Following up on Adam's comments, I love the idea of orienting medical students on day 1 to the multitude of stories and episodes of errors in medicine, including studies misinterpreted. It is too late to wait till these men and women are years into their training. There needs to be curiosity and humility.
Extending from your conversation in this video, can you all talk about quality measures (besides screening) in medicine that were tested and proved to be harmful or ineffective in more depth?
I have 2 comments. I have lot of respect for all of you and look forward to your podcasts. However Dr Cifu is being too charitable about Dr Fauci. I am a pediatrician and by the summer of 2020 it was evident who was at risk and who can continue to live a normal life. Sweden was a better example of reasonable public health recommendations. Dr Fauci made recommendations that were obviously lies and have significant consequences.
Dr Prasad is very knowledgeable and I am all for RCTs. However the reality of primary medicine is that 15 min checkup is considered adequate to deal with physical and mental health issues. The depression screen is a helpful shortcut to highlight issues that would otherwise not be discussed. Thank you for your discussions
On finding/choosing a PCP: interesting question and much depends on the availability of PCPs in your area.
Fauci: not a good pandemic leader. Why we have someone in their 80s as lead public health doctor is unclear - speaks to hubris and connections on his part. he showed absolutely no humility and seems quite likely he actually did much to suppress a wide range of information and other legitimate questions/ideas from respected physicians.
Opioid epidemic: The FDA chairperson and review committee approved Oxycontin with no evidence, then joined Purdue Pharma after leaving the FDA. Fault starts right there and what were/are the repercussions? Nothing. Made me realize the FDA is very tied to Pharma and big money. You can't just accept what they say at this point. (ie, where do Pfizer boosters fit into all this? Paxlovid? RSV vaccine?)
There were physicians and pharmacists who spoke out against liberal use of opioids, but it is difficult to fight against public and mainstream medicine opinion. It is mind-boggling how susceptible medicine is to big money influence behind the scenes.
Right now, if you as a physician question how good the data really is to support the state and level of transgender "diagnoses" and in treating children with hormones and surgery, you will be vilified. If you questioned how good the Covid vaccine or booster really is, you got labeled as "anti vax"
All the "quality measures" are pay-for-performance and have no business being used to direct patient care (the screening for depression and anxiety; the "last blood pressure of the year" being a surrogate marker for quality of BP control, etc etc) Never any study to show the negative outcomes associated with these directives. But if you question, disagree, speak up - nobody listens; administrators and other physicians throw fake "data" your way. We have allowed medicine to be driven by so many outside influences and pressures- in the name of "quality" for some reason.
If any physician is "mining" charts for Medicare Advantage HCC diagnoses, they are helping bilk CMS/federal Medicare of billions of dollars. Or if you are part of a big organization participating. When will this be brought to light?
So - beyond opioids, so many areas physicians should stand up and refuse to participate. And we just don't.
The other thing about opioids that I think is pertinent to the episode is that the evidence wasn’t there to begin with. All the studies were short term, so prescribing them for chronic pain, which is physiologically different than acute pain, was never supported by that literature. NIH convened a systematic review on opioids for chronic pain that came out in 2013 or so (so at least a decade after Oxycontin), and literally found zero studies that met their inclusion criteria. And this is after they reduced their definition of chronic and opened it up to nonrandomized studies. It was the most bizarrely comic research presentation I’ve ever listened to.
The eventual studies that did come out on opioids and chronic pain have been unimpressive. Many countries have perfectly good healthcare systems and never prescribed opioids routinely for chronic pain or minor procedures.
My point being that it’s not the case that there was a conflict between the benefits of opioids and the harms of addiction and diversion and so on, because the benefits were never proven in the first place. A good dose of EBM would have shut this whole thing down from the beginning.
When it comes to atrial fibrillation and risk of stroke I have a number of questions that I am not certain have been addressed. Is the risk for those with paroxysmal atrial fibrillation different from those with continuous afib? How does one distinguish a presumably embolic stroke from an atrial clot from those that may arise from an atherosclerotic plaque? Is there really any solid evidence that atrial fibrillation leads to clot formation within the atria due to "stasis"? Perhaps I am simply unaware of studies that address these issues but I have not seen them discussed in quite a few articles on the subject including those referenced in a number of recent studies.
Thank you for a very engaging, insightful discussion. First to the issue of anticoagulation with atrial fibrillation, the point that not anticoagulating a patient who ultimately suffers a stroke with an AF history still statistically would have very likely have suffered the stroke whether on AC or not. When approaching this matter in the all too familiar setting of an elderly unsteady frail patient with impaired vision who is excluded from the clinical trials, the decision making becomes very different. Also, your discussion towards the end invoking concerns that the trainees may lack the fundamental curiosity to track down and inform themselves of the seminal studies is a key issue which should be deeply embedded in the educational process and begun early and continued consistently. You guys are great and please keep it up!
There is an element of elitism in this episode, given that two of them are fairly high-end academics and one is making big bucks in private practice.
The reason people don’t want to practice medicine is largely because of the business side of it. Private practice is rapidly disappearing. Not everyone can work at a big academic center. And being employed by some big corporation who tells you how to practice medicine and treats you like Foot Locker treats a sales associate is not what most people went to med school for. So yes, people are searching for ways to get out of the business.
On the other hand, maybe in San Fransisco everyone wants to get into finance or whatever, but if you go to med school in Kentucky or if you go to a DO school, you are likely to end up practicing a primary care specialty in a rural area. And where I went to med school in Australia, they overwhelmingly pushed general practice, and their healthcare system is structured so it makes more sense to do that. People in the U.S. who go into primary care tend to burn out quickly. It sucks.
I think it’s genuine ignorance on their part, but as someone with a 99th percentile MCAT but a scraped from the bottom of the barrel medical career, I have a very different perspective on these issues than they do.
Here’s a question – does Dr Mandrola ever just relax and stop working in the EHR? I know those eye movements are going back-and-forth between the message center and the charts. Take a break. You guys are greatplease keep it coming.
The problem with not looking at data before preaching or acting on things in a way that affects others (I think believing things for oneself alone is okay, even if not always smart) to me is not just lack of curiousity. It's dishonesty. People lack the self-awareness to distinguish between what they know (or can at least substantiate in a way that invites falsifiability) and what they believe.
And for your general reading pleasure and terror, here is the latest Pfizer trial audit:
Following up on Adam's comments, I love the idea of orienting medical students on day 1 to the multitude of stories and episodes of errors in medicine, including studies misinterpreted. It is too late to wait till these men and women are years into their training. There needs to be curiosity and humility.
Extending from your conversation in this video, can you all talk about quality measures (besides screening) in medicine that were tested and proved to be harmful or ineffective in more depth?
I have 2 comments. I have lot of respect for all of you and look forward to your podcasts. However Dr Cifu is being too charitable about Dr Fauci. I am a pediatrician and by the summer of 2020 it was evident who was at risk and who can continue to live a normal life. Sweden was a better example of reasonable public health recommendations. Dr Fauci made recommendations that were obviously lies and have significant consequences.
Dr Prasad is very knowledgeable and I am all for RCTs. However the reality of primary medicine is that 15 min checkup is considered adequate to deal with physical and mental health issues. The depression screen is a helpful shortcut to highlight issues that would otherwise not be discussed. Thank you for your discussions
I enjoy these discussions!
On finding/choosing a PCP: interesting question and much depends on the availability of PCPs in your area.
Fauci: not a good pandemic leader. Why we have someone in their 80s as lead public health doctor is unclear - speaks to hubris and connections on his part. he showed absolutely no humility and seems quite likely he actually did much to suppress a wide range of information and other legitimate questions/ideas from respected physicians.
Opioid epidemic: The FDA chairperson and review committee approved Oxycontin with no evidence, then joined Purdue Pharma after leaving the FDA. Fault starts right there and what were/are the repercussions? Nothing. Made me realize the FDA is very tied to Pharma and big money. You can't just accept what they say at this point. (ie, where do Pfizer boosters fit into all this? Paxlovid? RSV vaccine?)
There were physicians and pharmacists who spoke out against liberal use of opioids, but it is difficult to fight against public and mainstream medicine opinion. It is mind-boggling how susceptible medicine is to big money influence behind the scenes.
Right now, if you as a physician question how good the data really is to support the state and level of transgender "diagnoses" and in treating children with hormones and surgery, you will be vilified. If you questioned how good the Covid vaccine or booster really is, you got labeled as "anti vax"
All the "quality measures" are pay-for-performance and have no business being used to direct patient care (the screening for depression and anxiety; the "last blood pressure of the year" being a surrogate marker for quality of BP control, etc etc) Never any study to show the negative outcomes associated with these directives. But if you question, disagree, speak up - nobody listens; administrators and other physicians throw fake "data" your way. We have allowed medicine to be driven by so many outside influences and pressures- in the name of "quality" for some reason.
If any physician is "mining" charts for Medicare Advantage HCC diagnoses, they are helping bilk CMS/federal Medicare of billions of dollars. Or if you are part of a big organization participating. When will this be brought to light?
So - beyond opioids, so many areas physicians should stand up and refuse to participate. And we just don't.
The other thing about opioids that I think is pertinent to the episode is that the evidence wasn’t there to begin with. All the studies were short term, so prescribing them for chronic pain, which is physiologically different than acute pain, was never supported by that literature. NIH convened a systematic review on opioids for chronic pain that came out in 2013 or so (so at least a decade after Oxycontin), and literally found zero studies that met their inclusion criteria. And this is after they reduced their definition of chronic and opened it up to nonrandomized studies. It was the most bizarrely comic research presentation I’ve ever listened to.
The eventual studies that did come out on opioids and chronic pain have been unimpressive. Many countries have perfectly good healthcare systems and never prescribed opioids routinely for chronic pain or minor procedures.
My point being that it’s not the case that there was a conflict between the benefits of opioids and the harms of addiction and diversion and so on, because the benefits were never proven in the first place. A good dose of EBM would have shut this whole thing down from the beginning.
When it comes to atrial fibrillation and risk of stroke I have a number of questions that I am not certain have been addressed. Is the risk for those with paroxysmal atrial fibrillation different from those with continuous afib? How does one distinguish a presumably embolic stroke from an atrial clot from those that may arise from an atherosclerotic plaque? Is there really any solid evidence that atrial fibrillation leads to clot formation within the atria due to "stasis"? Perhaps I am simply unaware of studies that address these issues but I have not seen them discussed in quite a few articles on the subject including those referenced in a number of recent studies.
Thank you for a very engaging, insightful discussion. First to the issue of anticoagulation with atrial fibrillation, the point that not anticoagulating a patient who ultimately suffers a stroke with an AF history still statistically would have very likely have suffered the stroke whether on AC or not. When approaching this matter in the all too familiar setting of an elderly unsteady frail patient with impaired vision who is excluded from the clinical trials, the decision making becomes very different. Also, your discussion towards the end invoking concerns that the trainees may lack the fundamental curiosity to track down and inform themselves of the seminal studies is a key issue which should be deeply embedded in the educational process and begun early and continued consistently. You guys are great and please keep it up!
There is an element of elitism in this episode, given that two of them are fairly high-end academics and one is making big bucks in private practice.
The reason people don’t want to practice medicine is largely because of the business side of it. Private practice is rapidly disappearing. Not everyone can work at a big academic center. And being employed by some big corporation who tells you how to practice medicine and treats you like Foot Locker treats a sales associate is not what most people went to med school for. So yes, people are searching for ways to get out of the business.
On the other hand, maybe in San Fransisco everyone wants to get into finance or whatever, but if you go to med school in Kentucky or if you go to a DO school, you are likely to end up practicing a primary care specialty in a rural area. And where I went to med school in Australia, they overwhelmingly pushed general practice, and their healthcare system is structured so it makes more sense to do that. People in the U.S. who go into primary care tend to burn out quickly. It sucks.
I think it’s genuine ignorance on their part, but as someone with a 99th percentile MCAT but a scraped from the bottom of the barrel medical career, I have a very different perspective on these issues than they do.
Here’s a question – does Dr Mandrola ever just relax and stop working in the EHR? I know those eye movements are going back-and-forth between the message center and the charts. Take a break. You guys are greatplease keep it coming.
The problem with not looking at data before preaching or acting on things in a way that affects others (I think believing things for oneself alone is okay, even if not always smart) to me is not just lack of curiousity. It's dishonesty. People lack the self-awareness to distinguish between what they know (or can at least substantiate in a way that invites falsifiability) and what they believe.
And for your general reading pleasure and terror, here is the latest Pfizer trial audit:
https://openvaet.substack.com/p/pfizerbiontech-c4591001-trial-audit
Speaks to my questions on data transparency.