be what is best for the patient or is there an alternative medicine, etc. I have been shut down for asking questions or making suggestions because of my location on the hierarchy even though some of these suggestions have been legitimate.
An additional point on conformity is that because of the hierarchy you can defer decision making to the next level up until one day you are the attending. If there are strong educators and leaders this can be done well, where the learner has increasing responsibility until they are ready to take over, but it also allows weak learners to pass through relatively unscathed because someone else is always watching their mistakes.
Feedback in academic medicine also makes it difficult for real assessment of learning as many give good evals hoping for good evals. Alternatively some people will give a standard set of evals no matter how well the learner excels. Only if they struggle greatly might actionable feedback be given.
Thanks for the observations. The effort to improve education is worth doing. I am curious about medical education in foreign countries. We now have a large percent of practicing doctors with degrees from elsewhere. Those treating my conditions have seemed quite adequate. I understand that the US has issues producing enough doctors because of school admission limitations, difficulties with residencies and general high costs. We always have a perpetual shortage of trained staff. In a really free marketplace such shortages would build more capacity, yet we still are constrained.
Please define FREE.
1. NUTRITION FIRST: a course of at least ONE YEAR!
2. DEEP dive Course on ALL SIDE EFFECTS of pharmaceutical drugs.
Respectfully, I do not want to SELECT FOR neurodivergence in most of the interactions I have ever had or am likely to have with a doctor.
This sounds a little too much like ad hoc "diversity is strength" reasoning.
Fair point. By neurodivergent we meant it literally, as in people who think differently than others- e.g., more obsessive or less agreeable.
For some non patient-facing roles like pathologists or radiologists, these qualities may actually be assets. For physician-scientists pursuing unusual hypotheses, what we currently select for (conformity, agreeableness) could even be detrimental to scientific discovery.
Missed the first post, just read through (maybe edit above to hyperlink for other readers who didn't catch this? Sometimes Substack "Inbox" doesn't aggregate all new posts. https://sensiblemed.substack.com/p/reforming-medical-education
NYT ran interesting piece on NYU firing a professor for students complaining about Organic Chemistry, Gift Link below for those without subscription.
If I understand VP correctly in the first piece, he argues gatekeeping medical school behind courses like the notoriously brutal Organic Chemistry is unnecessary / inefficient. I might agree too, though I also see value in a brutally hard course - even if it winds up being irrelevant in your career - to test whether you can absorb and understand a very difficult subject.
https://www.nytimes.com/2022/10/03/us/nyu-organic-chemistry-petition.html?unlocked_article_code=Svoqr8lnQasVDdE_fbd50hGpCsL-J5N80rmGbiUHSvOr4EqMfAeOb4qCcdJtBIi8B2iRZv8rpAYXNaW5_BZJusive1XFTZwTkLAZPUC5utTODkofkon_X7yojtNXQGBy7v44KYx7KWxo7FM6bqY74yq352kSpchCK3ZSHz5zZwAHhN-bd_vIESFAyujUidlhc_mKgih4KzojYAQVfYsRL41HeihalrlGyGk_nUSi8uOZ08hRd_TuD1wDIkFPeBGuHoNeBCt4jdi_HKe-E1ne8ZOEVzV6mWjizsEK_zJvEy1HovuyF6Y8rYOQhKlMck0E1_PB1F_N4syWp3DDI_4uFOsmlkw&smid=share-url
Since liability insurance ensures that the vast majority of doctors follow together as a herd, insurance is a bigger factor than med ed in restricting variation. Isn't getting doctors to think and practice outside the box in beneficial directions one aim of this med ed series? Perhaps some attention should be paid to insurance and legal issues in medicine.
Yes, insurance companies definitely make physician practice more uniform. Even outside of the realm of liability, what these companies will pay for can determine medical treatment. It could be argued that this even constitutes the practice of medicine—deciding what treatments patients can get and in what order. Doctors then are expected to conform to these demands or face prior auth hell. We actually discuss this in our episode with Christy Chapin: https://externalmedicinepodcast.com/christy-chapin/
I'm more interested in the liability angle, where the FDA gets to practice meta-medicine and tell doctors what they may and may not prescribe (with the implication that if doctors don't toe the line, they face potential liability lawsuits). If consumer health insurance companies won't pay for a treatment, that doesn't prevent someone else from paying, so CHIC isn't practicing meta-medicine. However, since CMS sets insurance standards, it could be argued that CMS is practicing de facto meta-medicine.
Consider the FDA warning that hydroxychloroquine was potentially dangerous to treat covid. With billions of doses prescribed, there were tens of reports of adverse events in the FDA reporting system. Contrast with hundreds of millions of vaccine doses given, with tens of thousands of VAERS reports of deaths and hundreds of thousands of reports of adverse events.
The FDA gets to pick and choose who wins and doctors have to toe the line or be punished.
Now California has passed a law that the medical board (chaired by a lawyer) gets to punish doctors for mis-speaking with no accountability. No way that could go wrong.
But why did the FDA, with no real science of real-world harm from HCQ--only theoretical harm, make its decision to publish an advisory against using HCQ to treat covid?
And why did physician influencers, especially cardiologists, speak out about the dangers to the heart from HCQ? Do they have any experience prescribing HCQ to their patients? Did the cardiologist influencers have a conflict of interest?
Why weren't rheumatologists consulted about HCQ and real world adverse effects by the FDA?
Nothing about all of this made any sense to me, except a potential conflict of interest of cardiologist influencers.
I also noticed that the professional medical societies should have noticed these things that I noticed and questioned the FDA advisory. But crickets....
So, in medical school, perhaps it's important to teach students to follow the $$$ and beware of pharma geeks bearing gifts. ;)
And it's also important for doctors to be able to voice their medical opinions freely, without fear of coercion. This means that there must be a society dedicated to freedom of speech for all health professionals. Which would not be the co-opted AMA.
Both are great points. It's definitely important to consider what drives uniformity and sets the standard of care. If uniformity in practice is created by non-conflicted consensus on a good evidence base (with all the complexity that those last three words entail) then is such uniformity a bad thing? If uniformity is driven more by reimbursements, conflicted expert opinion or simply practice inertia then it is at risk of preventing innovative challenges and seeding the view that a practice must be alright as everyone is doing it.
Secondly, when trying to push for unified practices for the right reasons, we should we wary of not making it excessively difficult to deviate when appropriate (insurance reimbursement doesn't help - though my knowledge of this area from the UK is more limited). Equally, too much freedom on behalf of clinicians to practice how they wish comes with real risks particularly when you sprinkle in some financial conflict of interest and a reluctance to change practice in the face of new evidence.
Good points- Uniformity of practice is not always a bad thing. I’d prefer my surgeon to use standardized scrubbing and aseptic technique thank you very much, and many times standardization can lead to superior outcomes.
The operative point though is who has that decision-making authority, and where on the margins is there room for innovation. In short, there are few circumstances in which an insurance administrator is best positioned to decide how a physician should practice. And if we want to have any progress in medicine at all, there must necessarily be good faith experimentation at the margins.
I think that the questioning of accepted wisdom should be encouraged. For example, are we really sure that staff wearing medical masks in the OR really reduce surgical wound infections? Or is there another purpose to masking which might be better accomplished by some other method?
But liability insurance subtly reaches down into medical education and practice, doesn't it? And the FDA and HHS get to decide which practices are protected and which aren't, right?
Being a good doctor starts with empathy. Speaking from experience I have found a few doctors to lack empathy or the better known "bed side manner".
Maybe it would be a positive addition to the first year of the course.
Honestly I don’t think empathy is a skill that can be thought in a course.
Why can't it be taught?
I am not sure you can teach empathy, although it can be cultivated. What most people don’t realize is that most US medical students are “taught” empathy. Most, if not all, medical students in the US have undergone some form of an Objective Structured Clinical Exam (OSCE). These are are standardized scenarios with a standardized patient that are often 15-20 minute long encounters where you are graded on a checklist. One checklist item is empathy where you get points for canned lines such as “I am sorry you feel this way” or “that sounds difficult”. Family Medicine residencies use something called Balint Group to also try and encourage empathy by working through the doctor patient relationship. So many doctors have had some form of empathy training, but still struggle. It is possible (and highly likely in my opinion) that the training is subpar, but I also believe it is not something you can teach well. Our admission system selects for high achieving students straight out of college and it is often times hard for them to relate to patients with diverse experiences when their entire life experience is medical education.
Your rhetoric here is skirting round the theme without solving anything...Cultivating issues is a form of teaching.
So the admission system fails the student by not teaching 'humanity' and perhaps humility and in the long run fails the patient emotionally.
The movie "The Doctor" shows how empathy is cultivated (learned).
I agree on both accounts. I was not attempting to solve anything, merely pointing out the challenges the system has created and how the current system is not designed to teach or cultivate empathy (which I also agree is a form of teaching) in a meaningful way, as someone who has been through it. The admissions process is also not designed to teach humanity, I am pointing out that life challenges are one way to naturally teach (and cultivate) empathy and the admissions process makes it harder for “non traditional” students to be accepted. One solution, then, would be to change admissions in a way that encourages students with life experiences to apply and decreases roadblocks to admissions. Not only would they potentially have had more experiences to cultivate this empathy, but could also share their experiences with classmates who may not have had them.
So we agree there needs to be a change, either in admissions or first year.
A lot of people share your sentiment, but not me. If given the choice, I'd choose skills over empathy. Nice to have both but that's a very rare find in doctors, especially those who don't have a lot of face time with patients, such as surgeons.
Both can be had Diana. Empathy goes hand in hand with skill. Both are learned. And since surgeons don't have a lot of face time with patients, the more reason to have empathy. I know many doctors that have both and this includes surgeons.
Empathy + skill is the gold standard, no argument there! It can sometimes be like searching for a unicorn looking for a doc with both. I worked in a surgical ICU for nine years, and I can tell you niceness of the surgeon had zero relationship to patient outcome. Often the real b@srards were technically excellent. I counsel friends and family to choose a technically outstanding surgeon and make sure your friends and family are there for hand-holding if the surgeon isn't very personable.
No wonder your medical system leaves a lot to be desired.
I never associate niceness with patient outcome. But niceness needs to be there, for me, before I will trust a surgeon with my life.
What is the real meaning of empathy? Not hand holding but the ability to understand and share someone's feelings.
Deep listening?