This was great! I’ve always been a little annoyed by the appeal to credentialism on social media and this post really describes why I feel that way quite eloquently
Vinay: It’s good to have you back to the complex world of medical decision making, after your hiatus.
In this case, the conceptual arguments make sense, but from a practical standpoint, is the question not this: When should a physician/clinician rely on standards and scientific evidence, and when should they make the judgement weighing intuition versus patient context?
That is a) agency lies and should continue lie with the physician b) the real question is what inputs they use.
And – why not consider the event of a physician using both data and experience to make the decision, but just weighing each differently, based on the case at hand?
I was right there with you, until this ... "8 billion people are alive today, and some estimate that 120 billion people have ever lived. Of these 1.5% were and are 7 year olds— say a billion 7 year olds have ever existed."
Um ... no. All of the 8 year-olds alive today were 7-year-olds last year. All of the 10-year-olds today were 7 year olds in 2023. In fact, of the 8 billion people alive today, more than 7 billion of them were once 7-year-olds. But it's a great example of how hard it can be to get data right!
Agree with this. My only nitpick is that many, many of those 120 billion would have died before they got to 7 years old. So the real numbers of how many 7 year olds have ever lived is somewhere less than 120 billion, but how many is very difficult to calculate.
I always thought my doctors knew the data and kept up with it. That’s the big surprise I’ve had in the last few years. I want a physician who knows the data AND is a subject matter expert. And as a patient I would like to have a say because the patient is the one who accepts the risk or derives the benefits of procedures and medication.
Bottom line is that data experts with clinical insight should make public health recommendations, expert clinicians with data insight should make individual recommendations.
What a great post! I'm a Family Practitioner and assessing my competence in data, psychiatry, cardiology, endocrinology, orthopedics and all the others is often frustratingly difficult. Your post was helpful because it gives words to the daily tension I feel when I give advise. Thank you.
Interesting results on the polls so far (20 hours left) - for 3 of the questions, respondents overwhelmingly selected the correct answer (90%+ in favor), but for the question about the psychiatric medication, it is almost 50-50, and as of now, the incorrect answer is winning. Curious about people’s responses to this question. AS A PSYCHIATRIST… I’ve definitely gotten consults for potentially lithium-related issues before so the answer seemed obvious.
I think the real dichotomy is between patients who have a straightforward yes and no decision to be made and to whom clinical trials apply to as opposed to patients who require complex decisions and/or decision with no good evidence available.
To distinguish between often requires a disease expert and data evaluation expert (though often not - as in the case examples).
Fortunately, there are experienced specialists who can apply their solid knowledge of evidence, critical appraisal, statistics and empathy to patient care, all instruments at our disposal in practicing the art of medicine :-)
I agree with those who call it a false dichotomy. Data experts who never talk to patients can make terrible decisions, not because they are stupid, but because the exact data for the exact patient in front of you rarely exists. Applying data from a mixed cohort of 7 year olds to the 7 year old in front of you, with all the nuances you picked up from a detailed history is the skill of the psychiatrist who is well aware of the evidence. There simply isn't and never will be an RCT of 1000 clones of the 7 year old in front of you.
As a family medicine doctor this is something I have been struggling with for a long time. I really like the distinction between a generic patient with x who is represented in large RCTs versus a complication or patient with comorbidities that makes them less represented by RCTs. It makes sense to me that if I feel well-versed in the trials for a generic condition like statins in an average risk patient vs anti-platetlet management in a patient with history of ASCVD.
Reminds me of when Emily Oster broke onto the pregnancy scene. An economist writing about pregnancy?! Gasp! What a scandal. I really admired her for that book (Expecting Better), and was disappointed but not surprised at the credentialism that ensued.
This was great! I’ve always been a little annoyed by the appeal to credentialism on social media and this post really describes why I feel that way quite eloquently
Vinay: It’s good to have you back to the complex world of medical decision making, after your hiatus.
In this case, the conceptual arguments make sense, but from a practical standpoint, is the question not this: When should a physician/clinician rely on standards and scientific evidence, and when should they make the judgement weighing intuition versus patient context?
That is a) agency lies and should continue lie with the physician b) the real question is what inputs they use.
And – why not consider the event of a physician using both data and experience to make the decision, but just weighing each differently, based on the case at hand?
I was right there with you, until this ... "8 billion people are alive today, and some estimate that 120 billion people have ever lived. Of these 1.5% were and are 7 year olds— say a billion 7 year olds have ever existed."
Um ... no. All of the 8 year-olds alive today were 7-year-olds last year. All of the 10-year-olds today were 7 year olds in 2023. In fact, of the 8 billion people alive today, more than 7 billion of them were once 7-year-olds. But it's a great example of how hard it can be to get data right!
Agree with this. My only nitpick is that many, many of those 120 billion would have died before they got to 7 years old. So the real numbers of how many 7 year olds have ever lived is somewhere less than 120 billion, but how many is very difficult to calculate.
I always thought my doctors knew the data and kept up with it. That’s the big surprise I’ve had in the last few years. I want a physician who knows the data AND is a subject matter expert. And as a patient I would like to have a say because the patient is the one who accepts the risk or derives the benefits of procedures and medication.
Bottom line is that data experts with clinical insight should make public health recommendations, expert clinicians with data insight should make individual recommendations.
Where the situation is acute, and/or the published RCT evidence is in flux or ambiguous, I'd find an expert's opinion important.
Hey Vinay, the psychiatry example was not good – and the results show.
Run it by a psych friend and let us know what you think. I can also do it if you're interested ‐ I'm a psychiatrist myself).
Take care
What a great post! I'm a Family Practitioner and assessing my competence in data, psychiatry, cardiology, endocrinology, orthopedics and all the others is often frustratingly difficult. Your post was helpful because it gives words to the daily tension I feel when I give advise. Thank you.
Interesting results on the polls so far (20 hours left) - for 3 of the questions, respondents overwhelmingly selected the correct answer (90%+ in favor), but for the question about the psychiatric medication, it is almost 50-50, and as of now, the incorrect answer is winning. Curious about people’s responses to this question. AS A PSYCHIATRIST… I’ve definitely gotten consults for potentially lithium-related issues before so the answer seemed obvious.
I think the real dichotomy is between patients who have a straightforward yes and no decision to be made and to whom clinical trials apply to as opposed to patients who require complex decisions and/or decision with no good evidence available.
To distinguish between often requires a disease expert and data evaluation expert (though often not - as in the case examples).
Fortunately, there are experienced specialists who can apply their solid knowledge of evidence, critical appraisal, statistics and empathy to patient care, all instruments at our disposal in practicing the art of medicine :-)
I agree with those who call it a false dichotomy. Data experts who never talk to patients can make terrible decisions, not because they are stupid, but because the exact data for the exact patient in front of you rarely exists. Applying data from a mixed cohort of 7 year olds to the 7 year old in front of you, with all the nuances you picked up from a detailed history is the skill of the psychiatrist who is well aware of the evidence. There simply isn't and never will be an RCT of 1000 clones of the 7 year old in front of you.
As a family medicine doctor this is something I have been struggling with for a long time. I really like the distinction between a generic patient with x who is represented in large RCTs versus a complication or patient with comorbidities that makes them less represented by RCTs. It makes sense to me that if I feel well-versed in the trials for a generic condition like statins in an average risk patient vs anti-platetlet management in a patient with history of ASCVD.
excellent examples and explanations Vinay
So good. So relevant.
Reminds me of when Emily Oster broke onto the pregnancy scene. An economist writing about pregnancy?! Gasp! What a scandal. I really admired her for that book (Expecting Better), and was disappointed but not surprised at the credentialism that ensued.