Great reminder to get back to basics once the emergency has passed. Another important aspect of caring for a hospitalized elder is to get them moving early and often. Even if they arrived due to a fall. (Maybe especially if they are there due to a fall). This seems to be low priority for nursing staff even after the elder has been cleared by PT. Often the long term damage is not from fractures or rhabdo, but from inactivity in the hospital environment.
The main takeaway I have from this example is a point I've been trying to make for several years: you do not treat a 90+ year old the way you treat a 50 or 60 year old!! That is really the bottom line to this story. And I don't think it is completely correct to generalize this example and its resulting adage to the general population or as a tenet of medical care.
This story is the perfect illustration to what I see as THE major problem in medical care at this particular time in history: we have more extreme elders than ever before. We have a medical system (most extremely noted on the inpatient side) that has very limited capacity to differentiate how it treats extreme elders from anyone else. The default - particularly in the fast-paced ER and inpatient settings - is to crank through the algorithms and treat all adults the same.
I would never use a 94 y/o as the "classic example" for anything in general medicine. To tout the "vibrant" status of a 94 y/o is to fall into the trap of most family members who are shocked when their 94 y/o mom is suddenly in the hospital when just a day ago she was "so healthy!" Even the most "robust", independent 94 year old is still - 94 years old! A 94 year old body is not anywhere near a 50, 60, etc year old body. I describe to patients and family members - the health status and health balance of a 90+ year old is balancing on the head of a pin. It can (and will) tip drastically out of balance from a seemingly-minor issue. And here is the big take away: THE LESS WE DO TO A 90+ year old, THE BETTER!!!!
It is impossible to expect that the busy ER and hospitalist physicians make these determinations on the fly. It is clear from current status that they cannot. They don't make these adjustments in care for 94 vs 62 year olds. From my observation, the only group that is truly able to see this and to treat these extreme elders appropriately IS the experienced, outpatient clinicians!
I tell all of my 88+ year olds: the less we do to you at this stage, the better. There is nothing that the health care system has to offer to this population that will really help them live longer or healthier. Caring for them is a delicate job.
Just consider if this example were a 60 year old woman. How likely would it have been that a sodium of 123 would just gently fix itself? not likely - an otherwise healthy 60 year old is not going to have that lab result. Just sitting back and letting it fix itself is very unlikely to work as well. And you'd be obligated to figure out why! As is clear here: all bets are off in a 90+ year old. This can totally be just a normal balance for them. Again, the less testing and treatment we can put on them, the better. The entire health care system is crumbling in a state of overwhelm as our nation ages. Everyday, more people turn 65 than ever before. The oldest baby boomers are 81 years old. True frailty tends to come on > 85 y/o as a rule. The next 15 years are going to crush what is left of our health care apparatus unless we can change the way we do things. The only solution I see is to transition the care of our extreme elders to a different (and more APPROPRIATE) system. Where experienced physicians who do understand that doing less - ie, doing nothing - will often be the absolute best course of action.
I am curious what diagnosis was made in this case? The account implies that the initial plasma sodium was extremely low. What drugs, or laxatives, etc. was this woman taking before she collapsed? Or was any other explanation found? How did she lose more sodium than water while lying on the floor?
Not long after duloxetine was licensed, my team hospitalized for "delirium" a woman of similar age, whose plasma sodium was about 108mM. She had taken 2 doses of duloxetine, prescribed to her after she made the mistake of responding to her doctor's questions about mood: "What's the point of living at my age?" (at age 91).
Her retired general internist husband, and pediatric RN daughter, recognized that this experience was indubitably an adverse reaction to duloxetine (Cymbalta) - perhaps SIADH. But because the junior medical student rejected that hypothesis and substituted "hyponatremia" as the most responsible diagnosis, I had to re-dictate the hospital discharge summary to substitute "duloxetine-induced hyponatremia," in addition to reporting the ADR to Health Canada.
This patient, a retired senior psychiatric nurse with a droll English sense of humour, contributed a teaching video about her experience, including a description and visualization of the revolting hospital food...
In another case in which corticosteroid-induced Type 2 diabetes caused profound diuresis and an ultimately fatal hypernatremic dehydration in an immigrant with little English who was about to be cured of testicular cancer. Our team debated in the traditional way the precise rate of infusion of hypotonic saline.
A few hours into the emergency department treatment, this patient suffered a fatal ischemic stroke, presumably from overly turgid blood. After this shocking experience, I looked again at the famous publications that led to the standard internal medicine calculations about correction rates for hyper or hyponatremia. They struck me as based on the work of exhausted junior house staff on patients in the most desperate conditions - prestigious, but not necessarily very scientific.
I concluded that we should have given our patient unlimited water to drink, avoided (as we did) the dexamethasone that he had received as anti-emetic for chemotherapy that caused his fatal hyperglycemia, and allowed his intestine, circulation, and kidneys to do the rest. On further thought, had I another chance to treat the same patient, I concluded that I might have tried to sit him upright and supervised in a bath, and allow him also to absorb H2O through his skin by osmosis.
I think it would be very interesting if one of the medical residents or students who reads Sensible Medicine, or perhaps Dr. Alexander or a smart but open-minded expert in fluids and electrolytes such as Dr. Brad F (comment below), could look independently at whether the fuss made about rates of electrolyte corrections is ever justified by scientific understanding of physiology.
If someone were willing to examine the issue, perhaps conclusions and references could rbe shared in a future posting, or further comments in this string?
Well, they were both challenging issues. Sadly, the one involving precipitate and unavoidable death was never presented to M&M rounds, let alone investigated by Coroner. We don't have much of a Coroner's service in BC, partly because it deliberately excluded MDs after about 1990 - on grounds that they might be "conflicted."
You might like the teaching video I made with the elderly retired nurse (trained at Maudsley Hospital, taught clinical nursing for many years, Australian-trained general internist husband of the "old school" courtesy, etc.). We used it for a special seminar about "informed consent" for health students of various disciplines. But I'm not sure I received her permission to share it beyond use where I showed it in person.
If interested, you can see some teaching videos that I have posted with consent at:
www.ti.ubc.ca (see in particular Therapeutics Letter 139 on dopamine antagonists), and you might find interesting the proposed consent to treatment form that we developed as the appendix (final page) to our Therapeutics Letters 156 and 157 on antidepresant withdrawal syndromes and deprescribing of antidepressants. (also at www.ti.ubc.ca - see Publications tab: Therapeutics Letter.
I am told that morbidity and mortality rounds in our large teaching hospital were of high quality in neurosurgery, cardiology, etc. In general internal medicine, they often avoided the key issues ... for example, how a false diagnosis of "UTI" from emergency room bedpan urinalysis ultimately led to death from C. difficile colitis.
I subscribed for many years to the NEJM, but usually found the case conferences too abstruse for my interest or use. Even as academic internist, still usually better to think horses (or deer, elk), not zebras when one hears hoofbeats in the night in Canada.
I've worked in primary care (family medicine) for about 25 years, some time in the VA system in Ohio, but in recent years, I have been in "Value Based Health Care"... for a while with Oak Street Health in Cleveland... I did enjoy that, but the pandemic burned me out with the constantly shifting guidance.
See my post above. When looking at examples of care involving extreme elders (ie, > 85 years old - my personal experience sets it at >/= 88 years old), these should not be used to guide anything in younger-aged adults. The extreme elders are a very unique population. Their bodies are not the same as younger adults (and again, this would be 60, 70 year olds, etc - not "young" people but not extreme elder). They will be much more sensitive to the adverse effects of medication (as your example was!) and treating them very gently with as little "intervention" as possible is the best approach (as the example in the original article of this Sensible Med post)
Your second example is an extremely medically complex acute illness. That situation was a truly life-threatening situation and had all the complexities possible. Thinking that person might have lived if all guidelines re: rehydration were generally ignored is not correct either.
As an EM physician, 'doing nothing' was a relatively more common approach than it perhaps would be in other settings. There are many situations in EM that would call for 'nothing'. An example:
An otherwise healthy adult arrives by ambulance with a history of being the lone driver of a late model sedan that had been struck from behind by a similar vehicle at moderate to low spread. The patient complained of left shoulder and neck pain, and was placed in 'spinal precautions' restraints (strapped to a backboard & with a cervical collar). EMS staff reported moderate damage to both vehicles, the other car had airbags deployed, and no one in that vehicle had complaints requiring intervention.
For this patient, many of my EM colleagues would have routinely ordered some form of imaging to 'rule out' an unstable c-spine injury (many would have these images done prior to anything beyond an 'A-B-C-N' exam). For the all such patients, I would do a sequenced exam and verbal history first as they were being admitted to the ED. With this exam, as findings supported 'soft tissue strain' I would start progresive relaxation of the restraints. In most cases, in less than 5 minutes I would have the patient out of restraints and getting a 'Trial of Life' walk around the exam room. These patients had no imaging, an NSAID for their discomfort, and a carefully rendered explanation of what to expect over the next 72 hours should my diagnosis of muscle strain prove to be correct. If the nursing & clerical staff could keep up, these patients were commonly discharged within 30 to 40 minutes from arrival.
So, of course, I did not 'do nothing', I did what was needed - a careful history, exam, and observation. This led to doing something good for the patient, and avoided doing anything unnecessary for the patient. The savings of resources was also a significant 'something'.
PS - Since none of these patient's outcomes resulted in any complaints about my care, I am reasonably confident that I caused no harm for these patients.
So - yes - sometimes doing nothing is the best way to do something good...
When it comes to care of the very elderly, not uncommonly less is more. Although not applicable to this case, where the neurologic, hyponatremic complications and risks of rhabdomyelysis, acute renal, failure, etc. warranted aggressive, initial management.
I’m sure all of the sensible medicine colleagues are aware of Hilton’s/Marriott’s syndrome. An elderly patient comes in with a mild to moderate complaint and some abnormality is noted and chased, treated, and the original complaint pales by comparison to the ultimate clinical condition of the unfortunate hospitalized patient. The patient would’ve been better off going to the hotel then coming to the hospital.
Agree!! The extreme elderly are not actually well-served by current medical structures. As our country deals with the "silver tsunami" (of which we are just at the leading edge), we need to acknowledge and accept this fact. Treating all adults the same is the crux of what will drive our health care system into oblivion.
Seniors won't want to accept "less" medical care and politically this will be touted as "limiting care to seniors!" - but treating 90 years olds the same as everyone else is honestly not in their best interest. Until we as a medical profession can accept and voice that to US healthcare, the stresses and decline of medical care in general will simply continue till it all breaks. We need to structure a health care system (acute care and post acute care) that is geared to exactly what the extreme elders need. Staff this system with very experienced clinicians who know how to avoid unnecessary testing and treatments as the best way to care for this population.
Great piece. Restraint is a dying art in medicine. Medical maximalism somehow feels like better care, both to doctors and patients. But as you say, sometimes the best tincture is time and patience.
Great example, thanks for taking the time to write. But if only you didn’t have to follow the sodium for two more days in house…😀
I live in the surgical world, so many people (not everyone) get frustrated with me when my plan is “let’s not decide right now and wait a bit”. When I recommend “do nothing”, sometimes they are downright apoplectic. What do we call that, the “aren’t you going to do something” bias? I think it stems partly from an overinflated idea of the efficacy of our interventions.
I object to “doing nothing”—you sat with her, listened to what makes her happy, and set a basic plan (rehab) to get her back to her independence. You did so much to meet her needs. Had her hyponatremia not improved, she still would have felt better after that.
This is where AI would be no help. It’s what I call Contrary or Paradoxical therapy. Do the opposite of what common medical wisdom would dictate. It is an intuitive approach. Forget guidelines and algorithms.
When I was an intern, we had an infant with 20-30 second breath holding (apneic) spells. We had no CT Scans in those days. Baby had numerous primitive scans and 24 hour monitors. In the corner, the grandmother quietly said, "I think he's just ornery." Chief of service said, try doing nothing. Intuition. Discretionary physician thought.
There is a lot of wisdom here. The longer I practice, the more I see that doing nothing and patiently waiting is the right thing to do—far more often than I appreciated early in my career.
I agree - the experienced clinician is often the best person to be patient and let things play out. It does take experience of watching the entire arc over and over to recognize how things will typically go and be comfortable in waiting for that to occur - and having the clinical acumen to spot when things are not going as they typically would/should.
Loved this post. Seems to me that Dr. Alexander’s “humility levels are a tad elevated” for a person in his profession. I recommend he should do nothing about that.
I despise hyponatremia. Before all the calculations 50/hr was just fine
Great reminder to get back to basics once the emergency has passed. Another important aspect of caring for a hospitalized elder is to get them moving early and often. Even if they arrived due to a fall. (Maybe especially if they are there due to a fall). This seems to be low priority for nursing staff even after the elder has been cleared by PT. Often the long term damage is not from fractures or rhabdo, but from inactivity in the hospital environment.
The main takeaway I have from this example is a point I've been trying to make for several years: you do not treat a 90+ year old the way you treat a 50 or 60 year old!! That is really the bottom line to this story. And I don't think it is completely correct to generalize this example and its resulting adage to the general population or as a tenet of medical care.
This story is the perfect illustration to what I see as THE major problem in medical care at this particular time in history: we have more extreme elders than ever before. We have a medical system (most extremely noted on the inpatient side) that has very limited capacity to differentiate how it treats extreme elders from anyone else. The default - particularly in the fast-paced ER and inpatient settings - is to crank through the algorithms and treat all adults the same.
I would never use a 94 y/o as the "classic example" for anything in general medicine. To tout the "vibrant" status of a 94 y/o is to fall into the trap of most family members who are shocked when their 94 y/o mom is suddenly in the hospital when just a day ago she was "so healthy!" Even the most "robust", independent 94 year old is still - 94 years old! A 94 year old body is not anywhere near a 50, 60, etc year old body. I describe to patients and family members - the health status and health balance of a 90+ year old is balancing on the head of a pin. It can (and will) tip drastically out of balance from a seemingly-minor issue. And here is the big take away: THE LESS WE DO TO A 90+ year old, THE BETTER!!!!
It is impossible to expect that the busy ER and hospitalist physicians make these determinations on the fly. It is clear from current status that they cannot. They don't make these adjustments in care for 94 vs 62 year olds. From my observation, the only group that is truly able to see this and to treat these extreme elders appropriately IS the experienced, outpatient clinicians!
I tell all of my 88+ year olds: the less we do to you at this stage, the better. There is nothing that the health care system has to offer to this population that will really help them live longer or healthier. Caring for them is a delicate job.
Just consider if this example were a 60 year old woman. How likely would it have been that a sodium of 123 would just gently fix itself? not likely - an otherwise healthy 60 year old is not going to have that lab result. Just sitting back and letting it fix itself is very unlikely to work as well. And you'd be obligated to figure out why! As is clear here: all bets are off in a 90+ year old. This can totally be just a normal balance for them. Again, the less testing and treatment we can put on them, the better. The entire health care system is crumbling in a state of overwhelm as our nation ages. Everyday, more people turn 65 than ever before. The oldest baby boomers are 81 years old. True frailty tends to come on > 85 y/o as a rule. The next 15 years are going to crush what is left of our health care apparatus unless we can change the way we do things. The only solution I see is to transition the care of our extreme elders to a different (and more APPROPRIATE) system. Where experienced physicians who do understand that doing less - ie, doing nothing - will often be the absolute best course of action.
Law #13 of the House of God:
The delivery of medical care is to do as much nothing as possible.
I am curious what diagnosis was made in this case? The account implies that the initial plasma sodium was extremely low. What drugs, or laxatives, etc. was this woman taking before she collapsed? Or was any other explanation found? How did she lose more sodium than water while lying on the floor?
Not long after duloxetine was licensed, my team hospitalized for "delirium" a woman of similar age, whose plasma sodium was about 108mM. She had taken 2 doses of duloxetine, prescribed to her after she made the mistake of responding to her doctor's questions about mood: "What's the point of living at my age?" (at age 91).
Her retired general internist husband, and pediatric RN daughter, recognized that this experience was indubitably an adverse reaction to duloxetine (Cymbalta) - perhaps SIADH. But because the junior medical student rejected that hypothesis and substituted "hyponatremia" as the most responsible diagnosis, I had to re-dictate the hospital discharge summary to substitute "duloxetine-induced hyponatremia," in addition to reporting the ADR to Health Canada.
This patient, a retired senior psychiatric nurse with a droll English sense of humour, contributed a teaching video about her experience, including a description and visualization of the revolting hospital food...
In another case in which corticosteroid-induced Type 2 diabetes caused profound diuresis and an ultimately fatal hypernatremic dehydration in an immigrant with little English who was about to be cured of testicular cancer. Our team debated in the traditional way the precise rate of infusion of hypotonic saline.
A few hours into the emergency department treatment, this patient suffered a fatal ischemic stroke, presumably from overly turgid blood. After this shocking experience, I looked again at the famous publications that led to the standard internal medicine calculations about correction rates for hyper or hyponatremia. They struck me as based on the work of exhausted junior house staff on patients in the most desperate conditions - prestigious, but not necessarily very scientific.
I concluded that we should have given our patient unlimited water to drink, avoided (as we did) the dexamethasone that he had received as anti-emetic for chemotherapy that caused his fatal hyperglycemia, and allowed his intestine, circulation, and kidneys to do the rest. On further thought, had I another chance to treat the same patient, I concluded that I might have tried to sit him upright and supervised in a bath, and allow him also to absorb H2O through his skin by osmosis.
I think it would be very interesting if one of the medical residents or students who reads Sensible Medicine, or perhaps Dr. Alexander or a smart but open-minded expert in fluids and electrolytes such as Dr. Brad F (comment below), could look independently at whether the fuss made about rates of electrolyte corrections is ever justified by scientific understanding of physiology.
If someone were willing to examine the issue, perhaps conclusions and references could rbe shared in a future posting, or further comments in this string?
This is as good as any case report discussion I have seen in the NEJM... (but I don't go there for "good" case discussions any more.)
Well, they were both challenging issues. Sadly, the one involving precipitate and unavoidable death was never presented to M&M rounds, let alone investigated by Coroner. We don't have much of a Coroner's service in BC, partly because it deliberately excluded MDs after about 1990 - on grounds that they might be "conflicted."
You might like the teaching video I made with the elderly retired nurse (trained at Maudsley Hospital, taught clinical nursing for many years, Australian-trained general internist husband of the "old school" courtesy, etc.). We used it for a special seminar about "informed consent" for health students of various disciplines. But I'm not sure I received her permission to share it beyond use where I showed it in person.
If interested, you can see some teaching videos that I have posted with consent at:
www.ti.ubc.ca (see in particular Therapeutics Letter 139 on dopamine antagonists), and you might find interesting the proposed consent to treatment form that we developed as the appendix (final page) to our Therapeutics Letters 156 and 157 on antidepresant withdrawal syndromes and deprescribing of antidepressants. (also at www.ti.ubc.ca - see Publications tab: Therapeutics Letter.
I am told that morbidity and mortality rounds in our large teaching hospital were of high quality in neurosurgery, cardiology, etc. In general internal medicine, they often avoided the key issues ... for example, how a false diagnosis of "UTI" from emergency room bedpan urinalysis ultimately led to death from C. difficile colitis.
I subscribed for many years to the NEJM, but usually found the case conferences too abstruse for my interest or use. Even as academic internist, still usually better to think horses (or deer, elk), not zebras when one hears hoofbeats in the night in Canada.
In what area do you work/teach and where?
Tom Perry
Vancouver, CANADA
Tom Perry
I've worked in primary care (family medicine) for about 25 years, some time in the VA system in Ohio, but in recent years, I have been in "Value Based Health Care"... for a while with Oak Street Health in Cleveland... I did enjoy that, but the pandemic burned me out with the constantly shifting guidance.
See my post above. When looking at examples of care involving extreme elders (ie, > 85 years old - my personal experience sets it at >/= 88 years old), these should not be used to guide anything in younger-aged adults. The extreme elders are a very unique population. Their bodies are not the same as younger adults (and again, this would be 60, 70 year olds, etc - not "young" people but not extreme elder). They will be much more sensitive to the adverse effects of medication (as your example was!) and treating them very gently with as little "intervention" as possible is the best approach (as the example in the original article of this Sensible Med post)
Your second example is an extremely medically complex acute illness. That situation was a truly life-threatening situation and had all the complexities possible. Thinking that person might have lived if all guidelines re: rehydration were generally ignored is not correct either.
As an EM physician, 'doing nothing' was a relatively more common approach than it perhaps would be in other settings. There are many situations in EM that would call for 'nothing'. An example:
An otherwise healthy adult arrives by ambulance with a history of being the lone driver of a late model sedan that had been struck from behind by a similar vehicle at moderate to low spread. The patient complained of left shoulder and neck pain, and was placed in 'spinal precautions' restraints (strapped to a backboard & with a cervical collar). EMS staff reported moderate damage to both vehicles, the other car had airbags deployed, and no one in that vehicle had complaints requiring intervention.
For this patient, many of my EM colleagues would have routinely ordered some form of imaging to 'rule out' an unstable c-spine injury (many would have these images done prior to anything beyond an 'A-B-C-N' exam). For the all such patients, I would do a sequenced exam and verbal history first as they were being admitted to the ED. With this exam, as findings supported 'soft tissue strain' I would start progresive relaxation of the restraints. In most cases, in less than 5 minutes I would have the patient out of restraints and getting a 'Trial of Life' walk around the exam room. These patients had no imaging, an NSAID for their discomfort, and a carefully rendered explanation of what to expect over the next 72 hours should my diagnosis of muscle strain prove to be correct. If the nursing & clerical staff could keep up, these patients were commonly discharged within 30 to 40 minutes from arrival.
So, of course, I did not 'do nothing', I did what was needed - a careful history, exam, and observation. This led to doing something good for the patient, and avoided doing anything unnecessary for the patient. The savings of resources was also a significant 'something'.
PS - Since none of these patient's outcomes resulted in any complaints about my care, I am reasonably confident that I caused no harm for these patients.
So - yes - sometimes doing nothing is the best way to do something good...
As usual, kudos to Dr. Alexander
When it comes to care of the very elderly, not uncommonly less is more. Although not applicable to this case, where the neurologic, hyponatremic complications and risks of rhabdomyelysis, acute renal, failure, etc. warranted aggressive, initial management.
I’m sure all of the sensible medicine colleagues are aware of Hilton’s/Marriott’s syndrome. An elderly patient comes in with a mild to moderate complaint and some abnormality is noted and chased, treated, and the original complaint pales by comparison to the ultimate clinical condition of the unfortunate hospitalized patient. The patient would’ve been better off going to the hotel then coming to the hospital.
Ben Hourani MD, MBA
Agree!! The extreme elderly are not actually well-served by current medical structures. As our country deals with the "silver tsunami" (of which we are just at the leading edge), we need to acknowledge and accept this fact. Treating all adults the same is the crux of what will drive our health care system into oblivion.
Seniors won't want to accept "less" medical care and politically this will be touted as "limiting care to seniors!" - but treating 90 years olds the same as everyone else is honestly not in their best interest. Until we as a medical profession can accept and voice that to US healthcare, the stresses and decline of medical care in general will simply continue till it all breaks. We need to structure a health care system (acute care and post acute care) that is geared to exactly what the extreme elders need. Staff this system with very experienced clinicians who know how to avoid unnecessary testing and treatments as the best way to care for this population.
This is great.
“Do nothing TID” is my plan more often than one might expect for a cardiologist.
Great piece. Restraint is a dying art in medicine. Medical maximalism somehow feels like better care, both to doctors and patients. But as you say, sometimes the best tincture is time and patience.
Wonderful article. A beautiful example of the essential role of common sense in the practice of medicine.
Great example, thanks for taking the time to write. But if only you didn’t have to follow the sodium for two more days in house…😀
I live in the surgical world, so many people (not everyone) get frustrated with me when my plan is “let’s not decide right now and wait a bit”. When I recommend “do nothing”, sometimes they are downright apoplectic. What do we call that, the “aren’t you going to do something” bias? I think it stems partly from an overinflated idea of the efficacy of our interventions.
I object to “doing nothing”—you sat with her, listened to what makes her happy, and set a basic plan (rehab) to get her back to her independence. You did so much to meet her needs. Had her hyponatremia not improved, she still would have felt better after that.
This is where AI would be no help. It’s what I call Contrary or Paradoxical therapy. Do the opposite of what common medical wisdom would dictate. It is an intuitive approach. Forget guidelines and algorithms.
When I was an intern, we had an infant with 20-30 second breath holding (apneic) spells. We had no CT Scans in those days. Baby had numerous primitive scans and 24 hour monitors. In the corner, the grandmother quietly said, "I think he's just ornery." Chief of service said, try doing nothing. Intuition. Discretionary physician thought.
There is a lot of wisdom here. The longer I practice, the more I see that doing nothing and patiently waiting is the right thing to do—far more often than I appreciated early in my career.
I agree - the experienced clinician is often the best person to be patient and let things play out. It does take experience of watching the entire arc over and over to recognize how things will typically go and be comfortable in waiting for that to occur - and having the clinical acumen to spot when things are not going as they typically would/should.
Loved this post. Seems to me that Dr. Alexander’s “humility levels are a tad elevated” for a person in his profession. I recommend he should do nothing about that.
🙂
I thought this was going be a parody with the title and George Costanza's real name. Nope. What a great read and enjoyed the positive outcome.