In this age of misinformation, where we seem to have become disdainful of genuine experts, no armor will protect us from folly more effectively than a healthy dose of disbelief.
The "Who has the medical degree? question. Besides getting the license to charge large fees, what is that medical school education really worth? . . . Some problems with modern medical school:
1) It teaches an intervention-centered model of health.
2) It confuses surrogate markers with meaningful health outcomes.
3) It insufficiently teaches overdiagnosis and overtreatment.
4) It teaches too little probability and decision theory.
5) It gives nutrition, exercise, sleep and behavioral change insufficient depth.
6) It is vulnerable to pharmaceutical and medical-device industry influence.
7) It rewards conformity more than independent judgment.
8) It produces a narrow and unusually selected professional class.
9) The training process can erode curiosity, empathy and intellectual humility.
10) It teaches medicine inside a distorted economic and reimbursement system.
When a patient says, "I'd like to do my research", the answer should be, "sure, here are some resources to get you started." It's the doctor's job to explain medical advice, and part of that is helping patients who want to be more informed about their treatment. If patients are coming to the doctor's office full of misinformation, the doctor should educate them (at whatever level is appropriate for the patient).
Also, keep in mind that anyone who's interacted with the medical system for any length of time has been lied to. Repeatedly. I was visiting a bedridden relative yesterday, and she was promised a visit that day to look at an issue. No one came. We talked about another relative who had received a scan. Doc came out and said, "Good news! There's nothing worrisome on your scan." Then the tech came in, "Sorry, doc. We have to redo the scan. It didn't come out."
Everyone has stories like these, and everyone has a right to be skeptical. My advice to doctors who want their patients' trust is that they have to earn it.
Gee, what a condescending attitude towards fellow humans! Why do doctors continue to allow themselves to be "demoralized" by the freedom adults have to seek out information and make their own decisions? To decry "the internet" as a cesspool of "misinformation" and allow themselves to be insulted when patients look for other sources besides the all-wise physician sitting in front of them? Why does a patient saying they'll do some further research threaten Dr Lickerman's sense of professional confidence or professional satisfaction?
The fact that the patient has chosen to come see him, paid to see him, should be proof enough that the patient values his input. And patients are so varied! Many will simply hear what he has to say and take it without another thought or any further "research". He's overlooking all of those people and focusing on the few who want to consider things further. Maybe because he's been associated with U of C and feels above any other consideration. Maybe he forgets when medicine actually got it wrong - how many things have been reversed over the past 30 years. When beta blockers were first line antihypertensives - until they weren't. When OxyContin wasn't as addictive as other formulations per the FDA. When we told parents to avoid giving their infants any exposure to peanuts/peanut butter. Etc, etc. "The best evidence we had at the time" only gets you so far.
There are so many times that I have been thoroughly impressed by my fellow humans! Times when a person who is not highly educated but has a good analytical thought process and common sense comes to conclusions I didn't see coming. Times when other professionals with expertise ask excellent questions. This is what makes medicine fun. Just enjoy it.
Thanks, Alex. You did not touch on the problem of information from acknowledged experts which turns out to be false. Anthony Fauci is our current paradigmatic example. He spoke earnestly and had the apparent support of many, if not most of the medical establishment. He wondered into public policy decisions that were well outside his expertise in infectious disease and immunology. All experts need to be asked questions and be expected to answer them.
I pay experts to share their expertise with me but never to make my decisions for me, unless it's an emergency. The research I often need to do is to verify what they said. After all, me taking responsibility for the decisions I make helps protect me and the experts I work with.
Alan, all I can say is that you come off as a highly credentialed know nothing. Reading your article I absolutely would do my own research and not take your word for anything. There are no absolutes in medicine or science I’m afraid.
You may be able to understand the pitfalls of observational and RCT research but most primary care doctors dont understand the difference between observational studies and RCT's. Further more they do not hav the science background and have almost no understanding of statistical methods in medicine to read journal articles even if they had the time. For many reasons they follow protocols coming from above their pay grade.
Thank you for this excellent piece! Lots for me to think about here regarding my own approach to health. We are in a difficult time in some ways. Many doctors do not take the time as you did to explain the risks and benefits. They repeat the "standard of care" narrative, which makes it harder to trust in what they are saying. Anyway, appreciate this one!
Excellent piece. Very apropos for the times. I’ve found that there is no stereotyped demographic that comes with the “I read online….” bit. And of course, with sycophantic AI, you can literally get it to agree with anything you want, based on your prompts. So any biases will be reinforced PRN.
It always amuses me when pts balk at solid evidence based treatments (eg statins in secondary prevention) but are all for vitamin D or assorted nutraceutical garbage with zero evidence.
But I’m a stoic, so I take no umbrage to it. I figure it’s a free country, my job is to tell them the science, and beyond that it’s whatever floats their boat. “You do you” is my typical message.
Really. Statins for secondary prevention in individuals who have not had a cardiovascular event. Seems to me you should perhaps do a little research and not be so sure of yourself because quite clearly you don’t know what you’re talking about.
I stand corrected on secondary prevention regarding statins. Yes statins have a significant effect post mi. But I wouldn’t be so careful to dismiss vitamin d either. And I suggest you stop talking about “the science” because I suspect you have zero scientific accomplishments behind you.
This is a marvelous piece. But I have been teasing this out in my practice, and you do not mention the 800 pound gorilla in the room: the lies that accompanied the covid debacle have made skeptics of people who once would have been much more trusting.
For most of my practice career, the statement you quoted (I have a sign that says that in my office) about medical degree and Google would have gotten a chuckle and an assent. But the events of the covid mess have shown (and more shows every day) that the people that individuals trusted most in health care, their doctors, lied to them (about masks, about anti-social distancing, about spikeshots) with a straight face and would brook no discussion nor argument. Masking has long been a hot button of mine (I have published on it) and it has long been known that virtually every word put out there by "doctors" during covid regarding masks was largely a lie. It was early known that covid shots did not blunt transmission, but that was lied about, too. There is a long list, not worth reprising here.
Early in the covid mess, I published a piece that noted that the likely outcome would be a deprecation of professional standing that would take decades to recover, if it were recoverable at all. Luckily for my own peace of mind, I never wore a mask (I am tenured full -- try to fire me), never required my patients to do so, and never lied to my patients either. I reported the uncertainties and wrong-speak I saw from the very beginning. But very few did so. And every patient I now see remembers virtually every element about the lies they were told and who told them.
As Shakespeare said, a good name is almost impossible to restore and the medical profession has lost much of its good name. Everything you said in your piece is spot on. But what did YOU tell patients during the covid mess? How much of it conflicts with what they are now learning daily? Those are questions I ask myself every day when patients look at me askance when I tell them something I know to be true.
As long as we ignore this gorilla, this is not getting better fast.
I love this example, it is an increasingly every day practice problem.
This case shows that even when a patient has access to trusted expertise and a continuing DPC relationship, the internet can still influence patient behavior and judgement.
Clinical stewardship helps the patient understand whether a treatment is appropriate. Financial stewardship should complete that decision by making the price, available coverage and patient responsibility clear before treatment. Bringing both together allows the patient to make an informed choice without confusing information with expertise or discovering the financial consequences afterward. That combination is central to the operating system we are building at YourHealthco.
If something seems too good to be true, it very likely is not true. Always a good nostrum to remember. Be especially skeptical when an "expert" recommends a pill, a diet, or any other intervention that promises to reduce your risk of future disease or disability. The doctor's role is to diagnose disease and recommend options for treatment in the present. That is difficult enough. Don't accept the bold predictions of future risk no matter how much you like or respect the person offering it. The figures quoted are often based on studies where the differences are minute and/or speculative but said to be "statistically significant" when common sense would indicate otherwise. Experts often disagree but when it comes to that largely fictional field of "preventive medicine", the correct default position is to decline the treatment offered.
There is a problem though for us - those of us who can reasonably claim to be experts - in that our expert opinions often enough are contradicted by others. Who is the expert on whose expertise is truly reliable…?
With this in mind, I recommend a book, and offer some excerpts…
The Crisis of Expertise by Gil Eyal
ISBN: 978-0-745-66577-1
November 2019
Put differently, considered historically and from the point of view of pragmatics, expertise is not a thing, not a set of skills possessed by an individual or even by a group, but a historically specific way of talking. It is a way of talking occasioned by a situation in which the number of contenders for expert status has increased, the bases for their claims have become more heterogeneous and uncertain, and the struggles between them have become more intense. It is a way of talking necessitated when the mechanisms of gate-keeping and adjudication between claims have become weaker and more uncertain, and yet the institutional demand for expert discourse is ever-increasing. Talking in terms of “expertise” communicates the new and urgent need to find accepted ways of adjudicating whose claim is legitimate, when the old definitions and exclusions no longer work. It is a way of talking, finally, about the intersection, articulation and friction between science and technology on the one hand, and law and democratic politics on the other. It points us at the problem, but it is no Ariadne's thread to lead us out of the maze of their entanglements.
To say that expertise is not a thing but a historically specific way of talking, however, does not exempt me from trying to clarify this way of talking and thereby reshape it for current purposes. There is an entire school of thought that insists that we must treat expertise in realist fashion, as a real set of accumulated experiences, abilities, skills, and knowhow. If they are correct, then I have muddied the waters considerably, perhaps even opened the floodgates by creating the impression that expertise is “nothing but” a way of talking, merely “socially constructed.” I must deal with these objections before I proceed.
…the point is that we often speak of expertise in a promissory mode, not as something that exists but as something that needs to be developed. The rapid pace of scientific and technological development creates numerous new problems that law and policy must address, in regard to which nobody is expert, yet expertise is the only legitimate way to address them.
Chapter 4 - Risk:
1. There is no expert on risk because there are too many experts on risk.
2. There is no expert on risk because there is no one with expertise exactly relevant to the problem at hand.
3. There is no expert on risk because (like trust) it is a de-differentiating concept, which transgresses the stable boundaries between disciplines and professions, ultimately the very boundaries between experts and laypeople.
4. Perhaps most importantly, there is no expert on risk because risk analysis is ethics and politics camouflaged by numbers.
I'm not a healthcare professional, but I have a scientific background: I studied physics for several years and had a long career in computing programming with a specialty in predictive analytics, and I agree with your observation:
"There is a problem though for us - those of us who can reasonably claim to be experts - in that our expert opinions often enough are contradicted by others. Who is the expert on whose expertise is truly reliable…?"
I personally, as a patient, have been misinformed -- almost killed in one instance, crippled for a year in another, by doctors I trusted. Given insufficient, incorrect, harmful information numerous times. In the first case above it was our trusted family doctor and I would have been dead if I had listened to him rather than heading to the emergency room where they rushed to treat my sepsis.
I have had doctors tell me with confidence that I should take a drug that has very harmful permanent side effects because I had "no choice," even after I quoted the Up To Date findings of the drugs which showed that what I was suggesting and concerned about meant that I had other, and in my case, much safer options, which were equally effective.
I would like to have a doctor I could trust. But I do not have one.
So before you question a patient's wish to "do their own research", please consider that you might be interacting with a patient like me. We have been living in our bodies for decades and you might be seeing us just for 15 minutes or maybe 30. You might be that careful MD who does know all the patient needs to know, but you might not be. And the patient will pay the price if you are the latter.
“Please don’t confuse your Google search with my medical degree.”
This is the snarkiest comment you guys can make and the reason many patients distrust doctors - it is demeaning and rude and pushy. Yes, you spent a lot of time trying to sell her GLP1s. She needs time to think about it. And as someone in the comments pointed out - she won't know that you're correct until she hears what others have to say. That's "Doing her research." And there are other doctors with real medical degrees that she'll hear from "on Google" aka youtube who might have other viewpoints.
You probably are one of the more educated doctors, especially if you're keeping up with studies, but some of us have come across doctors who aren't. I once had the head of the OBGYN department at Kaiser tell me that I couldn't possibly have obstetrical cholestasis so early in the pregnancy. And "Which one of us has the medical degree." Should've been her, but I guess she was asleep for that class.... This was my third pregnancy with OC, I knew the symptoms and I knew how it worked - because I'd done my research. She refused to treat me, and I tried to manage the symptoms through diet. When I got to the end of the pregnancy I asked for a blood test to see where my levels were, and was told "Oh I guess you do have obstetrical cholestasis!" Yeah no sh*t. If I'd been with the place I had my first two pregnancies they'd have put me on Urso right away and weekly blood draws because they took it VERY seriously and *had* done their research.
The "Who has the medical degree? question. Besides getting the license to charge large fees, what is that medical school education really worth? . . . Some problems with modern medical school:
1) It teaches an intervention-centered model of health.
2) It confuses surrogate markers with meaningful health outcomes.
3) It insufficiently teaches overdiagnosis and overtreatment.
4) It teaches too little probability and decision theory.
5) It gives nutrition, exercise, sleep and behavioral change insufficient depth.
6) It is vulnerable to pharmaceutical and medical-device industry influence.
7) It rewards conformity more than independent judgment.
8) It produces a narrow and unusually selected professional class.
9) The training process can erode curiosity, empathy and intellectual humility.
10) It teaches medicine inside a distorted economic and reimbursement system.
When a patient says, "I'd like to do my research", the answer should be, "sure, here are some resources to get you started." It's the doctor's job to explain medical advice, and part of that is helping patients who want to be more informed about their treatment. If patients are coming to the doctor's office full of misinformation, the doctor should educate them (at whatever level is appropriate for the patient).
Also, keep in mind that anyone who's interacted with the medical system for any length of time has been lied to. Repeatedly. I was visiting a bedridden relative yesterday, and she was promised a visit that day to look at an issue. No one came. We talked about another relative who had received a scan. Doc came out and said, "Good news! There's nothing worrisome on your scan." Then the tech came in, "Sorry, doc. We have to redo the scan. It didn't come out."
Everyone has stories like these, and everyone has a right to be skeptical. My advice to doctors who want their patients' trust is that they have to earn it.
Just my opinion as a layman.
Gee, what a condescending attitude towards fellow humans! Why do doctors continue to allow themselves to be "demoralized" by the freedom adults have to seek out information and make their own decisions? To decry "the internet" as a cesspool of "misinformation" and allow themselves to be insulted when patients look for other sources besides the all-wise physician sitting in front of them? Why does a patient saying they'll do some further research threaten Dr Lickerman's sense of professional confidence or professional satisfaction?
The fact that the patient has chosen to come see him, paid to see him, should be proof enough that the patient values his input. And patients are so varied! Many will simply hear what he has to say and take it without another thought or any further "research". He's overlooking all of those people and focusing on the few who want to consider things further. Maybe because he's been associated with U of C and feels above any other consideration. Maybe he forgets when medicine actually got it wrong - how many things have been reversed over the past 30 years. When beta blockers were first line antihypertensives - until they weren't. When OxyContin wasn't as addictive as other formulations per the FDA. When we told parents to avoid giving their infants any exposure to peanuts/peanut butter. Etc, etc. "The best evidence we had at the time" only gets you so far.
There are so many times that I have been thoroughly impressed by my fellow humans! Times when a person who is not highly educated but has a good analytical thought process and common sense comes to conclusions I didn't see coming. Times when other professionals with expertise ask excellent questions. This is what makes medicine fun. Just enjoy it.
Thanks, Alex. You did not touch on the problem of information from acknowledged experts which turns out to be false. Anthony Fauci is our current paradigmatic example. He spoke earnestly and had the apparent support of many, if not most of the medical establishment. He wondered into public policy decisions that were well outside his expertise in infectious disease and immunology. All experts need to be asked questions and be expected to answer them.
I pay experts to share their expertise with me but never to make my decisions for me, unless it's an emergency. The research I often need to do is to verify what they said. After all, me taking responsibility for the decisions I make helps protect me and the experts I work with.
Alan, all I can say is that you come off as a highly credentialed know nothing. Reading your article I absolutely would do my own research and not take your word for anything. There are no absolutes in medicine or science I’m afraid.
You may be able to understand the pitfalls of observational and RCT research but most primary care doctors dont understand the difference between observational studies and RCT's. Further more they do not hav the science background and have almost no understanding of statistical methods in medicine to read journal articles even if they had the time. For many reasons they follow protocols coming from above their pay grade.
My doctor had never heard of the USPSTF, and I suspect he doesn't know what NNT and NNH means.
I am assuming you're a big fan of Tom Nichols
Thank you for this excellent piece! Lots for me to think about here regarding my own approach to health. We are in a difficult time in some ways. Many doctors do not take the time as you did to explain the risks and benefits. They repeat the "standard of care" narrative, which makes it harder to trust in what they are saying. Anyway, appreciate this one!
Excellent piece. Very apropos for the times. I’ve found that there is no stereotyped demographic that comes with the “I read online….” bit. And of course, with sycophantic AI, you can literally get it to agree with anything you want, based on your prompts. So any biases will be reinforced PRN.
It always amuses me when pts balk at solid evidence based treatments (eg statins in secondary prevention) but are all for vitamin D or assorted nutraceutical garbage with zero evidence.
But I’m a stoic, so I take no umbrage to it. I figure it’s a free country, my job is to tell them the science, and beyond that it’s whatever floats their boat. “You do you” is my typical message.
Really. Statins for secondary prevention in individuals who have not had a cardiovascular event. Seems to me you should perhaps do a little research and not be so sure of yourself because quite clearly you don’t know what you’re talking about.
“Secondary prevention” is by definition in patients who have had an MI.
Your level of ignorance should clearly preclude you from having any opinion on this topic. Yet here you are. Go figure.
Keep taking your supplements, pal. You seem like a vitamin D type.
I stand corrected on secondary prevention regarding statins. Yes statins have a significant effect post mi. But I wouldn’t be so careful to dismiss vitamin d either. And I suggest you stop talking about “the science” because I suspect you have zero scientific accomplishments behind you.
Feel free to present causative evidence of benefit for vitamin D in people who are not vitamin D deficient. I’ll wait.
I sure hope you're not the Steve Cheung who is Trump's idiot Communications Director.
Haha yeah….not the most wonderful of coincidences 😂
This is a marvelous piece. But I have been teasing this out in my practice, and you do not mention the 800 pound gorilla in the room: the lies that accompanied the covid debacle have made skeptics of people who once would have been much more trusting.
For most of my practice career, the statement you quoted (I have a sign that says that in my office) about medical degree and Google would have gotten a chuckle and an assent. But the events of the covid mess have shown (and more shows every day) that the people that individuals trusted most in health care, their doctors, lied to them (about masks, about anti-social distancing, about spikeshots) with a straight face and would brook no discussion nor argument. Masking has long been a hot button of mine (I have published on it) and it has long been known that virtually every word put out there by "doctors" during covid regarding masks was largely a lie. It was early known that covid shots did not blunt transmission, but that was lied about, too. There is a long list, not worth reprising here.
Early in the covid mess, I published a piece that noted that the likely outcome would be a deprecation of professional standing that would take decades to recover, if it were recoverable at all. Luckily for my own peace of mind, I never wore a mask (I am tenured full -- try to fire me), never required my patients to do so, and never lied to my patients either. I reported the uncertainties and wrong-speak I saw from the very beginning. But very few did so. And every patient I now see remembers virtually every element about the lies they were told and who told them.
As Shakespeare said, a good name is almost impossible to restore and the medical profession has lost much of its good name. Everything you said in your piece is spot on. But what did YOU tell patients during the covid mess? How much of it conflicts with what they are now learning daily? Those are questions I ask myself every day when patients look at me askance when I tell them something I know to be true.
As long as we ignore this gorilla, this is not getting better fast.
I love this example, it is an increasingly every day practice problem.
This case shows that even when a patient has access to trusted expertise and a continuing DPC relationship, the internet can still influence patient behavior and judgement.
Clinical stewardship helps the patient understand whether a treatment is appropriate. Financial stewardship should complete that decision by making the price, available coverage and patient responsibility clear before treatment. Bringing both together allows the patient to make an informed choice without confusing information with expertise or discovering the financial consequences afterward. That combination is central to the operating system we are building at YourHealthco.
If something seems too good to be true, it very likely is not true. Always a good nostrum to remember. Be especially skeptical when an "expert" recommends a pill, a diet, or any other intervention that promises to reduce your risk of future disease or disability. The doctor's role is to diagnose disease and recommend options for treatment in the present. That is difficult enough. Don't accept the bold predictions of future risk no matter how much you like or respect the person offering it. The figures quoted are often based on studies where the differences are minute and/or speculative but said to be "statistically significant" when common sense would indicate otherwise. Experts often disagree but when it comes to that largely fictional field of "preventive medicine", the correct default position is to decline the treatment offered.
There is a problem though for us - those of us who can reasonably claim to be experts - in that our expert opinions often enough are contradicted by others. Who is the expert on whose expertise is truly reliable…?
With this in mind, I recommend a book, and offer some excerpts…
The Crisis of Expertise by Gil Eyal
ISBN: 978-0-745-66577-1
November 2019
Put differently, considered historically and from the point of view of pragmatics, expertise is not a thing, not a set of skills possessed by an individual or even by a group, but a historically specific way of talking. It is a way of talking occasioned by a situation in which the number of contenders for expert status has increased, the bases for their claims have become more heterogeneous and uncertain, and the struggles between them have become more intense. It is a way of talking necessitated when the mechanisms of gate-keeping and adjudication between claims have become weaker and more uncertain, and yet the institutional demand for expert discourse is ever-increasing. Talking in terms of “expertise” communicates the new and urgent need to find accepted ways of adjudicating whose claim is legitimate, when the old definitions and exclusions no longer work. It is a way of talking, finally, about the intersection, articulation and friction between science and technology on the one hand, and law and democratic politics on the other. It points us at the problem, but it is no Ariadne's thread to lead us out of the maze of their entanglements.
To say that expertise is not a thing but a historically specific way of talking, however, does not exempt me from trying to clarify this way of talking and thereby reshape it for current purposes. There is an entire school of thought that insists that we must treat expertise in realist fashion, as a real set of accumulated experiences, abilities, skills, and knowhow. If they are correct, then I have muddied the waters considerably, perhaps even opened the floodgates by creating the impression that expertise is “nothing but” a way of talking, merely “socially constructed.” I must deal with these objections before I proceed.
…the point is that we often speak of expertise in a promissory mode, not as something that exists but as something that needs to be developed. The rapid pace of scientific and technological development creates numerous new problems that law and policy must address, in regard to which nobody is expert, yet expertise is the only legitimate way to address them.
Chapter 4 - Risk:
1. There is no expert on risk because there are too many experts on risk.
2. There is no expert on risk because there is no one with expertise exactly relevant to the problem at hand.
3. There is no expert on risk because (like trust) it is a de-differentiating concept, which transgresses the stable boundaries between disciplines and professions, ultimately the very boundaries between experts and laypeople.
4. Perhaps most importantly, there is no expert on risk because risk analysis is ethics and politics camouflaged by numbers.
I'm not a healthcare professional, but I have a scientific background: I studied physics for several years and had a long career in computing programming with a specialty in predictive analytics, and I agree with your observation:
"There is a problem though for us - those of us who can reasonably claim to be experts - in that our expert opinions often enough are contradicted by others. Who is the expert on whose expertise is truly reliable…?"
I personally, as a patient, have been misinformed -- almost killed in one instance, crippled for a year in another, by doctors I trusted. Given insufficient, incorrect, harmful information numerous times. In the first case above it was our trusted family doctor and I would have been dead if I had listened to him rather than heading to the emergency room where they rushed to treat my sepsis.
I have had doctors tell me with confidence that I should take a drug that has very harmful permanent side effects because I had "no choice," even after I quoted the Up To Date findings of the drugs which showed that what I was suggesting and concerned about meant that I had other, and in my case, much safer options, which were equally effective.
I would like to have a doctor I could trust. But I do not have one.
So before you question a patient's wish to "do their own research", please consider that you might be interacting with a patient like me. We have been living in our bodies for decades and you might be seeing us just for 15 minutes or maybe 30. You might be that careful MD who does know all the patient needs to know, but you might not be. And the patient will pay the price if you are the latter.
“Please don’t confuse your Google search with my medical degree.”
This is the snarkiest comment you guys can make and the reason many patients distrust doctors - it is demeaning and rude and pushy. Yes, you spent a lot of time trying to sell her GLP1s. She needs time to think about it. And as someone in the comments pointed out - she won't know that you're correct until she hears what others have to say. That's "Doing her research." And there are other doctors with real medical degrees that she'll hear from "on Google" aka youtube who might have other viewpoints.
You probably are one of the more educated doctors, especially if you're keeping up with studies, but some of us have come across doctors who aren't. I once had the head of the OBGYN department at Kaiser tell me that I couldn't possibly have obstetrical cholestasis so early in the pregnancy. And "Which one of us has the medical degree." Should've been her, but I guess she was asleep for that class.... This was my third pregnancy with OC, I knew the symptoms and I knew how it worked - because I'd done my research. She refused to treat me, and I tried to manage the symptoms through diet. When I got to the end of the pregnancy I asked for a blood test to see where my levels were, and was told "Oh I guess you do have obstetrical cholestasis!" Yeah no sh*t. If I'd been with the place I had my first two pregnancies they'd have put me on Urso right away and weekly blood draws because they took it VERY seriously and *had* done their research.